Limb Lengthening Forum
Limb Lengthening Surgery => Limb Lengthening Doctors => Topic started by: Muse on November 15, 2013, 05:17:35 AM
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Note: please refer to our disclaimer about The Doctors Directory http://www.limblengtheningforum.com/index.php?topic=55.0
Updated Response from Dr Franz Birkholtz
: We do perform cosmetic lengthenings in highly selective cases and LON is one of the techniques we employ. 5cm can be achieved in the tibias in a single procedure, but it is important to note that this is risky surgery and that one can end up with bilateral amputations as a result.
Our rough selection criteria of 165 cm in males as the upper limit. There are cases where, after thorough evaluation, it may be appropriate to perform CLL. This should not be seen as the norm and is definitely not a topic for open discussion.
Methods and Cost of Treatment
Externals (new frames): $30,000 USD approx.
LON/LATN: $35,000 USD approx.
Internals (PRECICE): $52,000 USD approx.
*Dr Birkholtz's lengthening limit is 5 cm for tibias and 6 cm for femurs.
Cost Includes
- All professional fees for surgeon, anesthetist, physio, psychologist, occupational therapist.
- High care unit for 1 day.
- Normal hospital ward for 5 days.
- All followup visits, erc sessions and woundcare visits.
- Daily physio for 75 days.
- Doctor contact at least twice a week.
- Support by a multi disciplinary team experienced in limb reconstruction.
- Accommodation in a four star rated guesthouse close to hospital on a dinner bed and breakfast basis.
- Includes wifi and satellite tv. Also includes daily transfer to clinic for adjustments.
- The accommodation is for two people. This is a self catering unit.
Our lists are generally booked a couple of weeks in advance, but provided I am not on congress or holiday, we can accommodate most of the year.
Cost Excludes
- Cost excludes potential complications.
Consultation Process
Reference: http://www.limblengtheningforum.com/index.php?topic=137.msg5302#msg5302
Background
From his website: Dr Franz Birkholtz studied at the University of Pretoria and currently teaches courses in South Africa and abroad. He is practicing in Centurion with rooms in Lifestyle Management Park next to Unitas Hospital.
As of June, 2012 now does limb reconstruction operations bi-monthly at Vincent Pallotti Hospital in Cape Town. Contact the Cape Orthopaedic Trauma Group (Dr Bernstein) on 021 506 5555 to schedule an appointment.
Practice Number: 0280000226599
Contact Details
Dr Franz F Birkholtz
Orthopaedic Surgeon (MBChB(Pret) MMed(Orth)(Pret) FCOrth(SA))
Telephone: +27(0)12 644 2641
Fax: +27(0)12 644 2642
Website Url: www.walkamile.co.za
Email: reception@walkamile.co.za
Personal email: franz.birkholtz@walkamile.co.za
Postal address:
PO Box 11328
Centurion,
0046
Republic of South Africa
Practice address:
Suite 8C
Lifestyle Management Building
Unit 4
223 Clifton Ave
Lyttelton
Pretoria
South Africa
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Africa?!
I am simply not that brave.
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Why this doctor mentioned the risk of losing the limb? i've never read something like this related with LL... it sounds a bit disquieting!
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Why this doctor mentioned the risk of losing the limb? i've never read something like this related with LL... it sounds a bit disquieting!
Bc it's Africa. Nobody has any idea of what they're doing.
What sane person goes to Africa?
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Bc it's Africa. Nobody has any idea of what they're doing.
What sane person goes to Africa?
Haha, Jesus Christ. I'd rather do LL myself than go Africa, maybe that's prejudice, I dunno. But my balls are not that big no matter how cheap, when you also factor in the fact that it is more expensive than lots more options I literally could see no reason to go there, ever.
It is a scary, scary country.
That said I bet there are people in Somalia who would do the surgery for <$100. Good luck surviving a week post op though.
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Why this doctor mentioned the risk of losing the limb? i've never read something like this related with LL... it sounds a bit disquieting!
Some doctors like to give you the worst case scenario just to see if you're really sure you want to go through with the procedure, and are more conservative than other docs (as you see Dr. Birkholtz doesn't perform cosmetic lengthening on males over a certain height).
Also South Africa isn't even close to Somalia in terms of danger levels. It's one of the safer regions of Africa, but of course people there for tourism would want to take precautions that you wouldn't have to in other countries. Still, not really fair to knock a doctor purely based on practice location, considering there are doctors in more developed countries that have shady business practices and manage to cripple people.
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Yeah, South Africa is one of the more developed countries in Africa if I'm not mistaken, and it's a HUGE continent. Of course, I would never go there myself for something like this. But judging it straight away simply because of the continent it's on is a bit like saying you shouldn't do LL in China or South Korea because it's on the same continent as and right next to North Korea :P
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I dunno guys Africa is pretty lethal in all areas.
It took me a while to come around tot he idea of China and India, but Africa is whole next level.
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All of the countries in Africa are a total mess, even South Africa.
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My local G.P. hires white doctors from South Africa. I've met 3 of them so far and I always confuse them for being German or Dutch because they have these Australianised Dutch or German accents. Seem like nice people, though, whether the doctor was white or black, I still wouldn't travel to South Africa for surgery.
South Africa is rife with crime, I remember looking at a video of a black guy doing a carjacking and it was like a scene Grand Theft Auto because it happened in the middle of traffic. Apparently, carjackings are very common down there.
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Dear Friends,
As I am the doctor in question, I feel compelled to reply. Yes, Africa. South Africa is very different from your perceptions and I would challenge you to explore the country as a tourist before making general assumptions. The health system I work in and the unit I run is world renowned and I regularly (8 times per year) host surgeons from across the globe. During these weeks I teach the surgeons limb lengthening and reconstruction techniques. This includes surgeons from the US, UK, Sweden, UAE etc etc. Not really darkest Africa at all.
With regards to the lengthening itself, I stand by my comment that as a worst case scenario you could end up with an amputation and I would challenge you to discuss this with your chosen surgeon. This is how serious a decision cosmetic lengthening can be. Reasons for serious complications can vary, but may include injuring blood vessels, nonunions, infection etc. These complications happen anywhere, not only in Africa!
Although we perform lengthenings for malunions, congenital conditions and bone defects on almost every theatre list we do, and have vast experience in these techniques, we really do not perform cosmetic lengthenings anymore, and I would advise you to look elsewhere, but CHOOSE YOUR SURGEON CAREFULLY. Price should be the least of your concerns. Look for a doctor who communicates well and is happy to discuss potential complications with you...this is not a walk in the park.
Anyway, good luck in your search. Make sure that the extra inches will make you happy before you embark on your journey.
Best regards,
Franz Birkholtz
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Dear Friends,
As I am the doctor in question, I feel compelled to reply. Yes, Africa. South Africa is very different from your perceptions and I would challenge you to explore the country as a tourist before making general assumptions. The health system I work in and the unit I run is world renowned and I regularly (8 times per year) host surgeons from across the globe. During these weeks I teach the surgeons limb lengthening and reconstruction techniques. This includes surgeons from the US, UK, Sweden, UAE etc etc. Not really darkest Africa at all.
With regards to the lengthening itself, I stand by my comment that as a worst case scenario you could end up with an amputation and I would challenge you to discuss this with your chosen surgeon. This is how serious a decision cosmetic lengthening can be. Reasons for serious complications can vary, but may include injuring blood vessels, nonunions, infection etc. These complications happen anywhere, not only in Africa!
Although we perform lengthenings for malunions, congenital conditions and bone defects on almost every theatre list we do, and have vast experience in these techniques, we really do not perform cosmetic lengthenings anymore, and I would advise you to look elsewhere, but CHOOSE YOUR SURGEON CAREFULLY. Price should be the least of your concerns. Look for a doctor who communicates well and is happy to discuss potential complications with you...this is not a walk in the park.
Anyway, good luck in your search. Make sure that the extra inches will make you happy before you embark on your journey.
Best regards,
Franz Birkholtz
Doctor Franz,
Your reply is extremely appreciated! Please continue to post on this forums as I would love to hear more about your experiences, successes and failures as a surgeon in CLL.
Also, allow me to apologize on the behalf of the other posters in this thread. They are incredibly uncultured and know nothing about Africa besides what the media in their home countries tell them. I would be honored to get surgery done with you since you sound very knowledgeable and wise in this craft (it is an extremely dangerous procedure to do, which no doctor should sugarcoat).
Are you still doing CLL? Do you have any interest in using PRECICE? What about accommodations in your hospital?
Thank you!!
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I don't agree with most of you guys. South Africa is a developed country. I do think it would be a better option than India.
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Dear Friends,
As I am the doctor in question, I feel compelled to reply. Yes, Africa. South Africa is very different from your perceptions and I would challenge you to explore the country as a tourist before making general assumptions. The health system I work in and the unit I run is world renowned and I regularly (8 times per year) host surgeons from across the globe. During these weeks I teach the surgeons limb lengthening and reconstruction techniques. This includes surgeons from the US, UK, Sweden, UAE etc etc. Not really darkest Africa at all.
With regards to the lengthening itself, I stand by my comment that as a worst case scenario you could end up with an amputation and I would challenge you to discuss this with your chosen surgeon. This is how serious a decision cosmetic lengthening can be. Reasons for serious complications can vary, but may include injuring blood vessels, nonunions, infection etc. These complications happen anywhere, not only in Africa!
Although we perform lengthenings for malunions, congenital conditions and bone defects on almost every theatre list we do, and have vast experience in these techniques, we really do not perform cosmetic lengthenings anymore, and I would advise you to look elsewhere, but CHOOSE YOUR SURGEON CAREFULLY. Price should be the least of your concerns. Look for a doctor who communicates well and is happy to discuss potential complications with you...this is not a walk in the park.
Anyway, good luck in your search. Make sure that the extra inches will make you happy before you embark on your journey.
Best regards,
Franz Birkholtz
Hello Dr. Birkholtz,
Thank you for your reply. It would certainly be to everyone's benefit if more doctors really emphasized what to expect in a worst-case scenario with limb lengthening. I've spoken to a number of orthopedic surgeons in my various inquires and whenever one tells me that complications are minimal or that the worst to expect is a pin-site infection here and there, I automatically scratch the doctor off my list. I guess I just think that if they give you sunny expectations, then they might not address a potentially serious problem that could happen later down the line. I've never heard any accounts of people getting their legs amputated, but then again my only other resource for years had been that site old forum and it's known to sugarcoat and even hide serious complications that patients may receive. Now that that's a real possibility, it gives people a lot more to think about.
May I ask why cosmetic lengthening is something that you aren't fond of doing? Is it that you think it's too much risk for someone with perfectly healthy legs?
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Dr. Birkholtz is an honest man and a good doctor as can be seen from his posting. Yes indeed, cosmetic LL is too dangerous to be recommended. It should be only done as a last resort when you are totally unhappy with your life, not just as a luxury.
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Dear Kilokahn,
I think the debate around CLL goes wider. I suppose it has to do with cosmetic surgery in general. The reality is surgery is invasive and never perfectly safe. Up till recently we have not really had devices that were reliable, reproducible and predictable for femoral lengthening. Now with Precice we have that. In addition, the desired length is important. Anything beyond 4-5cm per segment becomes really problematic in terms of complication rates. Realistically the cost is almost prohibitive to go through a 4 segment lengthening, which means most patients end up with 5 cm either femoral or tibial. With this in mind, we have to ask whether the patient will really be happy with gaining 5 cm.
Having said all this, I realise very well that there are individuals who benefit greatly (physically and psychologically) from CLL, and it is this select group that I believe are the ideal patients.
As you can see this leaves us with a small group of patients who can a) afford it and b) be happy with it c) are healthy enough and d) are appropriate candidates (2 standard deviations shorter than the population average).
Once we've met all these criteria, there are few patients left.
From a doctor's perspective there are really 3 issues: patient safety, medicolegal risk and lastly a potential increased arthritis risk after CLL.
Hope this all makes sense?
Btw, Ballpark figure for CLL using bilateral Precice in our unit would be around 40 000 Euro. Tibial lengthening can be done with frames and would be a little less.
Rgds,
F
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Thank you Doctor. Could you let me know the best way to reach your office? I have many more questions and am very interested in having CLL done with you.
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You are welcome to phone the office at +27(0)126442641 and speak to Madelein. They will probably tell you we do not perform CLL's though. :-).
If you wish you can mail me your questions, then I'll endeavour to answer them as quickly as possible.
You can reach me at franz.birkholtz@walkamile.co.za
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I thnk the pricing is a bit too much for LL in south Africa.
At these prices i would rather go to china where they have done a thousand times more LL surgeries and benefit from all that experience that they have over there.
I thought South african prices would be slightly higher than those in India but not what i see quoted here.
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Dear Dr Franz, thanks for joining our forum and answering our questions.
After reading many of the posts here, I can see that people don't really know a lot about South Africa and it's nice to have someone enlightening us.
When you gave us the round figure of 40k euros for femoral lengthening with the Precice, what would that include exactly? Just the surgery and a few days at the hospital? Or would it include everything (accomodation at a safe location, food, medications, physio, etc)?
If it includes all that I've mentioned above, then the 40k euros are not really that steep. If not, then it's very expensive. (one can get internal femurs in South Korea with ISKD for 35k euros with everything included)
I'd also like to emphasive the need to guarantee patients' safety, since from what I've been told by an Afrikaner who emigrated to my country and from what one can read about in praag.org, Pretoria isn't exactly the same as a small town in Switzerland.
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Dear Kilokahn,
I think the debate around CLL goes wider. I suppose it has to do with cosmetic surgery in general. The reality is surgery is invasive and never perfectly safe. Up till recently we have not really had devices that were reliable, reproducible and predictable for femoral lengthening. Now with Precice we have that. In addition, the desired length is important. Anything beyond 4-5cm per segment becomes really problematic in terms of complication rates. Realistically the cost is almost prohibitive to go through a 4 segment lengthening, which means most patients end up with 5 cm either femoral or tibial. With this in mind, we have to ask whether the patient will really be happy with gaining 5 cm.
Having said all this, I realise very well that there are individuals who benefit greatly (physically and psychologically) from CLL, and it is this select group that I believe are the ideal patients.
As you can see this leaves us with a small group of patients who can a) afford it and b) be happy with it c) are healthy enough and d) are appropriate candidates (2 standard deviations shorter than the population average).
Once we've met all these criteria, there are few patients left.
From a doctor's perspective there are really 3 issues: patient safety, medicolegal risk and lastly a potential increased arthritis risk after CLL.
Hope this all makes sense?
Btw, Ballpark figure for CLL using bilateral Precice in our unit would be around 40 000 Euro. Tibial lengthening can be done with frames and would be a little less.
Rgds,
F
I understand where you're coming from and that does make a lot of sense. Thanks a lot for your response Dr. Birkholtz.
If it includes all that I've mentioned above, then the 40k euros are not really that steep. If not, then it's very expensive. (one can get internal femurs in South Korea with ISKD for 35k euros with everything included)
Can't really compare ISKD with PRECICE. Sure you can get ISKD cheaper for the initial price, but the ISKD is known throughout to have a very high rate of mechanical failure compared to other internal methods. Not only that, but it's hard to control the distraction rate and that can lead to difficulty in trying to prevent premature consolidation or when trying to slow lengthening in the possibility of non-union. If that happens, you can only guarantee that the ISKD stops lengthening by getting an additional surgery that puts an external fixator around the nail. When thinking of all those potential complications, you'd likely end up paying a whole lot more for ISKD than you would for PRECICE - not only in terms of money, but also in terms of recovery time.
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Hi,
South Africa is not as safe as Switzerland. Very few places are.
Remember that emigrants often paint a more negative picture of a country.
Nobody can guarantee anyone's safety anymore (Twin Towers, North Korea, Syria, Boston Marathon, Phillipine Hurricane). However, our patients are safe. Remember I raise my kids here!
The quoted BALLPARK figure includes:
Bilateral femoral lengthenings with Precice by experienced surgeons
Access to and use of our multi disciplinary team comprising psychology, physiotherapry, occupational therapy,orthotics, specialized nursing etc.
Hospitalization in a private room. 1 day high care and 5 days general ward.
All professional fees.
Guesthouse accommodation with three meals per day. (Safe)
Daily visits with nursing team to perform adjustments.
Xrays throughout.
A top notch mutlidisciplinary team.
Should tibial LONs be performed, the price will drop to approximately 25K euro.
As you can see, the single largest element in the cost (approx 25K) is the price of Precice nails.
Hope this helps?
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That sounds like a really good deal. If I hadn't already done LL I'd certainly consider going to you. South Africa isn't US/Canada/Japan/Western Europe, but it's certainly cleaner and nicer than the 3rd world countries that charge only slightly less for LL.
Is the air there breathable? ;) Because if it is, it sure beats New Delhi or Beijing. I was lucky enough to have gone in 2007 when they were restricting factories and cars to clean up the air for the Olympics, but when I went back afterward for IM nail removal in late 2008 the air made me sick.
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Can't really compare ISKD with PRECICE.
Yes, the ISKD sucks compared with the Precice. I've written about all those things you mentioned in another thread.
Sure you can get ISKD cheaper for the initial price, ...
This is incorrect. A friend of mine from southern Brazil (actually a distant relative) has lengthened 1 tibia with an ISKD nail, because of an accident. The costs were covered by her health insurance and she saw the break up of all the costs given by the hospital to the insurance company. The ISKD nail was marked as having a price of 34,000 BRL which is around 15k USD.
Dr Paley has confirmed that the price of 1 Precice nail is 13k USD, so basically around the same as the ISKD.
There's no reason for the costs for Precice to be higher than those for ISKD. Actually, because of the potential complications with the ISKD we all know about, the costs for Precice should actually be lower!
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Doctor Birkholtz,
Thanks for all your answers here; I sent you a lengthy email, please let me know if you received it. I'm very serious about doing LL with you.
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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.
So why not just go straight for External only and be done with the nail all together.
Sure you're in frames for longer, but once you're done, you're done.
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So why not just go straight for External only and be done with the nail all together.
Sure you're in frames for longer, but once you're done, you're done.
My thoughts exactly when I went to Dr. Mitkovic. I was going to do all-external and live in Serbia for 9 months, then I'd be done with the whole thing forever.
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Look, it is certainly the safest. It does mean long frame times though.
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Look, it is certainly the safest. It does mean long frame times though.
I have read that long time in frames = permanent muscle damage, is this rubbish?
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Hello Dr. Franz,
I've noticed that the new bone that is formed is not of a normal shape. It bulges out quite a bit. It is of a diameter greater than usual. Is this all right?
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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.
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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.
Thank you :)
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Dr. Birkholtz-
I have a honest and direct statement and question for you. I believe it is a big mistake to restrict who you perform cosmetic limb lengthening on based on the patients starting height. Doctors such as yourself who focus on patient safety and not money or self promotion are exactly the kind of doctors that need to be performing this surgery for patients. This surgery is loaded with money grubbing salesmen of doctors (Dr. Betz, Dr. Mahboubian,) just to name of few who use people on old forums to promote them and their business. Without doctors like you who focus on patient safety people interested in this surgery have very few safe affordable options. Now that a nail like the Precice is available that offers a much more cosmetic experience compared to external fixation will you consider offering your services to people of all heights?
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Dr. Birkholtz-
I have a honest and direct statement and question for you. I believe it is a big mistake to restrict who you perform cosmetic limb lengthening on based on the patients starting height. Doctors such as yourself who focus on patient safety and not money or self promotion are exactly the kind of doctors that need to be performing this surgery for patients. This surgery is loaded with money grubbing salesmen of doctors (Dr. Betz, Dr. Mahboubian,) just to name of few who use people on old forums to promote them and their business. Without doctors like you who focus on patient safety people interested in this surgery have very few safe affordable options. Now that a nail like the Precice is available that offers a much more cosmetic experience compared to external fixation will you consider offering your services to people of all heights?
Thanks for your kind words.
I get your point and accept that as complication rates drop, we can extend the indications. It is something that could be considered in the right individual, so I probably would not advocate it widely.
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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.
It sounds like the ROD can cause a lot of issues, suppose I wanted 5cm. And I did external only. If I have a favorable LL experience, what kind of recovery time frame would I be looking at? What would a price from a doctor like yourself be for external Illzarov only?
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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.
These are the kind of statistics we need to hear but never do! You will never read something like this on old forum or hear it from other doctors. But if you read any diary there, you'll easily see what he's saying is true.
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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.
Do you know why knee pain would persist even after the nails are taken out?
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These are the kind of statistics we need to hear but never do! You will never read something like this on old forum or hear it from other doctors. But if you read any diary there, you'll easily see what he's saying is true.
Another reason why "promoting" leg lengthening to be available to everybody who wants it is a bad idea, imo. So many people will jump into the thought of CLL with just the thought of getting taller but have little idea of what can potentially go wrong with them. In a way I think the relative obscurity of the procedure is for the best.
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Do you know why knee pain would persist even after the nails are taken out?
Nobody really seems to know. Initially we thought it may have do do with whether you split the patella tendon to insert the nail. Going through or next to the tendon does not seem to make a difference though.
It probably is multifactorial, but may have something to do with the change in threedimensional architechture of the proximal tibia as a result of the nail. Put in layman's terms: it's probably because we make a huge hole and shove a piece of metal down it!
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Another reason why "promoting" leg lengthening to be available to everybody who wants it is a bad idea, imo. So many people will jump into the thought of CLL with just the thought of getting taller but have little idea of what can potentially go wrong with them. In a way I think the relative obscurity of the procedure is for the best.
With regards to an earlier question you asked...do you now see why I am so careful about CLL?
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With regards to an earlier question you asked...do you now see why I am so careful about CLL?
I definitely do, and I'm thankful that you're answering these questions honestly. That's why I joined this forum and stopped going to the other site, because realistic no holds barred information on the medical aspects of cosmetic lengthening is what I'm interested in, not the marketing aspect of it.
I'm actually the one who sent you that e-mail you responded to that's shown in the first post of this topic (please keep my name and e-mail secret :D). I'm 164cm and I've been fired twice from temp jobs in foreign countries because of my stature and faced social problems because of it. My decision now comes to whether the possible (and maybe probable) physical negatives outweigh the physical and psychological benefits of undergoing CLL.
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With regards to an earlier question you asked...do you now see why I am so careful about CLL?
So despite the time in frames, what are the draw backs of external only?
To be honest I'd sooner just take the hit of one year, do 5cm external and forget about LL forever.
Thanks as always for your reply.
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I definitely do, and I'm thankful that you're answering these questions honestly. That's why I joined this forum and stopped going to the other site, because realistic no holds barred information on the medical aspects of cosmetic lengthening is what I'm interested in, not the marketing aspect of it.
I'm actually the one who sent you that e-mail you responded to that's shown in the first post of this topic (please keep my name and e-mail secret :D). I'm 164cm and I've been fired twice from temp jobs in foreign countries because of my stature and faced social problems because of it. My decision now comes to whether the possible (and maybe probable) physical negatives outweigh the physical and psychological benefits of undergoing CLL.
Your identity is safe (patient confidentiality ;) ).
It is not an easy decision. Good luck.
So despite the time in frames, what are the draw backs of external only?
To be honest I'd sooner just take the hit of one year, do 5cm external and forget about LL forever.
Thanks as always for your reply.
It is not a walk in the park. Pain, limitation in mobility etc. Recovery can take some time, but my honest opinion is that if you want 5 cms tibial with limited complications in my hands, this is the best way to go. Of course you'll get different opinions on the matter.
Femoral there's no question than internal makes more sense...
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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.
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Hi Dr Franz,
First of all, it is really an honor to have a CLL doctor here to clarify our concerns about this high risk surgery. As you stated earlier that doing 10 cm will keep the patient in a good proportion, so my question is: for those who do more than that, they will look odd!? . I am asking this question because there is a guy on the old forum( most likely the owner of the forum himself) did 20 cm and claimed that he looked fine, feel much better about himself and tell others to not worry much about proportion. Personally, I think he looks out of proportion. I would like to hear your opinions about this subject. Frequently, I saw so many comments on that forum stating something like this: I am 5'4 and my friend is 6' yet we have the same sitting height when we sit down => we have the same torso length => I could lengthen 7,8 inches to match his height and I will still look good.
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Your identity is safe (patient confidentiality ;) ).
It is not an easy decision. Good luck.
It is not a walk in the park. Pain, limitation in mobility etc. Recovery can take some time, but my honest opinion is that if you want 5 cms tibial with limited complications in my hands, this is the best way to go. Of course you'll get different opinions on the matter.
Femoral there's no question than internal makes more sense...
And what would that cost me sir?
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Hi Dr Franz,
First of all, it is really an honor to have a CLL doctor here to clarify our concerns about this high risk surgery. As you stated earlier that doing 10 cm will keep the patient in a good proportion, so my question is: for those who do more than that, they will look odd!? . I am asking this question because there is a guy on the old forum( most likely the owner of the forum himself) did 20 cm and claimed that he looked fine, feel much better about himself and tell others to not worry much about proportion. Personally, I think he looks out of proportion. I would like to hear your opinions about this subject. Frequently, I saw so many comments on that forum stating something like this: I am 5'4 and my friend is 6' yet we have the same sitting height when we sit down => we have the same torso length => I could lengthen 7,8 inches to match his height and I will still look good.
Hey Bruno,
I know many people go to a lot of trouble to talk about proportions, sitting height etc. What they're really trying to do is justify why they should lengthen extreme distances. Remember that longer distances may mean more height, but they also mean longer treatment times and exponentially more complications. This is especially common once we exceed the 2 inch mark for a segment. This is the main reason I would limit a lengthening to a maximum of 10cm in total - safety first. There is no sense in having beautiful long legs if you cannot use them!
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And what would that cost me sir?
The million dollar question. For top class treatment and 4 weeks accommodation with new frames (Truelok), the cost is 25K euro. This includes pretty much everything except for complications.
See an earlier post in this thread to get an idea of what is included.
Good luck with your decision.
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Hey dr franz i have a personal question ?
I recently did 8 cm on my tibia but now i have all this delima that i should have done 6 cm .
I was thinking is it advisable to do limb shortening for just 2 cm ?
If yes then when should i do limb shortening , m already 9 month post surgery.
Is limb shortening a dangerouse surgery ?
What methos is used for limb shortening?
Are there any regular cases of limb shortening?
If i did limb shortening on tibia bone by 2 cm so that i will get back to 6 cm will i get my flexiblity back?
I m not saying i would do it , unless m a millionare, very much curious to know .
Thank you
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Hey Bruno,
I know many people go to a lot of trouble to talk about proportions, sitting height etc. What they're really trying to do is justify why they should lengthen extreme distances. Remember that longer distances may mean more height, but they also mean longer treatment times and exponentially more complications. This is especially common once we exceed the 2 inch mark for a segment. This is the main reason I would limit a lengthening to a maximum of 10cm in total - safety first. There is no sense in having beautiful long legs if you cannot use them!
Bingo! This is the type of question that I always expect from a good surgeon. Your answer is very bold, yet hold the belief that I always hold on. And I also have another question: Is it true that you can lengthen your femur more than your tibia and expecting a quicker recovery? I have seen this is mentioned many times on most of the CLL surgeons website that I visited. My plan is to do 4.5 cm on tibia and 5.5 on femur. Do you think I can get back to my active sport life if I limit myself to this amount of lengthening?
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Yes please Dr Birkholtz tell us do Femurs heal two times faster than Tibias ?
And about this probability of loosing limbs, is it less than 1% or more ?
Thanks in advance.
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Dr. Franz, I have a couple and I hope you can answer them.
To start I have to tell that I'm not short, I'm 178~179cm, so if I ever did this surgery would be to reach my dream height of 185cm and to be a little happier with my body, it would not be life changing.
Also, I would prefer to length with the PRECICE 2(less scars, pain).
Okay, now the questions:
I was thinking of lengthening 3cm in the femurs and the 3cm in the tibias, that means 6cm max. Do you think I should length more in the femurs and less in the tibias or would it be irrelevant, in terms of recovery, since we are talking about small amounts of lengthening?
Do you think that I could regain, let's say, at least 90% of my previous athletic ability if I lengthened a max of 6cm?
Last question, imagine that I length my femurs first. Is it possible to do the surgery on the tibias as soon as I stop lengthening the femurs, maybe 2 weeks after? Or is it very risky?
Best regards,
The Plague
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Hey dr franz i have a personal question ?
I recently did 8 cm on my tibia but now i have all this delima that i should have done 6 cm .
I was thinking is it advisable to do limb shortening for just 2 cm ?
If yes then when should i do limb shortening , m already 9 month post surgery.
Is limb shortening a dangerouse surgery ?
What methos is used for limb shortening?
Are there any regular cases of limb shortening?
If i did limb shortening on tibia bone by 2 cm so that i will get back to 6 cm will i get my flexiblity back?
I m not saying i would do it , unless m a millionare, very much curious to know .
Thank you
Limb shortening post CLL is not done often. Whereas the technique is reasonably straight forward, the risk of nonunion would conceivably be high.
If the aim is to regain flexibility, I guess it makes sense to do it sooner rather than later, but it is very difficult to predict how much function will return.
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Bingo! This is the type of question that I always expect from a good surgeon. Your answer is very bold, yet hold the belief that I always hold on. And I also have another question: Is it true that you can lengthen your femur more than your tibia and expecting a quicker recovery? I have seen this is mentioned many times on most of the CLL surgeons website that I visited. My plan is to do 4.5 cm on tibia and 5.5 on femur. Do you think I can get back to my active sport life if I limit myself to this amount of lengthening?
I think your goals are realistic. Most surgeons would add a bit more to the femur than the tibia. Healing times are a little bit quicker on the femur, but not really to large extent. If you do not exceed 10cm, your chances of returning to sport are higher.
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Yes please Dr Birkholtz tell us do Femurs heal two times faster than Tibias ?
And about this probability of loosing limbs, is it less than 1% or more ?
Thanks in advance.
Unfortunately healing times are only slightly quicker on femurs.
Amputation rates post CLL not known. If you have a good surgeon this should be zero or very close to zero.
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Dr. Franz, I have a couple and I hope you can answer them.
To start I have to tell that I'm not short, I'm 178~179cm, so if I ever did this surgery would be to reach my dream height of 185cm and to be a little happier with my body, it would not be life changing.
Also, I would prefer to length with the PRECICE 2(less scars, pain).
Okay, now the questions:
I was thinking of lengthening 3cm in the femurs and the 3cm in the tibias, that means 6cm max. Do you think I should length more in the femurs and less in the tibias or would it be irrelevant, in terms of recovery, since we are talking about small amounts of lengthening?
Do you think that I could regain, let's say, at least 90% of my previous athletic ability if I lengthened a max of 6cm?
Last question, imagine that I length my femurs first. Is it possible to do the surgery on the tibias as soon as I stop lengthening the femurs, maybe 2 weeks after? Or is it very risky?
Best regards,
The Plague
Thanks for your questions. Lets get to them first. Small distances are safer, but end up being very expensive per cm! If youre really only looking for 3 each segment, one could shorten the times between top and bottom, but not before consolidation and full knee movement.
You may not like what I will tell you next, but as a doctor I have to.
Please think carefully about CLL. I do not think you are a candidate. The reason I say this is in your first paragraph where you state CLL will not be life changing. If it is not life changing, the potential risks are too high. In addition you are already at more than the target height most CLL patients dream of. Make up those 2-3 inches in personality and you will be much happier than with a CLL which may compromise your function for life...
My apologies if my response makes you angry! ;)
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When did you first develop an interest in orthopedics? What aspect of being an orthopedic surgeon do you like most?
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When did you first develop an interest in orthopedics? What aspect of being an orthopedic surgeon do you like most?
[/quote
As soon as I came across it in med school.
Repairing broken people.
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I think your goals are realistic. Most surgeons would add a bit more to the femur than the tibia. Healing times are a little bit quicker on the femur, but not really to large extent. If you do not exceed 10cm, your chances of returning to sport are higher.
Thank you for your answer dear sir. You sound like a good surgeon with a good heart, not like others who try to satisfy patients and let them lengthen insane amounts on their legs. Even though I have set my mind that no matter what would the doctor say I will go for max 5 cm per limb. And you just assured me that I have made a good decision.
To LL Forum: I think Dr Franz is a very interesting new option guys. Too bad that I don't have enough money to go with him next year. I have planned everything, I can only gather 20k for my surgery in India. I would be very interesting to see a new diary in S.Africa. I will probably go there for my femur surgery in 2,3 years though.
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When I sent an inquiry to another orthopedic surgeon about the use of PRECICE I was sent a word file talking about the advancements in cosmetic lengthening. Within it there was a section that addressed fibular complications.
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Fibular complications: With tibial lengthening the fibula has to be lengthened too. The implantable lengthening device only lengthens and fixes the tibia. The fibula has to be fixed to the tibia so that it lengthens together with it. If the fibula is not fixed or not fixed adequately it will not lengthen as much as the tibia and will lead to severe consequences including subluxation and arthritis of the ankle and flexion contracture of the knee. The method of fixation is critical. Many surgeons only fix the lower end of the fibula to the tibia. This can lead the fibula to prematurely consolidate and to pull down and dislocate from the tibia at its upper end. It is important to fix the fibula at both ends. With external fixation the fibula can be fixed with the wires of an external fixator. With implantable lengthening the fibula must be fixed with screws to the tibia; one screw at the upper end and one at the lower end. The angle, level, position, diameter, and type of screw are all important. E.g. a common mistake is to put the screw in horizontally between the two bones. This is not strong enough to prevent the fibula from pulling away from the tibia at the ankle. This is very subtle and even a few millimeters of difference in length of the fibula at the ankle lead to short term and/or long term consequences for the patient.
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I've seen many x-rays from other surgeons where the fibula is cut but it's not fixed to the tibia. There was an ongoing debate on that other site a while ago about how important fibula fixation really is. What is your opinion on the importance of the method of fixation of the fibula?
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Morning Dr Franz
I have a question.. I did quadrilateral Limb Lengthening with monorail fixator, " it is external only , no nail inside"
and right now I'm in the distraction phase, my callus is good according to my dr , but I want to speed up the consolidation time
so do you think if I take stem cell injection right now "in the distraction phase" will give me good result in term of achieving full consolidation in short time
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Dr. Franz, would you give us your opinion of which is better in terms of long-term complication rates: internal femurs or LON on tibias (assuming we lengthen 5-6 cm in each case)?
And what typically is the reason for non-union in LL patients? Could you look at a patient's X-Ray or do some tests to find out if he will have a non-union if he did LL?
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When I sent an inquiry to another orthopedic surgeon about the use of PRECICE I was sent a word file talking about the advancements in cosmetic lengthening. Within it there was a section that addressed fibular complications.
=====
Fibular complications: With tibial lengthening the fibula has to be lengthened too. The implantable lengthening device only lengthens and fixes the tibia. The fibula has to be fixed to the tibia so that it lengthens together with it. If the fibula is not fixed or not fixed adequately it will not lengthen as much as the tibia and will lead to severe consequences including subluxation and arthritis of the ankle and flexion contracture of the knee. The method of fixation is critical. Many surgeons only fix the lower end of the fibula to the tibia. This can lead the fibula to prematurely consolidate and to pull down and dislocate from the tibia at its upper end. It is important to fix the fibula at both ends. With external fixation the fibula can be fixed with the wires of an external fixator. With implantable lengthening the fibula must be fixed with screws to the tibia; one screw at the upper end and one at the lower end. The angle, level, position, diameter, and type of screw are all important. E.g. a common mistake is to put the screw in horizontally between the two bones. This is not strong enough to prevent the fibula from pulling away from the tibia at the ankle. This is very subtle and even a few millimeters of difference in length of the fibula at the ankle lead to short term and/or long term consequences for the patient.
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I've seen many x-rays from other surgeons where the fibula is cut but it's not fixed to the tibia. There was an ongoing debate on that other site a while ago about how important fibula fixation really is. What is your opinion on the importance of the method of fixation of the fibula?
I am not sure who sent you this info, but it sure sounds like dr Paley! :-). I agree that the fibula should be managed appropriately during lower limb lenghening. Not everyone fixes both proximally and distally, and they get away with it, but again an experienced surgeon will address this appropriately.
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Morning Dr Franz
I have a question.. I did quadrilateral Limb Lengthening with monorail fixator, " it is external only , no nail inside"
and right now I'm in the distraction phase, my callus is good according to my dr , but I want to speed up the consolidation time
so do you think if I take stem cell injection right now "in the distraction phase" will give me good result in term of achieving full consolidation in short time
If your callus (regenerate) is forming well, I would not bother with stem cells. We promote early weight bearing and non smoking to promote healing. (Even on monolaterals!)
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Dr. Franz, would you give us your opinion of which is better in terms of long-term complication rates: internal femurs or LON on tibias (assuming we lengthen 5-6 cm in each case)?
And what typically is the reason for non-union in LL patients? Could you look at a patient's X-Ray or do some tests to find out if he will have a non-union if he did LL?
They are both pretty similar. LON tibias have a higher chance of ballerina foot and knee flexion contracture, but I allow early weight bearing.
Femoral nail lengthening has lower infection risk and lower risk of contractures but cannot start weight bearing early.
I wish we could predict who will get nonunions. We simply dont know. Good general health, not smoking and a surgeon comfortable with growing new bone are your best tools.
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Dr Franz,
I've read several diaries of lower limbs lengthening and in only in a very small minority did the two parts of the broken fibula bone end up aligned after consolidation. I find this very scary.
I looked up the Truelok after I read one of your posts about it and the images on the Orthofix website show that only one wire is passed through the fibula bone at the lower end.
Is it possible to maintain the fibula bones with their original alignment? Or is it pretty much left to luck?
If one does internal tibiae, is this goal of maintaining the original alignment of the fibula bones out of the question?
Thanks in advance.
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If your callus (regenerate) is forming well, I would not bother with stem cells. We promote early weight bearing and non smoking to promote healing. (Even on monolaterals!)
the things is that I'm not allowed to stand.. so that's why I was thinking of the stem cell
thanks for replay Dr I really appreciate it
Also I have other question you mentioned earlier "During these weeks I teach the surgeons limb lengthening and reconstruction techniques. This includes surgeons from the US, UK, Sweden, UAE etc etc."
and since I'll be back home in the summer & in case if I'll have any complication or so on I guess it is better to go with LL Dr who trained under you, so could you provide for me his name and his clinic details
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Thanks for your questions. Lets get to them first. Small distances are safer, but end up being very expensive per cm! If youre really only looking for 3 each segment, one could shorten the times between top and bottom, but not before consolidation and full knee movement.
You may not like what I will tell you next, but as a doctor I have to.
Please think carefully about CLL. I do not think you are a candidate. The reason I say this is in your first paragraph where you state CLL will not be life changing. If it is not life changing, the potential risks are too high. In addition you are already at more than the target height most CLL patients dream of. Make up those 2-3 inches in personality and you will be much happier than with a CLL which may compromise your function for life...
My apologies if my response makes you angry! ;)
No, I'm not mad, I really aprecciate your honest answer.
I just have a final question:
You said you think I'm not a candidate but would you still perform this surgery on me, if I really wanted it?
Best regards,
ThePlague
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Dear Mr. Birkholtz,
Thank you so much for your participation on this forum! I was wondering if you would allow a patient to lengthen his femur one at a time? I understand that the Precise is not weight bearing, so to me it would make sense to do one femur and then the next using the Precise method. For a 5 CM gain I am sure it will take an entire year to complete, but would it perhaps enable a patient to work a desk job?
I was also wondering if you will use any other method of internal leg lengthening for femurs? I am considering pursuing this surgery with you primarily because of your active participation on this board.
Thank you,
Arche
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I've got a question that I have been googling and havent been able to get a solid answer for.
My height is 155cm with an armspan of 158cm. If I were to follow Dr Franz's advice (which is to lengthen 5 (or 6?) cm in each part as a maximum), then I would be 165/167 cm with a 158cm armspan.
Would this be painfully obvious? Obviously not Apo level of obvious, but still very obvious?
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I find the good doctor's willingness to field such a torrent of questions without any compensation in return admirable. To you, I extend absolute graciousness. I see this thread hasn't been tended to in quite some time, so I hope doc Birkholtz is merely taking respite from the frenzied onslaught. If you are ever to return, I would be indebted to you if you would be willing to take a moment of your precious time to grant insight to the following questions I've been yearning to have answered. I'm currently undergoing LON in India, by the way.
There are many occurrences in our guest house that have not been given satisfactory answers by our doctor. Could you provide generalized answers to the following?
1) Many of us have noticed that the rings on our Ilizarov fixators have been installed with the centre of the rings heavily displaced to one particular side. ie. there is a gap of only a few cm. between the frame and the inner side of my knee but there exists a great many cm. gap on the outer part of the knee with the frame. Our doctor assured us that this will have no bearing on the distraction quality of the frame, but in my layman mind I would think, through simple application of force analysis, that this displacement would cause an outer/inner pressure on the bones, causing them to bend one particular way. I would have preferred to have had my leg centred in the frame, as would have everyone else, but is this something you take into consideration when installing a frame? Everyone's legs seem to keep straight, but some people have turned in ankles and others have what appear to resemble x-legs.
2) Ever since my initial surgery I've not been able to enact function on the big toe of the left foot. The doctor continually assures me its function will return. He seems unsure as to what the cause is, though. He says it is sometimes a nerve, and other times a muscle/tendon. Is it something that should ameliorate over time, as he assures?
3) This is perhaps too audacious a request, but I would like to know if I can send a picture of my legs to you after my frames are off to see if you can identify any occurrence of x-leg. Is there a particular angle and stance one can use to readily identify the symptom? The doctor tells everyone they do not have it, but I think some must.
Thank you in advance for whenever you have the time to resolve these enquiries. I would not hesitate in considering precise femoral lengthening in the distant future with you if you were ever to absolve your practice of the height limit contraindication. I reckon to be close to 183cm after this round, but would possibly do another 5-6cm on femur if the circumstances allowed for it.
Best regards,
Ashoka
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In case Dr. Franz doesn't respond:
1. A lot of people in Beijing ended up with their feet turned inward (pigeon toed) toward the end of lengthening. During the 2nd surgery, the doctors rotated the part of the leg below the break so the feet would be pointing straight.
3. The angles of the whole leg are checked while standing, and should look something like this:
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Dear Mr. Birkholtz,
Thank you so much for your participation on this forum! I was wondering if you would allow a patient to lengthen his femur one at a time? I understand that the Precise is not weight bearing, so to me it would make sense to do one femur and then the next using the Precise method. For a 5 CM gain I am sure it will take an entire year to complete, but would it perhaps enable a patient to work a desk job?
I was also wondering if you will use any other method of internal leg lengthening for femurs? I am considering pursuing this surgery with you primarily because of your active participation on this board.
Thank you,
Arche
Hi thanks for the kind words. It is certainly possible to do one at a time and would give better mobility during treatment.
It is more costly though, because hospitalisation cost is effectively double. Also, should you for some reason not complete the second phase, you are left with 5cm discrepancy. Not too cool.
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Hi Dr. Birkholtz,
Will you take me on as a patient? I'm interested in completing 8cm with internal femur by the end of 2014.
Kind regards,
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I've got a question that I have been googling and havent been able to get a solid answer for.
My height is 155cm with an armspan of 158cm. If I were to follow Dr Franz's advice (which is to lengthen 5 (or 6?) cm in each part as a maximum), then I would be 165/167 cm with a 158cm armspan.
Would this be painfully obvious? Obviously not Apo level of obvious, but still very obvious?
I think ultimately only you can answer this question. I would not go beyond 165 though
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Hi Franz,
There has been a lot of talk about whether or not external fixation on femurs is really a feasible option. Most people on the forums say not to even consider external fixation on femurs due to the likelihood of a bad outcome, but recently there has been some discussion about whether the bad outcomes mentioned were because of the method or because of going to a surgeon who wasn't really qualified to be offering the surgery. If one were to go to a competent surgeon, do you think one could expect a positive outcome to happen with external femoral fixation (gaining back full range of motion, etc)? Or should external fixation on femurs be avoided in favor of internal methods for all cosmetic cases?
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I find the good doctor's willingness to field such a torrent of questions without any compensation in return admirable. To you, I extend absolute graciousness. I see this thread hasn't been tended to in quite some time, so I hope doc Birkholtz is merely taking respite from the frenzied onslaught. If you are ever to return, I would be indebted to you if you would be willing to take a moment of your precious time to grant insight to the following questions I've been yearning to have answered. I'm currently undergoing LON in India, by the way.
There are many occurrences in our guest house that have not been given satisfactory answers by our doctor. Could you provide generalized answers to the following?
1) Many of us have noticed that the rings on our Ilizarov fixators have been installed with the centre of the rings heavily displaced to one particular side. ie. there is a gap of only a few cm. between the frame and the inner side of my knee but there exists a great many cm. gap on the outer part of the knee with the frame. Our doctor assured us that this will have no bearing on the distraction quality of the frame, but in my layman mind I would think, through simple application of force analysis, that this displacement would cause an outer/inner pressure on the bones, causing them to bend one particular way. I would have preferred to have had my leg centred in the frame, as would have everyone else, but is this something you take into consideration when installing a frame? Everyone's legs seem to keep straight, but some people have turned in ankles and others have what appear to resemble x-legs.
2) Ever since my initial surgery I've not been able to enact function on the big toe of the left foot. The doctor continually assures me its function will return. He seems unsure as to what the cause is, though. He says it is sometimes a nerve, and other times a muscle/tendon. Is it something that should ameliorate over time, as he assures?
3) This is perhaps too audacious a request, but I would like to know if I can send a picture of my legs to you after my frames are off to see if you can identify any occurrence of x-leg. Is there a particular angle and stance one can use to readily identify the symptom? The doctor tells everyone they do not have it, but I think some must.
Thank you in advance for whenever you have the time to resolve these enquiries. I would not hesitate in considering precise femoral lengthening in the distant future with you if you were ever to absolve your practice of the height limit contraindication. I reckon to be close to 183cm after this round, but would possibly do another 5-6cm on femur if the circumstances allowed for it.
Best regards,
Ashoka
Dear Ashoka,
Thanks for the kind words... No, I haven't been scared away, but have tremendous demands on my time, as have all of you. Also, we have our summer holidays in dec/jan, so I was also away. as always, I will try and respond as quickly and accurately as possible.
Point 1: whereas eccentric mounting of a ring might not neccessarily equate to a malaligned limb, it is certainly better biomechanically to center the limb in the frame.
Point 2: although loss of extension of the big toe may be due to a muscle injury, it is usually because of an injury to the nerve that supplies the extensor hallucis muscle. This phenomenon usually occurs at the time of osteotomy and is often (unfortunately) permanent.
Point 3: You are welcome to send your xrays for a no strings attached opinion. The xray you need is full weight bearing standing, with the patellae facing forward. Them we can meaure your normal alignment. Normally we accept malalignments of 5-10 degrees in orthopaedics in general. In cosmetic work these tolerances should probably be lower.
With regards to the height limitation: this is something I have full control over. I am more reluctant to lengthen people with an increased starting height, but every case is unique.
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Hi Dr. Birkholtz,
Will you take me on as a patient? I'm interested in completing 8cm with internal femur by the end of 2014.
Kind regards,
Dear Smallguy,
8cm in a single go is unrealistic and the most you will get from me on femurs (provided everything goes well) is 6cm.
Getting it before the end of the year is possible (6), but full consolidation of the bone may not be complete by then.
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Hi Franz,
There has been a lot of talk about whether or not external fixation on femurs is really a feasible option. Most people on the forums say not to even consider external fixation on femurs due to the likelihood of a bad outcome, but recently there has been some discussion about whether the bad outcomes mentioned were because of the method or because of going to a surgeon who wasn't really qualified to be offering the surgery. If one were to go to a competent surgeon, do you think one could expect a positive outcome to happen with external femoral fixation (gaining back full range of motion, etc)? Or should external fixation on femurs be avoided in favor of internal methods for all cosmetic cases?
The two major issues with femoral exfix based lengthening are knee contractures and time in frame.
For every cm of length gained, an adult can expect to be wearing an exfix for 1.5 - 2 months. I.e. 6cm means 9-12 months in bilateral frames.
Almost all patients with femoral exfixes have some limitation of motion after frame removal. This may be acceptable in Trauma, but probably not in 'normal' people who need CLL.
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Wooo, the king is back! :D
Dr. Birkholtz, what is your opinion on releasing the ITB when lengthening femurs? Some doctors support it, but other doctors are strictly against it and mention that it can result in permanent athletic ability loss.
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Wooo, the king is back! :D
Dr. Birkholtz, what is your opinion on releasing the ITB when lengthening femurs? Some doctors support it, but other doctors are strictly against it and mention that it can result in permanent athletic ability loss.
I have no clear crystallized opinion on this. I would suggest that it is up to the patient to decide. One could argue both ways!
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By the way,
It looks like cost is a determining factor here. I will post updated detailed quotes in the next couple of days.
Hope it helps!
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Please post any quotes you can Dr. B, it's much appreciated. Something I'm very interested in is as well is the day-to-day living costs and transportation.
Cost should never be a factor when considering this type of surgery, but unfortunately a lot of us want to get this surgery sooner than later, and we don't have the finances for some doctors that can cost upwards of $100,000 USD. Your prices are incredible for the services offered, which is why my decision for LL is split between you and Dr. Jamal right now.
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What is inside my bones now, where the internal nails used to be?
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Dear Smallguy,
8cm in a single go is unrealistic and the most you will get from me on femurs (provided everything goes well) is 6cm.
Getting it before the end of the year is possible (6), but full consolidation of the bone may not be complete by then.
Hi Dr. Birkholtz,
Thanks for your reply. I already lengthen 8cm in the tibias and I'm looking to have the plates and rod remove in Canada in May. So what do you think would be the best time for me to start internal femur lengthening? And what method would you use? Can you purchase the precise 2?
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Hi Dr. Birkholtz,
Can the knee problem be solved in full by using this approach? Can you please clarified what this means?
Femoral lengthening with a rail external fixator:
“ Subtrochanteric femoral lengthening has the advantage of minimal interference with Knee ROM.”
“The cortical thickness of the femur rapidly increases distal to the lesser trochanter. This can sometimes make the osteotomy more difficult and predispose to a greater likelihood of crack propagation to the nearest pin. Due care and attention are needed, creating a ‘clean’ osteotomy…”
Thank you
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Hello Dr. Birkholtz,
I would just like to thankyou for the answers and clarifications you gave in this thread.
Although I have been following this forums for a long time, I learn a lot of thinghs that i didn't knew form your answers, and clarified others. And I enjoyed your direct, complete and kind writing style.
Many thanks,
Uber
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Please post any quotes you can Dr. B, it's much appreciated. Something I'm very interested in is as well is the day-to-day living costs and transportation.
Cost should never be a factor when considering this type of surgery, but unfortunately a lot of us want to get this surgery sooner than later, and we don't have the finances for some doctors that can cost upwards of $100,000 USD. Your prices are incredible for the services offered, which is why my decision for LL is split between you and Dr. Jamal right now.
I second this! If Dr.B offers a better deal, I am definitely flying to SA this summer!!!
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What is inside my bones now, where the internal nails used to be?
Good question. Adults don't really have true bone marrow in their long bones. It is mostly fatty tissue. It seems that when nails are removed, this is what is left in the bone.
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Hello Dr. Birkholtz,
I would just like to thankyou for the answers and clarifications you gave in this thread.
Although I have been following this forums for a long time, I learn a lot of thinghs that i didn't knew form your answers, and clarified others. And I enjoyed your direct, complete and kind writing style.
Many thanks,
Uber
Thanks for the kind words. As with most things in life, education is critical before making important decisions.
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Hi Dr. Birkholtz,
Can the knee problem be solved in full by using this approach? Can you please clarified what this means?
Femoral lengthening with a rail external fixator:
“ Subtrochanteric femoral lengthening has the advantage of minimal interference with Knee ROM.”
The short answer is no. Because the osteotomy is further from the knee when doing it at the top of the femur (subtroch region), the risk of knee contracture is decreased but not eliminated. This area does not create good regenerates and as such, frame times can be longer.
“The cortical thickness of the femur rapidly increases distal to the lesser trochanter. This can sometimes make the osteotomy more difficult and predispose to a greater likelihood of crack propagation to the nearest pin. Due care and attention are needed, creating a ‘clean’ osteotomy…”
Thank you
What this means is that breaking the bone improperly in this region has a tendency to shatter the bone. This can break into the pins and cause the fixator to become unstable.
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Hi Dr. Birkholtz,
Thanks for your reply. I already lengthen 8cm in the tibias and I'm looking to have the plates and rod remove in Canada in May. So what do you think would be the best time for me to start internal femur lengthening? And what method would you use? Can you purchase the precise 2?
The question is how well you have recovered from the tibial lengthenings. If you still have ballerina foot (equinus contracture) or knee flexion contracture (inability to fully straighten the knees), i would not proceed with the second phase.
My choice for femoral lengthening would be intramedullary lengthening.
We have Precice 2 available now.
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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!!
For q4. I would like to add: "whats the price of titanium if I chose to have it right after lengthening?"
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Hey doc,
Thank you for the prompt responses. I can move my toe in circles and can feel it and everything, it just won't flex upwards. Would this minimal movement indicate that the nerve is still intact, or are the nerves for these movements separate? I really want to get my toe's function back, but I heavily appreciate your honesty. My doctor is never that forthcoming. He keeps saying it'll come back, but in the back of my mind I knew that it is something that seems like it might end up being permanent. If it never returns to normal function, should I be able to walk and function normally?
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Forgot to let you know, for when you answer, doc, that my username is now Polycrates (from Ashoka). To expound some more on what's happening, I told my physio about the nerve damage today and he tried telling me that if it were a nerve issue the whole foot would be dropped. He says proudly how he's studied over 6 years in physiology so I'd hope he know, but even from the little I've read, I know there exists several branching nerves supplied by the main tibial nerves. It would be one of these that would have been severed, correct?
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Video of paralysed toe:
http://www.youtube.com/watch?v=QwHMwpRYIUg
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HI Dr. Birkholtz,
You are very smart and kind thank you!
5cm – femoral lengthening using monorail method what is the rate of time in most cases to regain full ROM after the device is removed?
(I’ve heard that it takes 5 months)
I look forward to hearing from you
Drew
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Dr. Franz,
Upfront question...how many precise rod have you implemented? Any way we can see the x-rays. It may be helpful for posterity.
Also, do you allow about 7.5 cm on femur if rehab is good.
Thanks
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Forgot to let you know, for when you answer, doc, that my username is now Polycrates (from Ashoka). To expound some more on what's happening, I told my physio about the nerve damage today and he tried telling me that if it were a nerve issue the whole foot would be dropped. He says proudly how he's studied over 6 years in physiology so I'd hope he know, but even from the little I've read, I know there exists several branching nerves supplied by the main tibial nerves. It would be one of these that would have been severed, correct?
Look, there is a possibility that it may return. If it is a nerve, it is the branch that supplies the muscle to the big toe and would certainly not give sensation loss in the whole foot.
Hope it returns!
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HI Dr. Birkholtz,
You are very smart and kind thank you!
5cm – femoral lengthening using monorail method what is the rate of time in most cases to regain full ROM after the device is removed?
(I’ve heard that it takes 5 months)
I look forward to hearing from you
Drew
Jip, 5-6 months. This is the main advantage of precice. The rom returns sooner.
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Dr. Franz,
Upfront question...how many precise rod have you implemented? Any way we can see the x-rays. It may be helpful for posterity.
Also, do you allow about 7.5 cm on femur if rehab is good.
Thanks
We've only had it available for a relatively short time. We've done five precice cases for indications other than cll.
Unfortunately I cannot make the xrays abailable (patient confidentiality).
7.5 is pushing it, but it may be possible in extreme cases where rehab is exceptional. I think a realistic goal for femur is 5-6 cm.
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Dear Dr. Birkholtz,
Thank you for all your contributions in this forum, we really appreciate your valuable input.
I'm a current LL patient still in the lengthening phase, currently lengthened around 4,60 cm in femurs. A couple weeks ago, my doctor suggested that I had fast bone consolidation, and told me to speed up the lengthening to 1,4 mm daily. After a while, I had a numbing sensation, particularly on my right tibia, starting from the knee (and the back part of the knee). I felt my hamstring stretching and it began to hurt, so on the follow-up consultation we lowered the lengthening speed to 1 mm again. However, during my last weekly follow-up, my doctor analyzed the X-ray and told me that we needed to speed up again for a while, left leg was fine but the right leg had a risk of early consolidation, so I'm currently lengthening both legs at 1,4 mm again. And once again, I have a numbing feeling on my leg (below the knee) - it feels as if someone is sticking needles to my leg, or an electric shock. My physiotherapist told me that it could be related to the femoral nerve trying to adjust to the lengthening pace of the leg. My feet and knees are still perfectly aligned and I have excellent range of motion, but the pain really bothers. I wonder if cold therapy or hot therapy could help, maybe placing an ice pad on my leg? Dr. Birkholtz, have you had a similar case in any of your patients? I'm not worried, just medical curiosity really :) Thanks in advance.
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We've only had it available for a relatively short time. We've done five precice cases for indications other than cll.
Unfortunately I cannot make the xrays abailable (patient confidentiality).
7.5 is pushing it, but it may be possible in extreme cases where rehab is exceptional. I think a realistic goal for femur is 5-6 cm.
I am considering CLL with you as an option along with Guichet and Dr.Donghoon.
I know you wrote that you would post a cost estimate, and I know that someone posted a quote from an email of 52k USD.
But it would be nice to hear it confirmed from you.
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Hi guys,
We've spent the last week number crunching and obtaining quotes from the relevant service providers.
Our cost for bilateral precice lengthening is 52K USD. This includes the following:
All professional fees for surgeon, anaesthetist, physio, psychologist, occupational therapist.
High care unit for 1 day.
Normal hospital ward for 5 days.
All followup visits, erc sessions and woundcare visits.
Daily physio for 75 days.
Doctor contact at least twice a week.
Support by a multi disciplinary team experienced in limb reconstruction.
Accommodation in a four star rated guesthouse close to hospital on a dinner bed and breakfast basis. Includes wifi and satellite tv. Also includes daily transfer to clinic for adjustments. The accommodation is for two people. This is a self catering unit.
As you can see, everything is included, except for potential complications.
Our lists are generally booked a couple of weeks in advance, but provided I am not on congress or holiday, we can accommodate most of the year.
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Dear Dr. Birkholtz,
Thank you for all your contributions in this forum, we really appreciate your valuable input.
I'm a current LL patient still in the lengthening phase, currently lengthened around 4,60 cm in femurs. A couple weeks ago, my doctor suggested that I had fast bone consolidation, and told me to speed up the lengthening to 1,4 mm daily. After a while, I had a numbing sensation, particularly on my right tibia, starting from the knee (and the back part of the knee). I felt my hamstring stretching and it began to hurt, so on the follow-up consultation we lowered the lengthening speed to 1 mm again. However, during my last weekly follow-up, my doctor analyzed the X-ray and told me that we needed to speed up again for a while, left leg was fine but the right leg had a risk of early consolidation, so I'm currently lengthening both legs at 1,4 mm again. And once again, I have a numbing feeling on my leg (below the knee) - it feels as if someone is sticking needles to my leg, or an electric shock. My physiotherapist told me that it could be related to the femoral nerve trying to adjust to the lengthening pace of the leg. My feet and knees are still perfectly aligned and I have excellent range of motion, but the pain really bothers. I wonder if cold therapy or hot therapy could help, maybe placing an ice pad on my leg? Dr. Birkholtz, have you had a similar case in any of your patients? I'm not worried, just medical curiosity really :) Thanks in advance.
It does sound like a nerve that is stretching a bit fast. It is a bit of a catch 22 in that premature consolidation would mean another osteotomy.
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Dr. B, is accommodation for 75 days as well? Also how much does LON/LATN cost??
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Dr. B, is accommodation for 75 days as well? Also how much does LON/LATN cost??
Accommodation in a four star rated guesthouse close to hospital on a dinner bed and breakfast basis. Includes wifi and satellite tv. Also includes daily transfer to clinic for adjustments. The accommodation is for two people. This is a self catering unit.
As you can see, everything is included, except for potential complications.
Should tibial LONs be performed, the price will drop to approximately 25K euro.
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Okay first off precise was quoted at 40K Euro, and so isn't it okay to inquire how much the Tibial LON price has changed?
Also where in your bolded sentences does it say how long the accommodation is? I'm not asking this just for myself, I'm asking this for the entire community. Don't PM me and say I'm polluting this thread when I am just trying to achieve as much transparency as possible.
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Okay first off precise was quoted at 40K Euro, and so isn't it okay to inquire how much the Tibial LON price has changed?
Also where in your bolded sentences does it say how long the accommodation is? I'm not asking this just for myself, I'm asking this for the entire community. Don't PM me and say I'm polluting this thread when I am just trying to achieve as much transparency as possible.
Hey Arche,
It is 75 days accommodation.
LON is still around 25K euro or 34K USD, depending on exchange rates.
Precice is 52K USD, which is 2K cheaper than the quoted euro amount.
Anyway, thanks for the interest.
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Hey Arche,
It is 75 days accommodation.
LON is still around 25K euro or 34K USD, depending on exchange rates.
Precice is 52K USD, which is 2K cheaper than the quoted euro amount.
Anyway, thanks for the interest.
Dear Dr. Birkholtz,
Thank you so much for your reply back. I apologize if I have bothered you in any way. I truly appreciate what you have done for this community.
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Dear Dr. Birkholtz,
Thank you so much for your reply back. I apologize if I have bothered you in any way. I truly appreciate what you have done for this community.
No problemo. Thanks for the kind words.
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Dr. Birkholtz,
Would you ever consider doing quadrilateral lengthening with PRECICE 2? What would be your upper lengthening limit with this process? How much would this cost?
What are the risks associated with quadrilateral lengthening? How long would someone be expected to be in a wheelchair for lengthening 12 cm in total?
Thank you so much for taking time out of your busy schedule for us!!
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Hi Dr Franz,
Since South Africa is quite far, if, say, we decide to do LL with you, and everything's been confirmed/paid/etc, can we just head on to Pretoria and do the LL in one go once everything's approved, or you need a personal consultation first, then return back to South Africa for the LL itself?
Do you do your own psychological assessment (just like other doctors do, like Dr Paley) or do you need a separate Psychiatrist?
Thanks.
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Dr. Birkholtz,
Would you ever consider doing quadrilateral lengthening with PRECICE 2? What would be your upper lengthening limit with this process? How much would this cost?
What are the risks associated with quadrilateral lengthening? How long would someone be expected to be in a wheelchair for lengthening 12 cm in total?
Thank you so much for taking time out of your busy schedule for us!!
Hi, it is possible, but risks of knee contracture is quite high. Maximum length around 10cm, but depends on whether range of motion can be maintained. Cost is slightly lower than for two separate events, but as the major cost drivers are theatre time and cost of the nails, it is not tremendously cheaper. The only advantage is that it is a single process.
Femur or tibia 52K. Both at the same time is around 94K.
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We've only had it available for a relatively short time. We've done five precice cases for indications other than cll.
Hey Dr. Birkholtz,
Your input to this forum has helped me tremendously and has elucidated many aspects of CLL that many doctors and other LL forums fail to clarify.
Just like to ask you about the five precice cases you have performed so far. Did you experience any Precice nail failure or complication that required the nail to be changed?
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Hi, it is possible, but risks of knee contracture is quite high. Maximum length around 10cm, but depends on whether range of motion can be maintained. Cost is slightly lower than for two separate events, but as the major cost drivers are theatre time and cost of the nails, it is not tremendously cheaper. The only advantage is that it is a single process.
Femur or tibia 52K. Both at the same time is around 94K.
Dear Dr. B.,
Your recent commitment to this forum has been nothing short of outstanding. There are so many questions regarding this surgery, and so much misinformation as well. I apologize if I have been annoying you in any manner.
How much would it cost to do Quad lengthening with Tibial LON and PRECISE Femurs? Would it be advisable for 10 cm?
Thank you,
Arche
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Hi Dr Franz,
Since South Africa is quite far, if, say, we decide to do LL with you, and everything's been confirmed/paid/etc, can we just head on to Pretoria and do the LL in one go once everything's approved, or you need a personal consultation first, then return back to South Africa for the LL itself?
Do you do your own psychological assessment (just like other doctors do, like Dr Paley) or do you need a separate Psychiatrist?
Thanks.
Hi,
It is unrealistic to expect you as a patient to travel twice. My suggestion would be to follow these steps:
- make up your mind about CLL and calculate whether you have the finances (remember plane tickets and contingencies)
- contact me via email with a detailed history, including medical history. Remember your height, weight and reasons for CLL (also where you come from). No smokers! (franz.birkholtz@walkamile.co.za)
- once I clear you provisionally as a suitable candidate, I will send you an xray protocol to have an xray done at home, which you can forward via email
- I will measure the Xray and we will discuss options and realistic goals.
- If you are looking for more than 5cm per segment (10 in total), please look elsewhere.
- Once we are happy to proceed, we can schedule you for a consultation and surgery.
- The consultation will be the final 'hurdle'. During this phase, we will involve my psychologist, but by this time we will know enough about you! This consultation costs $100. I will not ask for an additional deposit before this step, as long as you understand that I have the right to cancel your operation after this consultation if I do not think it is appropriate to continue for medical reasons. The previous steps should prevent this.
- Once you pass this test (which hopefully you will), we can confirm your place on the list upon receipt of payment. This can be done via eft or credit card.
- The surgery can essentially proceed within a couple of days after the consultation.
- I have a lead time to order Precice and as such, we will need to measure your xrays at least 4 weeks before the surgery date, to ensure we order the correct size nail.
- Upon scheduling the consultation, we will provisionally book your accommodation. A cancellation fee may be necessary if we do not proceed for whatever reason.
- I would prefer for you to stay in Preotria until distraction is complete, and until we can be sure your rehabilitation is well-established.
Hope this gives you clarity.
BTW, the accommodation rate is quoted for a double room, so if you want to bring a friend, spouse or family member, this is included in the price.
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Hey Dr. Birkholtz,
Your input to this forum has helped me tremendously and has elucidated many aspects of CLL that many doctors and other LL forums fail to clarify.
Just like to ask you about the five precice cases you have performed so far. Did you experience any Precice nail failure or complication that required the nail to be changed?
Love your profile name!
No, up to now, touch wood, we have not had to revise any of the nails. They were, however, all unilateral, post-traumatic cases.
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Dear Dr. B.,
Your recent commitment to this forum has been nothing short of outstanding. There are so many questions regarding this surgery, and so much misinformation as well. I apologize if I have been annoying you in any manner.
How much would it cost to do Quad lengthening with Tibial LON and PRECISE Femurs? Would it be advisable for 10 cm?
Thank you,
Arche
No worries.
Again, you will essentially save on the cost of the Precice, which will, partly, be replaced with the cost of the fixators, nails and locking procedures. Probably in the region of 80K USD.
I think 10 cm is possible, but it is certainly not guaranteed. It is easier to guarantee a good result with a single level somewhere between 5 and 6 cm, followed by a second phase 1 year later...
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Thanks Dr Franz for the detailed steps of getting surgery under you.
A question re: Precice: I'm reading Precice 2 Femur diary at the old forum and at least a couple of them are documenting that the measured lengthening is not equal bilaterally (they're still in lengthening phase). One side is off by few mm and so they compensate by adjusting Precice (more catching up with lengthening on the slower side obviously).
I thought Precice is accurate or is this to be expected and it just needs adjustment till lengthening has finished/consolidated?
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Thanks Dr Franz for the detailed steps of getting surgery under you.
A question re: Precice: I'm reading Precice 2 Femur diary at the old forum and at least a couple of them are documenting that the measured lengthening is not equal bilaterally (they're still in lengthening phase). One side is off by few mm and so they compensate by adjusting Precice (more catching up with lengthening on the slower side obviously).
I thought Precice is accurate or is this to be expected and it just needs adjustment till lengthening has finished/consolidated?
This is a good question. The beauty of precice is that the surgeon can control the eventual distraction accurately, by speeding up, slowing down, or even backing up the nail. The final result is what counts.
You will appreciate that different forces act upon different parts of the body, and as such, it is possible that the left and right legs may see different forces. This may result in minor differences during lengthening.
This is why it is important that your surgeon oversees the whole distraction process.
Rgds,
F
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Thank you, sir!
This is a good question. The beauty of precice is...
Rgds,
F
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Dear Doctor,
I will be most likely to come alone. Do I need to hire a care taker or the package cost includes the helper?
Some of the precise patients have reported precise not distracting at the rate it supposed to and therefore they have premature consolidation. If similar occurrence happens how much it would ost for second osteonomy?
Thank you sir!
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Dear Dr. Birkholtz,
Also, one of the precise patient had to cut his journey short because risk of severe nerve damage. He only lengthen ~3.5cm on femur. It took years of effort to saved up the money and now regrets profoundly having this done.
Could this be prevented early on or the course can be changed with surgery? I am very nervous and loosing my sleep over this.
Hoping to hear from you soon.
Thank you,
Cooper
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Hey Dr.Birkholtz,
Just wondering if Precice 2 has any mechanical/functional advantage over Precice other than giving longer length?
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Dear Doctor,
I will be most likely to come alone. Do I need to hire a care taker or the package cost includes the helper?
Some of the precise patients have reported precise not distracting at the rate it supposed to and therefore they have premature consolidation. If similar occurrence happens how much it would ost for second osteonomy?
Thank you sir!
The price does not include a caretaker, but presumably you should be able to cope reasonably well without one. Of course it is possible to arrange someone.
Unlikely that premature consolidation will occur if process is managed correctly.
Cost for re-osteotomy in the region of 4K.
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Dear Dr. Birkholtz,
Also, one of the precise patient had to cut his journey short because risk of severe nerve damage. He only lengthen ~3.5cm on femur. It took years of effort to saved up the money and now regrets profoundly having this done.
Could this be prevented early on or the course can be changed with surgery? I am very nervous and loosing my sleep over this.
Hoping to hear from you soon.
Thank you,
Cooper
There is a lot of individual variability and unpredictability. I have performed literally hundreds of lengthenings (for nonCLL reasons) and have not seen this complication. It is rare. Dont lose sleep over it, but remember that expectations and reality sometimes dont match up. Murphy is alive and well!
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dr franz,
one of dr. lee's patients in korea is undergoing LL with precice 2 on his femurs. He is saying that his rod is malfunctioning because this muscle mass is too much for the rod to lengthen, do you have any more info about precice 2 malfuctions?
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Hi Dr Franz,
What oral anticoagulant will you be using?
How long to take it?
Roughly how much would be the cost?
Thanks.
Hi guys,
We've spent the last week number crunching and obtaining quotes from the relevant service providers.
Our cost for bilateral precice lengthening is 52K USD. This includes the following:
All professional fees for surgeon, anaesthetist, physio, psychologist, occupational therapist.
High care unit for 1 day.
Normal hospital ward for 5 days.
All followup visits, erc sessions and woundcare visits.
Daily physio for 75 days.
Doctor contact at least twice a week.
Support by a multi disciplinary team experienced in limb reconstruction.
Accommodation in a four star rated guesthouse close to hospital on a dinner bed and breakfast basis. Includes wifi and satellite tv. Also includes daily transfer to clinic for adjustments. The accommodation is for two people. This is a self catering unit.
As you can see, everything is included, except for potential complications.
Our lists are generally booked a couple of weeks in advance, but provided I am not on congress or holiday, we can accommodate most of the year.
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We use subcutaneous low molecular weight heparin for 2 weeks after discharge. Incl in cost
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Hello doctor Franz,
I would like lengthening 5cm my tibias, i think that for my small goal is better only external device, to avoid problems with my kness.
if i would make this surgery with you? Which method would you use with me?.
I am 36 years old, my heigh is 1,63 with 63kg. I'm not a child, and i like you are very conservative, i don't knew anything about you
until know this fórum. My option is doctor salameh but i am reading about one patient here and i have a lot doubt about him
Thank you very much to cooperate in this fórum.
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Hello doctor Franz,
I would like lengthening 5cm my tibias, i think that for my small goal is better only external device, to avoid problems with my kness.
if i would make this surgery with you? Which method would you use with me?.
I am 36 years old, my heigh is 1,63 with 63kg. I'm not a child, and i like you are very conservative, i don't knew anything about you
until know this fórum. My option is doctor salameh but i am reading about one patient here and i have a lot doubt about him
Thank you very much to cooperate in this fórum.
I tend to use TSF or Truelok rings in an Ilizarov type construct.
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I am uncertain but read that Bilteral Damage is 5'6 or higher without LL.
What would need to happen for you to accept a 5'7 patient for cosmetic LL?
Excluding surgery to fix a botched attempt by another doctor?
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And do you see yourself ever doing cosmetic precise 2 tibias for 5cm?
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@kneehowguys:
Thanks for your comments.
Firstly, I stand by our rough selection criteria of 165cm in males as the upper limit. There are cases where, after thorough evaluation, it may be appropriate to perform CLL. This should not be seen as the norm and is definitely not a topic for open discussion. Patient confidentiality also prevents me from commenting on another patient's treatment or surgery indications. Hope you understand. I would suggest that you follow the outline elsewhere in this thread on how to go about CLL in our unit.
With regards to precice 2 for tibias. It certainly is feasible, but again this will be up to an individual patient's preference and decision.
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hello doctor franz,
In my case i would like lengthening my tibias 5 cm but i would like only external to avoid problems with my kness. i am 36 years old,
how much time do i need with external fixator?, I like doctor salameh device, and doctor mitkovic. they offer smaller external devices,
but i like your ethics and conservative doctor. how much do you charge for one appoinment?
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Hello again Dr. B my question is why did you become interested in cosmetic
limb lengthening? It seems that many doctors shy away from it due to ethics
and that it's deemed unnecessary and too risky.
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hello doctor franz,
In my case i would like lengthening my tibias 5 cm but i would like only external to avoid problems with my kness. i am 36 years old,
how much time do i need with external fixator?, I like doctor salameh device, and doctor mitkovic. they offer smaller external devices,
but i like your ethics and conservative doctor. how much do you charge for one appoinment?
5cm in an adult means between 7 and 10 months in an exfix.
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Hello again Dr. B my question is why did you become interested in cosmetic
limb lengthening? It seems that many doctors shy away from it due to ethics
and that it's deemed unnecessary and too risky.
This is a very good question. Firstly, lengthening and limb reconstruction is a long-time interest. I just love the magic that happens when you create new tissue from nothing - like magic.
The ethical question is more complex. I guess I have a sort of reverse ethical opinion about this. My take is not whether it is ethical to perform the surgery, but whether it is ethical not to. You see, I know I can lengthen patients safely with relatively low complication risks and I do that almost daily. I also know that there are individuals who will get CLL no matter what the risk. They often end up with the wrong doctors and end up losing function etc. If I have the tools, skills and capabilities, am I not unethical by not preventing these disasters?
Anyway, this is controversial, but there's my 5 cents worth...
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very good answer.
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This is a very good question. Firstly, lengthening and limb reconstruction is a long-time interest. I just love the magic that happens when you create new tissue from nothing - like magic.
The ethical question is more complex. I guess I have a sort of reverse ethical opinion about this. My take is not whether it is ethical to perform the surgery, but whether it is ethical not to. You see, I know I can lengthen patients safely with relatively low complication risks and I do that almost daily. I also know that there are individuals who will get CLL no matter what the risk. They often end up with the wrong doctors and end up losing function etc. If I have the tools, skills and capabilities, am I not unethical by not preventing these disasters?
Anyway, this is controversial, but there's my 5 cents worth...
Even I've decided to do CLL, there is always smth that boders me about it especially when u're reading diaries from patients who went through agony. Reading Your posts dr. Birkholtz I become more and more confident in doing CLL. I wish all the doctors are like You! From what I've been reading here on forum I can say You are such a great doctor and I love how You behave and act as a human being.
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Hitting the nail on its head.
My take is not whether it is ethical to perform the surgery, but whether it is ethical not to...
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Hitting the nail on its head.
Hitting the bone with the osteotome! haha
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Exactly! ;)
Hitting the bone with the osteotome! haha
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Hi guys,
We've spent the last week number crunching and obtaining quotes from the relevant service providers.
Our cost for bilateral precice lengthening is 52K USD. This includes the following:
All professional fees for surgeon, anaesthetist, physio, psychologist, occupational therapist.
High care unit for 1 day.
Normal hospital ward for 5 days.
All followup visits, erc sessions and woundcare visits.
Daily physio for 75 days.
Doctor contact at least twice a week.
Support by a multi disciplinary team experienced in limb reconstruction.
Accommodation in a four star rated guesthouse close to hospital on a dinner bed and breakfast basis. Includes wifi and satellite tv. Also includes daily transfer to clinic for adjustments. The accommodation is for two people. This is a self catering unit.
As you can see, everything is included, except for potential complications.
Our lists are generally booked a couple of weeks in advance, but provided I am not on congress or holiday, we can accommodate most of the year.
It would be super nice if you can post some pictures of the guest house. If I decide to go through 2 operations with you, could it be possible for me to have some discounts?
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The guesthouse link is posted on BigD's thread
http://www.natanja.co.za/
Are you thinking of Precice 2 for both femur and tibia? Or Precice 2 femur and tibial LON?
It would be super nice if you can post some pictures of the guest house. If I decide to go through 2 operations with you, could it be possible for me to have some discounts?
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Hey Dr Birkholtz!
For the last several years, I have made a transition to a lacto-vegetarian diet for personal reasons.
My diet includes wide range of grains, seeds, nuts, vegetables/fruits, milk, soya products etc.
I am wondering if this would affect me during CLL and also whether the guest house you mentioned earlier provide vegetarian meals?
Your diet will not be a problem provided you take enough calcium magnesium vit c and d.
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Hey Dr Birkholtz!
For the last several years, I have made a transition to a lacto-vegetarian diet for personal reasons.
My diet includes wide range of grains, seeds, nuts, vegetables/fruits, milk, soya products etc.
I am wondering if this would affect me during CLL and also whether the guest house you mentioned earlier provide vegetarian meals?
With enough lead time, I am sure your requirements could be accommodated. Within reason.
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It would be super nice if you can post some pictures of the guest house. If I decide to go through 2 operations with you, could it be possible for me to have some discounts?
Look at www.natanja.co.za
My prices are mostly dependent on subcontractors. My practice sees around 10% of the cost quoted. I have no financial interest in the xrays, hospital, nails, guesthouse etc, so the price is essentially already cost price. This is why it is cheaper than anywhere else in the world for a similar service. I hope you can understand that discounts under these circumstances are virtually impossible.
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Hey Dr Franz. If I want to arrange for personal consultation by April, do I just arrange it with madelein?
I'm planning on staying in Pretoria for a couple of days tour and at the same time consultation with you and also do my bone x-ray there.
This is of course if my April dates would be okay with your schedule.
Thanks.
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Hey Dr Franz. If I want to arrange for personal consultation by April, do I just arrange it with madelein?
I'm planning on staying in Pretoria for a couple of days tour and at the same time consultation with you and also do my bone x-ray there.
This is of course if my April dates would be okay with your schedule.
Thanks.
Thats perfect. You can mail her at reception@walkamile.co.za. Xrays are done close by so can be done on the day. Alternatively you can phone the office at +27 12 6442641
I have a conference and a short break in april, but there are a number of dates that could work.
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Dear Dr. Franz,
I’m interested in doing internal femur lengthening in Africa.
How many operations did you do for femur lengthening and what is the percentage of compartment syndrome out of every 500
cases, could internal lengthening have a higher risk rather than external?
Thank you
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Please read the rest of the thread with regard to experience and patient numbers.
In more than 1000 distraction osteogenesis cases, I have yet to see a compartment syndrome. The risk is low, but present.
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This is a very good question. Firstly, lengthening and limb reconstruction is a long-time interest. I just love the magic that happens when you create new tissue from nothing - like magic.
The ethical question is more complex. I guess I have a sort of reverse ethical opinion about this. My take is not whether it is ethical to perform the surgery, but whether it is ethical not to. You see, I know I can lengthen patients safely with relatively low complication risks and I do that almost daily. I also know that there are individuals who will get CLL no matter what the risk. They often end up with the wrong doctors and end up losing function etc. If I have the tools, skills and capabilities, am I not unethical by not preventing these disasters?
Anyway, this is controversial, but there's my 5 cents worth...
Dr. Birkholtz's philosophy is sound in my book. There seems, in general, to be an enlightenment occurring in medicine, as doctors seem to be realizing that certain physical quiddities people obsess over can most easily and most readily be ameliorated by treating the condition directly. This is proven by the fact so many people completely distance themselves from their LL story and simply enjoy their new height, as if it were always there.
This not only applies to a height complex, but a whole variety of procedures. People get braces to straighten crooked teeth, breast augmentation for small breasts, laser eye surgery for poor vision, etc. Of course, some of these procedures carry far more medical necessity than an increase in height, but leaving someone to deal with height dysphoria when they are willing to pay their own hard earned money to free themselves of it should be allowed to do so, in my humble opinion. Leaving someone in a lifetime of mental anguish is more cruel than informing them of the complications that can occur during this procedure and allowing them to decide for it of their own volition.
Take this story for instance: I remember when I was young I developed moderate gynecomastia and my family doctor told me that I had to simply accept it and that it would resolve itself eventually. This condition affected me severely through adolescence. I finally saw a doctor at 19 and had it removed. Now its torment is but a distant memory and it was even covered by my country's health insurance, so it was free. In this case, I deemed my doctor to be more of a tormentor than a helper.
Even Dr. Paley himself has revamped his philosophy towards cosmetic LL and checked conventional ethics at the door. He's conceded to the fact that many people obsess to no end over this procedure and will venture to other worlds to have it done if it cannot be performed in their own countries. He's also done what many other doctors still feel trepidation in allowing: he's removed the height contraindication from his checklist. This makes complete sense to me, as someone can be entirely happy at 165cm as a male, while in a country with a taller average, such as the Netherlands or most other developed countries, we can see a young male at 170-175cm despise his height. It is of course all relative and I applaud Dr. Birkholtz for offering his services to those who want them. I hope it will save a great many from venturing to shady doctors as a last resort in the future.
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For those doing LL this year with Dr Franz, I wonder if you'll be able to catch the live trial of Oscar Pistorius in Pretoria.
This would be a welcome distraction during LL—good time to pass by.
Not sure how long trials in S. Africa last.
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a welcome distraction during LL
Nice pun there. :D
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Hello Dr. Franz I would like to ask your opinion about lenghtening speed when doing external only tibias.
I am currently 5 days post op, and in beginning i will lengthen at 1 mm/day for 4 days then slow down to 0.75/day, and depending on how i react to the lengthening, i will stay at 0,75 or slow down to 0,5 if it gets to painful. Im only going to lengthen 4 cm.
However, the most important thing to me is to get off the frames before august, i know that is very difficult but should be possible with some luck.
To increase my chances to be frame free as early as possible do you think lengthening at a faster rate for the whole lengthening phase (at 1 mm/day and only slow down temporarily if it gets to painful) or slower lengthening rate (like 0,75 mm or 0,5 mm/day) is the better option?
Because my doctor says that slower lengthening rate improves the speed of which the bone regenerates as well, meaning that even with a longer lengthening phase, the consolidation phase would be faster when lengthening slower.
I realize that lengthening slow is better for pain management and soft tissue recovery, but as long as soft tissue eventually recovers that is okey with me, if possible i would choose to lengthen faster if it meant that i would be out of frames earlier even if i had more problems walking etc for longer.
Sorry for the overly convoluted question but i would really like your expert opinion on this, i trust my own doctor as well, but im sure he would only tell me to do what is best for my health and advice against doing whatever is the fastest if it means more risk, its also hard to ask him specific questions because his english is limited, and his assistant who translates is not available that often.
Thank you Dr Franz for all the advice you brought this forum.
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I am wondering, since I am doing intense pre-op yoga for my legs and hips, whether strains and sprains could delay or affect CLL surgery and its outcome?
And also the possibility of strain/sprain during physical therapy and stretching while lengthening?
Thanks Dr.B!!
Hey
Moderation is the key. Small strains or sprains will have no negative effect on your cll journey
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Hello Dr. Franz I would like to ask your opinion about lenghtening speed when doing external only tibias.
I am currently 5 days post op, and in beginning i will lengthen at 1 mm/day for 4 days then slow down to 0.75/day, and depending on how i react to the lengthening, i will stay at 0,75 or slow down to 0,5 if it gets to painful. Im only going to lengthen 4 cm.
However, the most important thing to me is to get off the frames before august, i know that is very difficult but should be possible with some luck.
To increase my chances to be frame free as early as possible do you think lengthening at a faster rate for the whole lengthening phase (at 1 mm/day and only slow down temporarily if it gets to painful) or slower lengthening rate (like 0,75 mm or 0,5 mm/day) is the better option?
Because my doctor says that slower lengthening rate improves the speed of which the bone regenerates as well, meaning that even with a longer lengthening phase, the consolidation phase would be faster when lengthening slower.
I realize that lengthening slow is better for pain management and soft tissue recovery, but as long as soft tissue eventually recovers that is okey with me, if possible i would choose to lengthen faster if it meant that i would be out of frames earlier even if i had more problems walking etc for longer.
Sorry for the overly convoluted question but i would really like your expert opinion on this, i trust my own doctor as well, but im sure he would only tell me to do what is best for my health and advice against doing whatever is the fastest if it means more risk, its also hard to ask him specific questions because his english is limited, and his assistant who translates is not available that often.
Thank you Dr Franz for all the advice you brought this forum.
Thanks for the question. I cannot really give you personalized advice when you seem to be under the care of a good doctor already.
In my practice we very rarely deviate from the 1mm per day rule. This seems to still give the best External Fixation Index (EFI). This is the number of months in a frame per cm of lengthening achieved. In young adults in our practice this runs at around 1.5 months per cm for anything fro
4cm and up.
My suggestion: go with your doc on this.
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Thanks for the question. I cannot really give you personalized advice when you seem to be under the care of a good doctor already.
In my practice we very rarely deviate from the 1mm per day rule. This seems to still give the best External Fixation Index (EFI). This is the number of months in a frame per cm of lengthening achieved. In young adults in our practice this runs at around 1.5 months per cm for anything fro
4cm and up.
My suggestion: go with your doc on this.
Thank you for the answer Dr. Franz!
Just to clarify, from your answer it seems like you think that a 1mm/day lengthening speed would have a higher chance of getting patients out of the frames sooner, but you still think I should follow my doctors advice of going slower?
This makes it even harder to decide.. :-\
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Hi Guys
I want to lengthen 10cm on my femurs.
If I use precise 2, can I re-break, resert the nails and lengthen a further 2cm?
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Hi Guys
I want to lengthen 10cm on my femurs.
If I use precise 2, can I re-break, resert the nails and lengthen a further 2cm?
The short answer is no. It is not advisable. 10 in one segment is around double the safe distance. Sorry...
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Do you really think a "world class" orthopedic surgeon has time to post on a forum all day? Seriously, ask yourself that question. And what exactly makes this surgeon you are referring to "world class"? Because someone claiming to be him says so? How do you even know that person is a doctor, let alone a real orthopedic surgeon or someone who specializes in LL. Have you been to his facilities, or even seen evidence of them?.
This is a quote from the old forum admin. I actually asked myself the same question about this. Unfortunately, I don't know many orthopaedics myself, so I really don't know how much time they could spare for free lectures about CLL on these kinds of forums. Don't take me wrong DR.Franz! I very very much appreciate what you have done for this community, I especially like your philosophy in doing this type of surgery. However, I do find it a bit strange that an orthopaedic could spare so much time to interact with potential patiences like us. It actually makes sense to me that LL doctors come to these forums and answer people questions. However, why none of the orthopaedics at least try to do this but you? I hope you could clarify this :) This means that I am very intersting with the idea of going to SA.
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Do you really think a "world class" orthopedic surgeon has time to post on a forum all day? Seriously, ask yourself that question. And what exactly makes this surgeon you are referring to "world class"? Because someone claiming to be him says so? How do you even know that person is a doctor, let alone a real orthopedic surgeon or someone who specializes in LL. Have you been to his facilities, or even seen evidence of them?.
This is a quote from the old forum admin. I actually asked myself the same question about this. Unfortunately, I don't know many orthopaedics myself, so I really don't know how much time they could spare for free lectures about CLL on these kinds of forums. Don't take me wrong DR.Franz! I very very much appreciate what you have done for this community, I especially like your philosophy in doing this type of surgery. However, I do find it a bit strange that an orthopaedic could spare so much time to interact with potential patiences like us. It actually makes sense to me that LL doctors come to these forums and answer people questions. However, why none of the orthopaedics at least try to do this but you? I hope you could clarify this :) This means that I am very intersting with the idea of going to SA.
Hehe,
I was waiting for a comment or question like this. I happen to spend time on these forums via my phone during 'dead time' inbetween cases. I have, for example, seen 40 patients in my clinic today and operated 20 this week. I am currently waiting for my practice management meeting to start and have 10 minutes to spare, hence I can respond to this and other queries. Hope this makes sense? In fact, where I get time to do this is really my own business, but I can assure you that the practice is busy enough and that my patients don't suffer as a result. Having said this, I have been very active on the forum and will probably not be able to maintain this intensity of involvement in the long term. This is however a new phase for both the forum and myself, and therefore it deserves adequate time to develop this relationship. You will see over time that I will only post in my own thread and also probably once a week. I also do not want to hog the forum with my presence for fear of limiting free speech (patients may feel apprehensive discussing their opinions freely if they know I am watching :-).)
With regards to being an experienced orthopaedic surgeon and the insinuation by Sysop that I may not even be a doctor...I see these allegations in a very serious light, as it questions my integrity, experience and name. I wanted to address this on the old forum in person, but they have not approved my application to register (dare I say I smell a rat?). Would one of you who have access to that forum please post this entire message there?
I do not think it is necessary for me to prove anything...if you don't believe me, you're welcome, but read my posts and you will agree that no non-doctor or indeed non-expert could post this way. If you still don't believe me, email me or set up a skype talk, heck, phone my office if you want. Those of you who have done so will vouch for my authenticity.
Lastly, with regards to no other doctors doing this... what can I say? I've always been different and it has stood me in good stead.
In short, I am a doctor and an orthopaedic surgeon (I have 14 years at university to prove it). I would not necessarily call myself an expert or world-class, but my patients do. And so do the surgeons that come and spend time with me to learn.
You make up your own mind!
By the way, I find it ironic that I am probably the only person on both forums posting under my own name, yet my identity is questioned...
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Sysop is a real piece of work who has had no problem lying and censoring information. He has tried to shut down this forum because he views it as a threat to the site he bought off the previous web owner. I think most of us here do not doubt your authenticity, Dr. Birkholtz. With how you respond to questions I think it's clear you're not someone pretending to be a doctor, as Sysop insinuated. Already you have made a world of difference in the online cosmetic limb lengthening community, such as warning about risks of knee pain with LON/LATN for starters.
Really I think the only who would take what sysop said about you seriously is himself. His comment already urged a member of that site and a limb lengthening patient to chastise him publicly and announce his voluntary leaving of the forum.
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Thanks for your support. Much appreciated.
I think these are however important questions and I believe I've answered them adequately...
I'm off to bed. This fake doctor has 8 fake patients to operate tomorrow. LOL
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Do you really think a "world class" orthopedic surgeon has time to post on a forum all day? Seriously, ask yourself that question. And what exactly makes this surgeon you are referring to "world class"? Because someone claiming to be him says so? How do you even know that person is a doctor, let alone a real orthopedic surgeon or someone who specializes in LL. Have you been to his facilities, or even seen evidence of them?
Why dredge up that crap from old forum on this forum? Apotheosis wants to stir up trouble and will always try to paint our forum in a bad light. He's also jealous that the only doctor he gets to post on his forum is the one he's clearly arranged advertising deals with. Dr. Birkholtz has down time, in which he graciously dedicates to answering our forum questions. Let's not screw that up. It's embarrassing that he even has to respond to this type of criticism.
Also, he's a world class surgeon for many different reasons. In May, he's teaching other surgeons on his field of expertise in Dallas, Texas (I know this because I tried scheduling my consult with him around then). He gets patients from around the world, which should fit that definition as well...
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Thanks for your support. Much appreciated.
I think these are however important questions and I believe I've answered them adequately...
I'm off to bed. This fake doctor has 8 fake patients to operate tomorrow. LOL
Thanks for your participation here Dr. B.
I hope to be one of your fake patients one day. :)
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Not to detract from Dr. Birkholtz's generosity, but people should remember that a doctor's presence on a message board is not some revolutionary feat. You see it all the time on more mainstream sites. It's just that this site is so niche that it is surprising to see a doctor show up to post. One more time on this next matter, and then I'll be forever done with it: what Sysop said really pissed me off and it's the first time I've personally felt the anger that so many others have felt by his pitiful tantrums. Deep down he must know what he's doing is wrong.
He can make the argument that he tried to help me, but what he really did was con me. I could very well be in Serbia with Dr. Mitkovic or one of the other doctors who have been revealed by this forum that would have fit well within my budget. Instead of leaving the Sarin disaster behind and counting the site's losses, he went out of his way to find the next willing surgeon to participate in his scheme. Unfortunately for me, I didn't establish a solid presence on this site until too late. My surgeon is by no means a quack, but he is clearly inexperienced/rusty in Ilizarov. I just hope I come out okay, but if not I should be able to receive care back home. Some patients here, due to their nationalities, may not be as fortunate...
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Dr B I really appreciated your answer on why you are now
performing cosmetic LL and wanted to ask why you set limits
of 5cm on tibs and 6 on femur when other well known doctors such
as Guichet allows up to 10cm on femur and Betz will allow 11cm
on femur and 10cm on tibia. Is this due to personal reasons/studies/experiences?
I ask as the discrepancy of what you and these other doctors allow is large.
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Alright. alright. alright.
Me too, I wanna be your patient one day.
Thanks for your participation here Dr. B.
I hope to be one of your fake patients one day. :)
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Dr Franz is the best thing that has ever happened to this forum. The information he posts here and his interaction with prospective LLers is pure gold.
It's because of him that I've changed my own personal goals into something more realistic, learned a lot about methods and became much more aware of our body limits and the seriousness of this procedure.
I don't think I'd be accepted as one of his patients though as I'm 173cm (which is over his 165cm limit but nevertheless short here in Europe), but if I had the time right now and he accepted me, he'd definitely be my choice.
I'm not questioning every other doctors' integrity, but there seems to be a lot of mercenaries in this business, operating in countries that will not provide you with any protection if anything goes wrong.
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Also do patients have a choice of spinal anesthetic or is it only general available?
Thanks again Dr B
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Hi guys,
Again thanks for the kind words and support.
My limits are less than other doctors allow, because of safety. I will inevitably have less patients interested, but I am happy, since their outcomes should be good. These limits are however arbitrary and may change somewhat it individuals. I do not want to promise 8cm on a femur and then we achieve only 4 because of knee contractures etc.
The cutoff of 165 is a general rule. There may be exceptional circumstances where this rule can be relaxed. This is best discussed on a one-to-one basis.
Anaesthesia is offered by a very experienced group and they offer different options like general anaesthesia with nerve blocks, GA with patient controlled analgesia, spinal, or combinations. This is individualized per patient. Safety is always the primary concern and awareness has not been an issue at all.
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Dr. Birkholtz,
Should a length gained in the tibia by an Ilizarov apparatus correspond to the actual gain in height, or is it similar to the internal nail's mechanism? Thanks.
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dr franz,
thank you for all your valuable info,
I just want to do one surgery and want to gain 8 or 9 on my femurs and be done with LL, are you saying that the larger femur:tibia ratio will eventually cause arthritis or the malalignment?
so if i go all the way to 8cm with precice 2 on my femurs i will eventally get knee pain or arthritis? I am not worried about contracture because if I go with paley he will prob do itb and fb release.
thank you for all your info!!
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hello doctor Frank,
what method do you prefer for lengthening 5,5 cm in tibias? LON or LATN.
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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.
Dr. Birkholtz- Why would lengthening 5-6cm be any safer than 6.1-8cm in terms of only malalignment? If lengthening along the anatomic axis with internal nails causes malalignment, since you're not lengthening along the mechanical axis, wouldn't any amount of lengthening then cause malalignment? What is it about lengthening 5-6cm and malalignment that makes it any safer than 6.1-8cm if all internal lengthening causes malalignment?
Thanks for all your information.
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Think I might answer my own question. Read online that in the tibia these axes are coincidental, so I assume height achieved is equal to height distracted.
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Dr. Birkholtz- Why would lengthening 5-6cm be any safer than 6.1-8cm in terms of only malalignment? If lengthening along the anatomic axis with internal nails causes malalignment, since you're not lengthening along the mechanical axis, wouldn't any amount of lengthening then cause malalignment? What is it about lengthening 5-6cm and malalignment that makes it any safer than 6.1-8cm if all internal lengthening causes malalignment?
Thanks for all your information.
I have the same question specifically about malalignment.
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Dr. Birkholtz,
Should a length gained in the tibia by an Ilizarov apparatus correspond to the actual gain in height, or is it similar to the internal nail's mechanism? Thanks.
In tibias the mechanical and anatomic axes are parallel, thus it should correspond. There may be some subsidence after frame removal though.
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dr franz,
thank you for all your valuable info,
I just want to do one surgery and want to gain 8 or 9 on my femurs and be done with LL, are you saying that the larger femur:tibia ratio will eventually cause arthritis or the malalignment?
so if i go all the way to 8cm with precice 2 on my femurs i will eventally get knee pain or arthritis? I am not worried about contracture because if I go with paley he will prob do itb and fb release.
thank you for all your info!!
It is not the femur to tibia ratio that changes alignment, but the fact that youre lengthening along a different axis. 8cm is a long distance and you should be worried. Remember paley is not the only surgeon doing releases. Contractures happen despite releases also.
Stick to safe distances if you can.
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hello doctor Frank,
what method do you prefer for lengthening 5,5 cm in tibias? LON or LATN.
I would prefer LON, but it is a personal preference.
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Dr. Birkholtz- Why would lengthening 5-6cm be any safer than 6.1-8cm in terms of only malalignment? If lengthening along the anatomic axis with internal nails causes malalignment, since you're not lengthening along the mechanical axis, wouldn't any amount of lengthening then cause malalignment? What is it about lengthening 5-6cm and malalignment that makes it any safer than 6.1-8cm if all internal lengthening causes malalignment?
Thanks for all your information.
You are right. ANY lengthening along the anatomic axis will cause malalignment. As with most things in life, it is the magnitude that counts. Smaller distances will cause smaller malalignments and larger distances may lead to significant malalignments.
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Think I might answer my own question. Read online that in the tibia these axes are coincidental, so I assume height achieved is equal to height distracted.
[/quote
Yep absolutely right!
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It is not the femur to tibia ratio that changes alignment, but the fact that youre lengthening along a different axis. 8cm is a long distance and you should be worried. Remember paley is not the only surgeon doing releases. Contractures happen despite releases also.
Stick to safe distances if you can.
thanks for your repsonse dr. franz,
so your saying if anyone does 8cm on their femurs they WILL get knee pain and arthritis in the future?
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thanks for your repsonse dr. franz,
so your saying if anyone does 8cm on their femurs they WILL get knee pain and arthritis in the future?
No, they will get a change in alignment. This may lead to knee pain and arthritis. It is very individual, but we cannot really predict who will and who wont.
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No, they will get a change in alignment. This may lead to knee pain and arthritis. It is very individual, but we cannot really predict who will and who wont.
Could this misalignment be corrected through a subsequent tibial LL with axis correction, on a later date after the femur LL?
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Hi Dr. B,
Does have muscular legs affect the lengthening process. For example is having muscular calves bad for tibia lengthening and strong muscles in the upper leg bad for femur lengthening. Not sure if others might know the answer to this.
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Hi Dr. B,
Does have muscular legs affect the lengthening process. For example is having muscular calves bad for tibia lengthening and strong muscles in the upper leg bad for femur lengthening. Not sure if others might know the answer to this.
Hey shawty this question was answered somewhere in the general limb lengthening section a while back I'm sure you'll be able to find it. The answer was along the lines of Pilates is an ideal exercise for those doing LL to give you an idea of the degree of muscularity and flexibility that is good for LL.
One thing I've noticed with people who want big distances like 9-10 cm is that their doctor doesn't seek to stop them going for it. Some even encourage them to go at least 7 cm.
Would you stop a patient from lengthening any further than 5-6 cm or let them continue at their own risk?
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Hey shawty this question was answered somewhere in the general limb lengthening section a while back I'm sure you'll be able to find it. The answer was along the lines of Pilates is an ideal exercise for those doing LL to give you an idea of the degree of muscularity and flexibility that is good for LL.
One thing I've noticed with people who want big distances like 9-10 cm is that their doctor doesn't seek to stop them going for it. Some even encourage them to go at least 7 cm.
Would you stop a patient from lengthening any further than 5-6 cm or let them continue at their own risk?
Thank you brother. I'll search there.
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Hi Dr. B,
Does have muscular legs affect the lengthening process. For example is having muscular calves bad for tibia lengthening and strong muscles in the upper leg bad for femur lengthening. Not sure if others might know the answer to this.
Hey Shawty,
This was addressed here http://www.limblengtheningforum.com/index.php?topic=347.0
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Can someone please give me Dr. Franz's email id? The one in the first post doesn't work.
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This worked for me.
reception(at)walkamile.co.za
His secretary will reply back. If you want his personal email, maybe you can ask her.
Can someone please give me Dr. Franz's email id? The one in the first post doesn't work.
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Dr. B,
Do you lengthen femurs by any external methods?
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I was looking at short term rentals in the Pretoria area, and they are pretty cheap. I saw many 3 bedroom townhmhomes for under 1000 USD. If 3 people split the unit..it shouldn't cost more than 800 a month living expenses during lengthening/consolidation.
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Could this misalignment be corrected through a subsequent tibial LL with axis correction, on a later date after the femur LL?
We could readjust the mechanical axis by adjusting the tibia, but that will mean your joint is at a slight angle.
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Can someone please give me Dr. Franz's email id? The one in the first post doesn't work.
You can try:
fbirkholtz@gmail.com
franz.birkholtz@walkamile.co.za
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Dr. B,
Do you lengthen femurs by any external methods?
Not advised due to lengthy times in frame and also knee stiffness.
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Such a pity this doctor doesn't do cosmetic lengthening for patients over 165cm. He is responsive and conservative with regards to length. If he didn't have that requirement I would book tibia surgery with the precice asap.
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The cutoff of 165 is a general rule. There may be exceptional circumstances where this rule can be relaxed. This is best discussed on a one-to-one basis.
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I was 171cm and am recovering from femur surgery and am now 176.5 cm. I don't have any exceptional circumstances other than wanting all the benefits that come with being average height and up and am far over the cutoff, so I doubt I would be a candidate.
What sort of circumstances would constitute being exceptional?
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I was 171cm and am recovering from femur surgery and am now 176.5 cm. I don't have any exceptional circumstances other than wanting all the benefits that come with being average height and up and am far over the cutoff, so I doubt I would be a candidate.
What sort of circumstances would constitute being exceptional?
The most important thing is that the patient should understand what theyre letting themselves into. For this reason I think you may qualify.
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What is the minimum stay will you require to stay for femur. Most of us are working professional and will be impossible to take off 75-90 days. Is it possible to return home after 30 days and lengthen rest at home?
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What is the minimum stay will you require to stay for femur. Most of us are working professional and will be impossible to take off 75-90 days. Is it possible to return home after 30 days and lengthen rest at home?
Good question. It would be cheaper and easier to spend only 4-6 weeks, BUT you would lose out on the meticulous monitoring and daily physio by an experienced team. The problem is if things start going pear shaped, you would want to be close to the doctor who performed the op.
The calculation is as follows: 2 days pre-op. 5 days in hospital. 5-7 days before distraction. Ie 14 days until distraction starts. Then at least another 3-4 weeks to establish a physio routine and also pass through the biggest risk phase for thrombosis. So reluctantly, a minimum of 6 weeks. Provided you can get Ellipse to lend you an ERC unit to perform adjustments. You will also need to send me pictures of your range of motion hip knee and ankle weekly. You will need to send me xrays every two weeks.
So in theory it is possible although not advised.
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I was 171cm and am recovering from femur surgery and am now 176.5 cm. I don't have any exceptional circumstances other than wanting all the benefits that come with being average height and up and am far over the cutoff, so I doubt I would be a candidate.
What sort of circumstances would constitute being exceptional?
176.5cm / 5'9.5 is exactly average in the US for all males. Are you in a different country?
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Man, I'm trying to get from just about 165 to 170. 176 would be my goal after a second if I get through my first successfully.
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Dr B would you stop a patient from lengthening any further than 5-6 cm or let them continue at their own risk?
Assuming they don't have any problems during the lengthening period.
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You will need to send me xrays every two weeks.
So in theory it is possible although not advised.
Dr. Franz,
You are awesome doctor. It will be my stupidity not to be your CLL patient. Can you please check on ERC device? I think it will be OK because patient in US are allowed to take it home.
It appears I might be your first patient unless someone beats me :). I am looking forward to come in end of May.
Cheers!!!
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Dr B would you stop a patient from lengthening any further than 5-6 cm or let them continue at their own risk?
Assuming they don't have any problems during the lengthening period.
In my mind there is no such thing as patients own risk. In terms of safety, it is my responsibility to make the decisions, as I am the professional in this case. Sorry if this sounds paternalistic, but I need to sleep at night!
Having said this, if we reach 5cm and everything seems good, we may together decide to continue. Do not bargain on this, though.
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Dr. Franz,
You are awesome doctor. It will be my stupidity not to be your CLL patient. Can you please check on ERC device? I think it will be OK because patient in US are allowed to take it home.
It appears I might be your first patient unless someone beats me :). I am looking forward to come in end of May.
Cheers!!!
I am teaching in Dallas end of may, but can slot you in as from first week june. Please confirm by email. I do not want to schedule official appointments via open forums.
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I am teaching in Dallas end of may, but can slot you in as from first week june. Please confirm by email. I do not want to schedule official appointments via open forums.
Yes Sir. Email already sent.
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I am teaching in Dallas end of may, but can slot you in as from first week june. Please confirm by email. I do not want to schedule official appointments via open forums.
You're coming to Dallas?! That's awesome! I live there
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So you guys know, Dr Birkholtz's contact e-mails and website have been updated on the first post of this thread.
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The ratio is normally 0.8, ie tibia 80% of the length of the femur give or take.
So ideally, if one is able to do 2 LLs, one should aim to lengthen tibiae around 80% of the amount lengthened previously in the femurs to maintain the bio-mechanical ratio.
For example:
Femur: original length 40cm + 6cm of lengthening = 46cm final femur length
Tibia: original length 32cm + 4.8cm of lengthening = 36.8cm final tibia length
Original ratio: 32 / 40 = 80%
Increase ratio: 4.8 / 6 = 80%
Final ratio: 36.8 / 46 = 80%
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So ideally, if one is able to do 2 LLs, one should aim to lengthen tibiae around 80% of the amount lengthened previously in the femurs to maintain the bio-mechanical ratio.
For example:
Femur: original length 40cm + 6cm of lengthening = 46cm final femur length
Tibia: original length 32cm + 4.8cm of lengthening = 36.8cm final tibia length
Original ratio: 32 / 40 = 80%
Increase ratio: 4.8 / 6 = 80%
Final ratio: 36.8 / 46 = 80%
No. That would increase the ratio further. You can lengthen both equally and the ratio will be maintained.
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No. That would increase the ratio further. You can lengthen both equally and the ratio will be maintained.
You're wrong.
If your original dimensions are: tibia = 32cm and femur = 40cm >>> Tibia to femur ratio = 32/40 = 80%
If you increase the same amount, say 6cm on both tibia and femur you get >>> Tibia to femur ratio = (32+6)/(40+6) = 38/46 = 82,6%
To maintain the original ratio you have to increase the segments in proportion to the original ratio. This is basic math...
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Yeah, that was quite the blunder. Not only basic math but common sense. What I was trying to get at is that taking for instance, a lengthening of the femur 6cm, you can lengthen the tibia 6cm rather than 4.8cm and still have a ratio far closer to the original than you would create with adding just 6cm to the femur. With average limb lengths you'd probably change the ratio by 3% or so, as you've demonstrated, but the change becomes more drastic the shorter the original limbs are. With sensible lengthening in the 5-6cm range, I don't think maintaining the ratio to equality is needed at all, since most people lengthen one or the other and get away fine with a far different ratio than the original. Ideally, like you asked, I suppose you would if you wanted exactness. Nevertheless, you're completely correct and I'm quite the idiot for telling you that the opposite would be correct, and I'm sure your question was intended for Dr. Birkholtz anyway, so I'll let him answer.. Take it as a momentary lapse of reason. Sorry.
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double post...
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So ideally, if one is able to do 2 LLs, one should aim to lengthen tibiae around 80% of the amount lengthened previously in the femurs to maintain the bio-mechanical ratio.
For example:
Femur: original length 40cm + 6cm of lengthening = 46cm final femur length
Tibia: original length 32cm + 4.8cm of lengthening = 36.8cm final tibia length
Original ratio: 32 / 40 = 80%
Increase ratio: 4.8 / 6 = 80%
Final ratio: 36.8 / 46 = 80%
Absolutely correct. One of the reasons why we advocate 4-5 on tibias and 5-6 on femurs.
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In tibias the mechanical and anatomic axes are parallel, thus it should correspond. There may be some subsidence after frame removal though.
Can one prevent callus subsidence and height loss by doing LON instead of external and LATN, since the IM rod will be in place before frame removal?
What is the expected range of subsidence (min-max) after frame removal?
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Hi TRS,
subsidence in the region of 5-10mm. Only a problem with externals only. With LATP it can be prevented with meticulous surgical technique.
Rgds,
FFB
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Pics as promised.
State of the art technology in action...
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The office. Where all the thinking happens!
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Main hallway inside the hospital. Why does it always smell of antiseptic?
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TSF frame for femoral re-alignment and lengthening being performed. Sorry about the blood.
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The entrance to the children's ward. They get cartoons on the walls.
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Modern operating theatres
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More OR
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Reception@walkamile.co.za
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Teaching other surgeons from all over in our viewing room
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Unitas is the largest private hospital in SA and has 500 beds.
It is owned and run by Netcare. Our practice is a completely separate entity and we are not employed by the hospital.
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The woundcare room in our office. This is normally where adjustments take place.
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Wow Dr. Birkholtz, these photos are amazing. You're doing God's work!
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Tx Arche. It is indeed a calling.
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Thank you dr. Franz for pictures.
Picture does speak thousand words :)!
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looks ace those pictures, some of the setup reminds me of the hospital standards in my country so I am very happy with this.
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Hi TRS,
subsidence in the region of 5-10mm. Only a problem with externals only. With LATP it can be prevented with meticulous surgical technique.
Rgds,
FFB
Wow...i cant believe this, is subsidence common? i mean is there nothing one can do to prevent it when doing externals only? It would mean that i would likely have to lengthen 5 cm to get 4 cm in the end, and thats not counting the pin bending i will have to make up for..
It sounds terrible and really there should be some kind of way to prevent it..im really worried now. Especially when doing small ammounts 4 cm, losing 10 mm would be catastrophic.
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That is my concern too only with external. Because of that i am thinking in LON.
i think you should make mínimum 4,5cm, because you will lose some milimetres.
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That is my concern too only with external. Because of that i am thinking in LON.
i think you should make mínimum 4,5cm, because you will lose some milimetres.
Logically it would seem that Subsidence occurs because of removing the frames to early, the bone might be solid enough to hold the body weight but still not completely solid. If you have the frames on long enough for the bone to become as hard as it can, it should not be able to compress and removing a few pins with the frame removal should not have any effect on the new calles that solidified between the pin sites.
But i dont know of course and would appreciate if Dr. Franz could offer a deeper insight to subsidence and why it happens and what can be done to prevent it.
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In the case of salameh's device, the bottom part of device is out when you have some consolidation after lengthening. Then he take off the screws bit a bit. Then the device is smaller, and it still support the body.
I think you need to stay with the device the time necessary for consolidation without urgency, perhaps minimun 1,5 months by centimetre and you should make somes milimetres plus, mínimum 0,5 plus to secure 4 cm because lose lengthening.
That it will be that i will make if i do the surgery only with external, with doctor salameh
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Hi,
Subsidence is something we cannot fully explain. Logically if the bone is strong enough, the length should stay the same. There are however some patients where some length is lost gradually afterwards -> probably due to some 'plastic deformation' of the new bone. This is disconcerting. Especially since it tends to happen gradually and long after the procedure.
Most doctors would recommend slow destabilization of an external only frame, in order to strengthen up the bone gradually before frame removal.
Preventing subsidence? Using internal methods, or combinations of internal and external may be the answer...
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Hi,
Subsidence is something we cannot fully explain. Logically if the bone is strong enough, the length should stay the same. There are however some patients where some length is lost gradually afterwards -> probably due to some 'plastic deformation' of the new bone. This is disconcerting. Especially since it tends to happen gradually and long after the procedure.
Most doctors would recommend slow destabilization of an external only frame, in order to strengthen up the bone gradually before frame removal.
Preventing subsidence? Using internal methods, or combinations of internal and external may be the answer...
Thank you for the answer, this is definitely concerning, i guess i will have to lengthen around 4,5 cms to make sure..
But it seems like if plastic deformation is the explanation, then it could happen after the surgery to remove the internal nails as well.. or maybe after a year or so when the nail is removed, is long enough for subsidence to no longer be possible..
Ive looked at 2 studies about this:
one study claims that the median subsidence loss was insignificant at around 0.28 - 0.6 mm, such a small loss would be acceptable to me.
The other one however reports the large losses mentioned in this thread...and it doesnt even seem to be uncommon to experience large losses, some even above 3 cm..that must be a case of removing the frame way to early..
http://informahealthcare.com/doi/full/10.3109/17453674.2010.533934
http://www.ncbi.nlm.nih.gov/pubmed/18923832
However reading further, it is interesting that the positive study actually argues against the other study where large losses where reported, and the authors of the first study acknowledged the errors that where brought up. So it seems the positive study of less than 0.6 mm subsidence loss on average is the more reliable one based on this. I hope it holds true, still gonna lengthen some mm extra to make up for the potential loss.
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Thank you very much Frank, for your answers.
You look like a very good option but the idea that you only have made two cosmetic lengthening it go me to back.
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it would be good idea to wear somes braces or cast when you take off the device to protect the new bone.If one person makes only external.What do you think?
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Excellent update, Dr. Birkholtz. Looks like a great hospital.
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Thank you very much Frank, for your answers.
You look like a very good option but the idea that you only have made two cosmetic lengthening it go me to back.
Why, paco? My doctor had only done 30-ish cosmetic lengthenings but everything went great. Keep in mind that these doctors have done hundreds to thousands of normal, non-cosmetic lengthenings both for achondroplasia patients (dwarfism) and leg length discrepancy lengthenings. It's actually better for the doctors as they face all sorts of complications in these patients and become more experienced in treating possible complications in simpler cosmetic cases. That being said, isn't it also technically the same thing? Leg length discrepancy or cosmetic, one leg or both legs, it's the same procedure.. (Yes there's increased risk of fat embolism when you add a leg, but it's not a problem in bilateral lengthenings when the doctor is experienced, the risk is surpassed with proper venting methods during surgery and post-op medications). In brief.. You make it seem like Dr.Birkholtz has only done two surgeries so far (I know you don't mean that, no offense) whereas his actual experience is so much more than that. I only wrote this to assure you that hopefully everything should go fine.
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Hello, Dr. Birkholtz,
Can you please give a rough estimation, for a normal patient, after how many months can he walk in crunches ?
Thank you,
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Dr B regarding safety in S.A. Are there any special security precautions that have to be taken
in day to day life.
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Hello, Dr. Birkholtz,
Can you please give a rough estimation, for a normal patient, after how many months can he walk in crunches ?
Thank you,
It depends on the type of technique we use. For external fixator based lengthenings we encourage full weight bearing as soon as possible. In general, for bilateral cases, most patients are walking on crutches before discharge from hospital and progress to full weight bearing over the next 6 weeks or so.
For Precice 2, it depends on the patients weight. If you weigh below 150 pounds, we can get you onto crutches pretty soon, provided weight is shared between the two legs. Most patients should be on crutches by 6 weeks though.
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Dr B regarding safety in S.A. Are there any special security precautions that have to be taken
in day to day life.
This is a good and very important question.
South Africa is not the safest place in the world, but common sense keeps most of us safe.
Don't walk around after dark, avoid danger areas, don't get drunk and pass out, be careful with personal belongings, especially electronics, don't visibly display cash etc etc.
The area around the hospital and guesthouses is safe with ample security in and around the hospital. We are also located close to a police station (2 street blocks away).
Whereas I cannot say that crime is not a problem, some basic precautions will keep you safer than in most places in the developing world.
As I said before: Remember, I raise my kids here...
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How much would it cost to do Precise with just a two week hospital stay in South Africa, and to have the device removed in another country?
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How much would it cost to do Precise with just a two week hospital stay in South Africa, and to have the device removed in another country?
Our recommendation is for you to stay in Pretoria for 3 months. In certain selected cases this may be dropped to 6 weeks, but not less.
This is in the interest of patient safety.
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I was looking into South Africa's visa situation where if you want to stay over 3 months you need a visa,
has anyone who's been there know which one you would need for having LL there. Planning to be there
6 months.
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With the limit of 5cm on tibias and possible bone shrinkage (I forgot the exact term) it's recommended to do .5-1cm extra. Does that mean max a person can get 4 -4.5 cm on tibias or the bone will be stretched to 5.5-6 cm to get a final gain of 5cm. Sorry if my question isn't written well. It's way too early for me here and is my day off, so I'm still in bed.
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Hello Dr. Franz and thank you for your help.
In general, the nerve deterioration starts how many years after limb lengthening and how many ways can nerve deterioration affect my health?
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With the limit of 5cm on tibias and possible bone shrinkage (I forgot the exact term) it's recommended to do .5-1cm extra. Does that mean max a person can get 4 -4.5 cm on tibias or the bone will be stretched to 5.5-6 cm to get a final gain of 5cm. Sorry if my question isn't written well. It's way too early for me here and is my day off, so I'm still in bed.
I would suggest overlengthening a bit to prevent subsidence.
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Hello Dr. Franz and thank you for your help.
In general, the nerve deterioration starts how many years after limb lengthening and how many ways can nerve deterioration affect my health?
Not sure I follow you... nerve deterioration?
Nerve injury or neurological deficit due to stretching happens during distraction.
I am not aware of nerve deterioration starting late after lengthening.
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Dr Franz,
I looked at some studies earlier about subsidence after LL, and this is the most interesting study i found:
http://informahealthcare.com/doi/full/10.3109/17453674.2010.533934
Im wondering if you have read this study before and what you think about it. It makes a strong argument that subsidence loss is only in the 0.6 mm or lower range. It also directly argues against earlier studies which claimed losses of 1 cm or more.
Is most of your current knowledge of subsidence based on your own experience in the field or from reading studies like this one?
thank you
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All of the countries in Africa are a total mess, even South Africa.
Says the world expert sweden whose international expertise probably derives from American news channels and not his own travel or personal experiences. So now I know you hate Muslims and think ALL of Africa is a mess. Please stop spreading misinformation. Stick to LL and martial arts as these are things u have first hand experience of.
SA can be unsafe but it's a modern country with Western levels of health care if you pay for it. Probably a lot safer than India. I've been to both places more than 10 times.
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Hey gettingtaller,
That quote from Sweden was from 6 months ago and do we have to bring the Muslim topic into every thread? Let it go.
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Hey gettingtaller,
That quote from Sweden was from 6 months ago and do we have to bring the Muslim topic into every thread? Let it go.
Apologies. This is the only time I've brought this up though. Sorry but I just very wound up at false bad information being put across in an overly confident way. It's simply not good for the people that don't know better and factor it into their decision making. I'll shut up about the Muslim thing but I'll continue to call out misinformation. Hope that's on.
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Apologies. This is the only time I've brought this up though. Sorry but I just very wound up at false bad information being put across in an overly confident way. It's simply not good for the people that don't know better and factor it into their decision making. I'll shut up about the Muslim thing but I'll continue to call out misinformation. Hope that's on.
Sorry if I sounded rude. Dr. Franz has voiced his disapproval about some of the comments and language used on this forum. Dr. Franz is an asset to this forum and I hope that he continues to contribute to this forum. I also hope to visit him in South Africa in a couple years so I hope he continues posting.
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Question for Dr Franz (assuming he has time!).
Is your safe limit in place to minimise issues during lengthening/consolidation? Or are you looking to reduce risk beyond that? If the latter, then what risks due you perceive. Obviously, you will see from my sig that I am already well beyond your safe limit so wondered that since my LL has thus far (touch wood) been pretty easy, am I in your opinion storing up problems for later on in life?
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Also, gettingtaller do you have a diary on here or the old forum?
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Also, gettingtaller do you have a diary on here or the old forum?
I'm sorry. Never got round to creating a diary.
A little too busy (and disorganised) to keep one current.
Happy to answer any questions in the betz thread (probably the most relevant place to consolidate as there are other betz patients looking in there).
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(Mods you can make a new thread from my posts if you think I'm hijacking Dr Franz thread)
New thread moved here: http://www.limblengtheningforum.com/index.php?topic=663.0
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Dr Franz,
I looked at some studies earlier about subsidence after LL, and this is the most interesting study i found:
http://informahealthcare.com/doi/full/10.3109/17453674.2010.533934
Im wondering if you have read this study before and what you think about it. It makes a strong argument that subsidence loss is only in the 0.6 mm or lower range. It also directly argues against earlier studies which claimed losses of 1 cm or more.
Is most of your current knowledge of subsidence based on your own experience in the field or from reading studies like this one?
thank you
It is a combination, but mostly from discussions with other surgeons. It is a phenomenon that is poorly understood. I do think the larger subsidence values would be because of soft regenerates at frame removal.
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Hello again Dr B, after lengthening is complete do you remove the nails or plates from the body. If so is this a separate cost?
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Question for Dr Franz (assuming he has time!).
Is your safe limit in place to minimise issues during lengthening/consolidation? Or are you looking to reduce risk beyond that? If the latter, then what risks due you perceive. Obviously, you will see from my sig that I am already well beyond your safe limit so wondered that since my LL has thus far (touch wood) been pretty easy, am I in your opinion storing up problems for later on in life?
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.
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Hello again Dr B, after lengthening is complete do you remove the nails or plates from the body. If so is this a separate cost?
Its better to remove the nails, as we do not know what the longterm effects of the precice magnets would be. The nail also has moving parts which conceivably could cause metal debris theoretically. Plates I would leave up to the patient to decide.
Cost for removal around 2K USD at the day surgery clinic.
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do you know how much do you have to wait before u're able to run if u do 5cm on tibiae with ilizarov external device, and also for lengthening and consolidation how much should I expect ( 8 months?)
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can you please answer to me franz?
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do you know how much do you have to wait before u're able to run if u do 5cm on tibiae with ilizarov external device, and also for lengthening and consolidation how much should I expect ( 8 months?)
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.
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Dr Franz I'm curious to get your opinion on lengthening two segments at once on the same leg e.g tibia+femur on right leg while weight bearing
on the left then proceeding to lengthen the left after the right leg has sufficiently healed as some Doctors suggest.
Also do you accept payment in rand?
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Dr Franz I'm curious to get your opinion on lengthening two segments at once on the same leg e.g tibia+femur on right leg while weight bearing
on the left then proceeding to lengthen the left after the right leg has sufficiently healed as some Doctors suggest.
Also do you accept payment in rand?
We do accept Rands. It has Mandela's face on it afterall! The reason we quote in USD is that it is more universally used...
Two possible scenarios: do one side first, ipsilateral femur and tibia. Good, but will result in a leg length discrepancy until the second side is done. If the second side is never done because of pain, finances etc, it means we have turned you into a 'cripple'.
The second scenario (preferred), is to perform femoral precice on the one side with an exfix tibial lengthening on the other of roughly equal amounts. This means the overall leg lengths stay the same throughout and the exfix leg becomes the weight bearing leg. Again, if we do not proceed with the second phase, the knees will end up on different levels, but at least the legs will be roughly equal in length.
If a patient is very committed I would choose the second option.
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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.
Ah I see!
Just to make sure im not misinterpreting you, do you mean that after the frames have been removed, it is already possible to run and jump from day one? but "comfortable" running will be possible on average after 6 months after frame removal like you mentioned earlier?
is this because of muscle atrophy and the body needing to relearn how to run the reason why running comfortably takes so long after frame removal?
Thank you again Dr Franz!
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Ah I see!
Just to make sure im not misinterpreting you, do you mean that after the frames have been removed, it is already possible to run and jump from day one? but "comfortable" running will be possible on average after 6 months after frame removal like you mentioned earlier?
is this because of muscle atrophy and the body needing to relearn how to run the reason why running comfortably takes so long after frame removal?
Thank you again Dr Franz!
It is so difficult to predict exactly, but I would certainly allow a patient to run on a fully conslidated bone. Whether it would be comfortable is an entirely different question...
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It is so difficult to predict exactly, but I would certainly allow a patient to run on a fully conslidated bone. Whether it would be comfortable is an entirely different question...
Okey i understand what youre saying :)
Im just confused because my own doctor (or his assistant rather) told me that the bone wouldnt exactly be 100% consolidated until about 6 months to a full year after frame removal, but strong enough to walk on the day they remove the frames.
And they adviced me not to do sports or work out the legs like doing legpress until the bone was strong enough, apparantly according to them it isnt strong enough for those activities when they remove the frames.
I didnt get an specific answer from them (its hard because they dont speak english very well) but i assume i would risk a fracture if i didnt follow those instructions, maybe even lose height due to compression? (like subsidence maybe?)
Sorry for making the question so convoluted, but im very paranoid about this stuff, thank you again for your help Dr. Franz
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What time of year do you think it's best to come to Pretoria based on weather? I heard south africa is hot but if I come for consultation I'd like it to be in the cooler months.
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Is anyone here asking for visa to SA? My parents will be supporting me with the money. I have less than $2000 in the bank. I dont know if they will provide me the visa seeing that my money has been decreasing only( I am a student without a job).
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This whole visa thing is the only reason why I am not being in SA with DR Franz right now....
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Hi Dr Franz,
Is there any benefit for bone consolidation if the climate is especially warm/cold or if temperature affects the rate of consolidation at all?
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Sorry Dr Franz I should have specified further as to the cost in rand?
Thanks
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Did you send them Xray already? If it's PRECISE nail then they need 4 weeks to order the right size for you.
I am going to do LON. Visa is a pain in the ass because there is no ambassador in my city.
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Get email inquiry from Dr Franz secretary and they can provide you with date possible for and you can request for letter of consultation that you will show to SA Embassy.
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I went there late April and weather that time is perfect (for me). It's sunny but cool.
What time of year do you think it's best to come to Pretoria based on weather? I heard south africa is hot but if I come for consultation I'd like it to be in the cooler months.
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We do accept Rands. It has Mandela's face on it afterall! The reason we quote in USD is that it is more universally used...
The second scenario (preferred), is to perform femoral precice on the one side with an exfix tibial lengthening on the other of roughly equal amounts. This means the overall leg lengths stay the same throughout and the exfix leg becomes the weight bearing leg. Again, if we do not proceed with the second phase, the knees will end up on different levels, but at least the legs will be roughly equal in length.
If a patient is very committed I would choose the second option.
Hi Dr B, Im very curious regarding this method. How long would it take to achieve a goal of 11cms(5 tibia and 6 femur) and how long does a patient need to stay in South Africa for before they can go home and into consolidation? I understand every patient is different but could you give a rough estimate of how much time is needed for this kind of procedure?
Thanks
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Okey i understand what youre saying :)
Im just confused because my own doctor (or his assistant rather) told me that the bone wouldnt exactly be 100% consolidated until about 6 months to a full year after frame removal, but strong enough to walk on the day they remove the frames.
And they adviced me not to do sports or work out the legs like doing legpress until the bone was strong enough, apparantly according to them it isnt strong enough for those activities when they remove the frames.
I didnt get an specific answer from them (its hard because they dont speak english very well) but i assume i would risk a fracture if i didnt follow those instructions, maybe even lose height due to compression? (like subsidence maybe?)
Sorry for making the question so convoluted, but im very paranoid about this stuff, thank you again for your help Dr. Franz
It is always safer to follow your own docs guidelines. It is unlikely that the bone will suddenly break with exertion after removal. Should the bone still be soft, it may bend slowly. Once fully consolidated, it will not go anywhere.
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What time of year do you think it's best to come to Pretoria based on weather? I heard south africa is hot but if I come for consultation I'd like it to be in the cooler months.
Any time is good. In winter (currently) temperatures range from 0 degrees celsius at night to around 20 degrees at midday. In summer temps range between 15 and 32 generally. The hospital is airconditioned, though.
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Hi Dr Franz,
Is there any benefit for bone consolidation if the climate is especially warm/cold or if temperature affects the rate of consolidation at all?
Interesting question. I am not aware of any relationship between temperature and bone consolidation. Because the Ilizarov method was devised in Siberia, maybe cold is beneficial...it could also be the vodka...lol.
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Did you send them Xray already? If it's PRECISE nail then they need 4 weeks to order the right size for you.
Jip, our lead time needed for Precice 2 is around 2-4 weeks.
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Sorry Dr Franz I should have specified further as to the cost in rand?
Thanks
The cost in rand will essentially be the same as the cost in usd at the current conversion rate. Thw absolute value is a bit difficult to pin down for this reason. Should the patient be a South african, some costs could be saved if they use their own accommodation etc.
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Hi Dr B, Im very curious regarding this method. How long would it take to achieve a goal of 11cms(5 tibia and 6 femur) and how long does a patient need to stay in South Africa for before they can go home and into consolidation? I understand every patient is different but could you give a rough estimate of how much time is needed for this kind of procedure?
Thanks
Essentially the minimum time in SA would be 90 days, which is the same as for the precice 2 bilateral femorals. The patient could then go home and consolidate and return for the opposite combination after around 9 months. The femur must be strong enough to carry full weight. In total, I think the shortest time to reasonable recovery should be around 18m-2yrs.
Cost will be in the region of 42K USD per step, ie a total of 84K for all 4 segments.
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Thanks for the quick reply Dr B, one last question. What are the advantages of doing it that way over say Precice femur(both femurs) first and then going home to consolidate and then coming back a year or so later to do the tibias? Could a precice femur patient be able to come back and do their tibias after 9 months as well? Theoretically speaking of course
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Thanks for the quick reply Dr B, one last question. What are the advantages of doing it that way over say Precice femur(both femurs) first and then going home to consolidate and then coming back a year or so later to do the tibias? Could a precice femur patient be able to come back and do their tibias after 9 months as well? Theoretically speaking of course
The biggest advantage would be the ability to weight bear on the exfix side theoretically.
Jip if the bone growth is good.
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Hello Dr. B. Hope you're having a good day. I was wondering if, should a CLL patient have a natural tibia/femur ratio of 0.8, they should lengthen their tibiae or femurs to have better athletic recovery and favorable walking mechanics. How far beyond the 0.8 ratio can patients go, generally speaking with regards to single segment lengthening of femur or tibiae, before mechanics start to suffer and arthritis becomes a concern?
Thank you.
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Hello Dr. B. Hope you're having a good day. I was wondering if, should a CLL patient have a natural tibia/femur ratio of 0.8, they should lengthen their tibiae or femurs to have better athletic recovery and favorable walking mechanics. How far beyond the 0.8 ratio can patients go, generally speaking with regards to single segment lengthening of femur or tibiae, before mechanics start to suffer and arthritis becomes a concern?
Thank you.
Thanks. I did have quite a busy day with 7 operations, but am able to relax now.
I am not aware of a lot of scientific literature on the topic.
It is however true that visually, tibial lengthening has more of an effect. Ie tibial lengthening looks longer than femoral.
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For most people a 5cm tibial lengthening should not result in major functional longterm issues, as the ratio is changed from around 0.8 to 0.95.
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Hi Dr. Franz,
Often, I wonder if when I undergo LL, I'm putting myself in a situation where even a slight waver of the surgeon's hand can leave a life-long impact on my legs. :o
Is this true to an extent?
You say you did 7 surgeries in a single day, and I wonder if a surgery is a "monotonous" job.
If I went to a "hair dressing machine" that did a fixed hair-style, I wouldn't feel scared even if I have to live that hair-style for the rest of my life (and my hair won't grow back, say ;) ). It is monotonous to the machine, and I wouldn't think anything would go wrong.
But if is a barber who's doing it routinely on a large chain of people, I would have my fears.
poor example, but I hope you got my point. :P
What is your take on this?
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DR Franz. I want to know your opinion about doing femurs with externals. Do you think is very risky to do 5/6cm with monorail? And LON in femurs?
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DR Franz. I want to know your opinion about doing femurs with externals. Do you think is very risky to do 5/6cm with monorail? And LON in femurs?
LON in femurs is very difficult to do and hence has a relatively high complication rate. It is not recommended for cll.
Monorail femurs have a high risk of knee stiffness and is not recommended.
Should an exfix be considered, I would strongly recommend opting for a tibial procedure.
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Hi Dr. Franz,
Often, I wonder if when I undergo LL, I'm putting myself in a situation where even a slight waver of the surgeon's hand can leave a life-long impact on my legs. :o
Is this true to an extent?
You say you did 7 surgeries in a single day, and I wonder if a surgery is a "monotonous" job.
If I went to a "hair dressing machine" that did a fixed hair-style, I wouldn't feel scared even if I have to live that hair-style for the rest of my life (and my hair won't grow back, say ;) ). It is monotonous to the machine, and I wouldn't think anything would go wrong.
But if is a barber who's doing it routinely on a large chain of people, I would have my fears.
poor example, but I hope you got my point. :P
What is your take on this?
An interesting point. Whereas the techniques used during an operation (eg suturing) may be repeated so often that they become engrained in muscle memory, it is important for us as surgeons to remember that each 'case' is in fact a person with hopes, fears etc. Each patient is different and needs the personal, human touch. This is why I think we will not be replaced by machines too soon. We can however harness technology to make us better surgeons. An example would be the hexapod fixators like the tsf or tlhex.
The day I do 7 cases on a list and forget that they belong to 7 patients and their families is the day I should hang up my gloves.
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An interesting point. Whereas the techniques used during an operation (eg suturing) may be repeated so often that they become engrained in muscle memory, it is important for us as surgeons to remember that each 'case' is in fact a person with hopes, fears etc. Each patient is different and needs the personal, human touch. This is why I think we will not be replaced by machines too soon. We can however harness technology to make us better surgeons. An example would be the hexapod fixators like the tsf or tlhex.
The day I do 7 cases on a list and forget that they belong to 7 patients and their families is the day I should hang up my gloves.
But are there any *critical* actions? You do it just *once* and if you felt like sneezing while doing it... there it goes.
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You can also get struck by lightening :P it all comes down to how dangerously you want to live your life! When I rode my bike at 270km/h I knew that "complications" could occur, its the same with LL.
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But are there any *critical* actions? You do it just *once* and if you felt like sneezing while doing it... there it goes.
What like Dr Franz sneezes and next thing you know you don't have a right foot anymore?
I think its highly unlikely that anything like that would ever happen also even if you knew about it you're under anesthetic so
your knowledge about critical points in a surgical operation would not matter anyway.
You just have to trust your surgeon.
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Of course, there is no
What like Dr Franz sneezes and next thing you know you don't have a right foot anymore?
well, kinda. Not that serious, but a serious complication at a later stage? Of course I'm *asking* about this and not suggesting this is true.
And yeah, it's just to know what I'm signing up for and not about how I'll react during the surgery, lol.
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I think there's a team who do this surgery, all highly experienced doctors who know and control every single step, hence why you pay that much
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I think there's a team who do this surgery, all highly experienced doctors who know and control every single step, hence why you pay that much
I guess this is why we spend 14 years at University...
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Franz pics not wotk :( can you upload some photos from hospital? rooms. etc.
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Franz pics not wotk :( can you upload some photos from hospital? rooms. etc.
Admin,
Could you guys maybe look into this?
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Admin,
Could you guys maybe look into this?
Sure thing. The admin will look into it. Hopefully the photos can be restored.
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Hi Dr Franz,
If you have the time, could you please tell me your opinion about my x-rays i took yesterday and how my healing is going? Maybe a rough idea about how much time i might need? i asked my local doctor as well as my Russian doctor, but your opinion would be just as valuable.
I uploaded them just now in this thread on the bottom:
http://www.limblengtheningforum.com/index.php?topic=320.msg13342#new
I did the surgery, Mars 01 this year, so almost 5 months since then. Lengthened about 4.3 cm, my left leg is a bit behind due to shlatters disease (i did less weight bearing on it in the early LL phase) and i added 1.5 mm extra on it in consolidation phase to lessen the discreprency.
Thank you in advance would appreciate your opinion alot
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Hi Dr Franz,
If you have the time, could you please tell me your opinion about my x-rays i took yesterday and how my healing is going? Maybe a rough idea about how much time i might need? i asked my local doctor as well as my Russian doctor, but your opinion would be just as valuable.
I uploaded them just now in this thread on the bottom:
http://www.limblengtheningforum.com/index.php?topic=320.msg13342#new
I did the surgery, Mars 01 this year, so almost 5 months since then. Lengthened about 4.3 cm, my left leg is a bit behind due to shlatters disease (i did less weight bearing on it in the early LL phase) and i added 1.5 mm extra on it in consolidation phase to lessen the discreprency.
Thank you in advance would appreciate your opinion alot
Your doctor will be the best person to help you there. But your healing seems to be going well.
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Your doctor will be the best person to help you there. But your healing seems to be going well.
okey thank you :)
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okey thank you :)
I'm sorry, but it would not be a good idea to get involved im advising when your frames should come off. I can only really do that with my own patients. But the average is around 1.5-2 montha per centimetre. My guess is you'll be closer to the lower end of the range.
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I'm sorry, but it would not be a good idea to get involved im advising when your frames should come off. I can only really do that with my own patients. But the average is around 1.5-2 montha per centimetre. My guess is you'll be closer to the lower end of the range.
No worries, im happy for the response! i hope you are right about the lower end, my local doctor seems to think so too :p
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Hi Dr Franz,
I have been emailing you for a few days. The South Africa high commission is asking me for the surgery schedule, and the estimated cost. I think these are the last documents that they ask from me before I could get the visa and go to SA.
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Hi Daylight, what kind of visa are you applying for?
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Hi Daylight, what kind of visa are you applying for?
I am applying for a visitor visa.
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Hello Dr. Birkholtz. I have a question for you, if you don't mind.
During your time practicing and studying orthopedic medicine, how much variation in the following proportional ratios have you seen between your patients?
Leg to upper body height ratio
Femur to tibia ratio
Femur to torso ratio
Thank you very much for your time.
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Bc it's Africa. Nobody has any idea of what they're doing.
What sane person goes to Africa?
SOUTH Africa. It's a developed, relatively-peaceful country--especially the big cities. It would be ridiculous to compare South Africa to undeveloped rest of Africa.
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I like this doctor very much.
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Why
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Why
BEcause of his relatively good prices and his good answers at the forum. This is an option to consider.
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SOUTH Africa. It's a developed, relatively-peaceful country--especially the big cities. It would be ridiculous to compare South Africa to undeveloped rest of Africa.
people think Africa as a continent is undeveloped.. S. Africa a developed nation? or is it developing and close to developed...?
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people think Africa as a continent is undeveloped.. S. Africa a developed nation? or is it developing and close to developed...?
I don't know much about South Africa but I think it's pretty developed.
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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!
Hi Doctor,
My Russian doctor initially suggested me to do femur + tibia. But once he learnt I could be happy with 8 cm, he said I would have greater athletic recovery with 8 cm tibia (even though my femur-tibia ratio would be very close to 1); at first, he said 7-8 cm tibia, 4 cm femur. But now, he seems reluctant to do femur if I wanna retain athleticism.
In other words, it seems you agree with him:
1. minimise surgical trauma - avoid a second surgery
2. the ratio may not be that important
3. minimise muscle and soft tissue changes by avoiding 2nd surgery
Of course, no studies are done, but this is what you think?
Am I right?
I know you said not to exceed 5 cm but I am now at 5.2 with no soft tissue problems or much pain or sleep problems.
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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!
Thanks for the reply. I'd much rather have the honest information over what I would ideally like to hear. I'm kind of happy that there's more reason for me to not have to go through this again. :D
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Hi guys,
We've looked at the numbers again. There is currently a lot of volatility in the international currency exchange rates. For this reason we have decided to change our costing model so that the quoted price is in South African Rand (ZAR). We pay the subcontractors in Rand so it makes sense to peg the price locally. This will obviously make our prices more competitive to some people and less so to others.
Secondly, we have started a second office at the brand new state of the art Mediclinic Midstream Hospital with fantastic facilities. We will be offering our CLL services at this hospital. It is more upmarket and discreet. The price quoted is for a private room in this facility (flat screen tv, private bathroom etc).
Remember that although we are getting progressively more known for internal lengthening with Precice, we have had many years of experience with the Ilizarov method, Taylor Spatial Frame, Truelok and Truelok Hex frames as well as other techniques. Therefore we can offer a high level of expertise and care should you require external fixator based treatment.
Lastly, we have decided to include all medical related costs into our package price estimates, but to leave accommodation costs out for now. The issue with accommodation is that the cost can vary widely depending on the option chosen. We can however put you in touch with relevant facilities that provide accommodation services.
The package includes:
- all hospital fees
- surgeon, assistant and anaesthetic fees
- prosthesis (implant) fees
- multidisciplinary team support
- physio daily in hospital and 3-5 days per week as outpatient
- regular doctor and nursing follow ups
- xray follow ups
- walking frame and wheelchair rental
For Precice 2 femorals it works out to 550K ZAR. Current exchange rate = 45800 USD.
Externals only: 300K ZAR. Current exchange rate = 25000 USD.
LON/LATP: 400K ZAR. Current exchange rate = 33000 USD.
I hope this clears up some confusion.
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Hi guys,
We've looked at the numbers again. There is currently a lot of volatility in the international currency exchange rates. For this reason we have decided to change our costing model so that the quoted price is in South African Rand (ZAR). We pay the subcontractors in Rand so it makes sense to peg the price locally. This will obviously make our prices more competitive to some people and less so to others.
Secondly, we have started a second office at the brand new state of the art Mediclinic Midstream Hospital with fantastic facilities. We will be offering our CLL services at this hospital. It is more upmarket and discreet. The price quoted is for a private room in this facility (flat screen tv, private bathroom etc).
Remember that although we are getting progressively more known for internal lengthening with Precice, we have had many years of experience with the Ilizarov method, Taylor Spatial Frame, Truelok and Truelok Hex frames as well as other techniques. Therefore we can offer a high level of expertise and care should you require external fixator based treatment.
Lastly, we have decided to include all medical related costs into our package price estimates, but to leave accommodation costs out for now. The issue with accommodation is that the cost can vary widely depending on the option chosen. We can however put you in touch with relevant facilities that provide accommodation services.
The package includes:
- all hospital fees
- surgeon, assistant and anaesthetic fees
- prosthesis (implant) fees
- multidisciplinary team support
- physio daily in hospital and 3-5 days per week as outpatient
- regular doctor and nursing follow ups
- xray follow ups
- walking frame and wheelchair rental
For Precice 2 femorals it works out to 550K ZAR. Current exchange rate = 45800 USD.
Externals only: 300K ZAR. Current exchange rate = 25000 USD.
LON/LATP: 400K ZAR. Current exchange rate = 33000 USD.
I hope this clears up some confusion.
More expensive then... So sad! It was my first option.
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More expensive then... So sad! It was my first option.
In US dollars is about 10k less now...
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In US dollars is about 10k less now...
There is some minor price adjustments done from the original price list (on page one) because now the accommodation is no longer included in the total package. There isn't much of a difference from the original price quotes, it's just that you will now be responsible for obtaining your own accommodation. Depending on your housing preferences/needs, that may or may not save you a few bucks.
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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.
If surgical trauma is a big factor, would that mean that athletic ability is adversely affected the least using external only methods? Because there is no reaming or going through the knee isnt surgical trauma from exfix minimal on tibias? Or is this incorrect?
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Hello Dr Franz Birkholtz. I am currently residing in Vereeniging. I would like to undergo the limb lengthening with the PRECICE 2 but only in 2 years time from now. My problem is I don't want to lengthen my legs but rather shorten it. I read from Dr Paley's webpage that the Precice device can either shorten or lengthen legs. I have really long and lanky legs and it makes me feel uncomfortable. But I have a long torso as well. I would like to shorten my femurs so that my legs are just a little longer than my torso, not very long. How long would it take it shorten the femurs 6 cm? And can I still do normal activities while I am undergoing leg shortening? I would like to shorten my legs purely for aesthetic and cosmetic reasons
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Hello Dr Franz Birkholtz. I am currently residing in Vereeniging. I would like to undergo the limb lengthening with the PRECICE 2 but only in 2 years time from now. My problem is I don't want to lengthen my legs but rather shorten it. I read from Dr Paley's webpage that the Precice device can either shorten or lengthen legs. I have really long and lanky legs and it makes me feel uncomfortable. But I have a long torso as well. I would like to shorten my femurs so that my legs are just a little longer than my torso, not very long. How long would it take it shorten the femurs 6 cm? And can I still do normal activities while I am undergoing leg shortening? I would like to shorten my legs purely for aesthetic and cosmetic reasons
Hi Lucy,
How tall are you and could you tell us your age?
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Hi Lucy,
How tall are you and could you tell us your age?
I am 23 and im 174 cm tall i would like to be 168 cm tall. I would like to be shorter than I am now purely for aesthetic reasons
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I think your height is fine.
your height is like the models.
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there is no way you should do that, your height is perfectly fine, most males are taller than you and your height is considered a model height so you only could get benefits for that, long legs in womens are beautifull
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Modeling isnt the be all end all for women. Statistically 174 cm is quite tall for a woman so it makes sense she may feel awkward or too leggy.
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Modeling isnt the be all end all for women. Statistically 174 cm is quite tall for a woman so it makes sense she may feel awkward or too leggy.
You are right I feel awkward and too leggy. I want to be shorter than most males and this may sound weird but I want my legs a bit shorter than my torso it just looks nice to me that way
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there is no way you should do that, your height is perfectly fine, most males are taller than you and your height is considered a model height so you only could get benefits for that, long legs in womens are beautifull
I don't think most males are that taller than I am. I want to wear heels without looking too tall. I always want to be shorter than men. And I want a long torso and short legs. I like it that way. I know it sounds weird.
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I don't think most males are that taller than I am. I want to wear heels without looking too tall. I always want to be shorter than men. And I want a long torso and short legs. I like it that way. I know it sounds weird.
you are shorter than the average man in most occidental countries, obviously not if you wear high heels , you should wear médium or low heels and thats fine.
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Hello guys, thank you so much of your input. I have decided against limb lengthening surgery. I have to accept what nature gave me and appreciate what I have. At least none of my limbs are shorter than each other. After lengthy research about the complications of limb lengthening and the lengthy time of lengthening and recovery. I don't want to undergo any trauma. But thank you all for taking the time to add valuable input.
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We have started an educational platform with some video material you may find interesting.
https://walkamile.pivotshare.com
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Hi guys,
We've looked at the numbers again. There is currently a lot of volatility in the international currency exchange rates. For this reason we have decided to change our costing model so that the quoted price is in South African Rand (ZAR). We pay the subcontractors in Rand so it makes sense to peg the price locally. This will obviously make our prices more competitive to some people and less so to others.
Secondly, we have started a second office at the brand new state of the art Mediclinic Midstream Hospital with fantastic facilities. We will be offering our CLL services at this hospital. It is more upmarket and discreet. The price quoted is for a private room in this facility (flat screen tv, private bathroom etc).
Remember that although we are getting progressively more known for internal lengthening with Precice, we have had many years of experience with the Ilizarov method, Taylor Spatial Frame, Truelok and Truelok Hex frames as well as other techniques. Therefore we can offer a high level of expertise and care should you require external fixator based treatment.
Lastly, we have decided to include all medical related costs into our package price estimates, but to leave accommodation costs out for now. The issue with accommodation is that the cost can vary widely depending on the option chosen. We can however put you in touch with relevant facilities that provide accommodation services.
The package includes:
- all hospital fees
- surgeon, assistant and anaesthetic fees
- prosthesis (implant) fees
- multidisciplinary team support
- physio daily in hospital and 3-5 days per week as outpatient
- regular doctor and nursing follow ups
- xray follow ups
- walking frame and wheelchair rental
For Precice 2 femorals it works out to 550K ZAR. Current exchange rate = 45800 USD.
Externals only: 300K ZAR. Current exchange rate = 25000 USD.
LON/LATP: 400K ZAR. Current exchange rate = 33000 USD.
I hope this clears up some confusion.
Price update: Current rand/dollar exchange rate means our prices are adjusted as follows:
Precice 2 femorals (above package): 42000 USD
Externals only: 22000 USD
LON/LATP: 28500 USD
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Price update: Current rand/dollar exchange rate means our prices are adjusted as follows:
Precice 2 femorals (above package): 42000 USD
Externals only: 22000 USD
LON/LATP: 28500 USD
Still a 165 cm upper limit? I thought I was 5'7 but in my last doctor visit, they measured me 5'6.5 though both are slightly above 165
In American feet/inches
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Still a 165 cm upper limit? I thought I was 5'7 but in my last doctor visit, they measured me 5'6.5 though both are slightly above 165
In American feet/inches
The upper limit of 165 is a general safety guideline, but is not an absolute limit. It depends on each individual.
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Hello Dr. Franz,
Just out of curiosity, you have mentioned that the price of Precise is 550k ZAR. That translates to around $ 37k. Why is the case that the newly quoted price is $ 42k ? :)
Thanks !
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Hello Dr. Franz,
Just out of curiosity, you have mentioned that the price of Precise is 550k ZAR. That translates to around $ 37k. Why is the case that the newly quoted price is $ 42k ? :)
Thanks !
It is because the nails are from the US and as the Rand weakens, the price to access them in rands increases. Remember that around 25-30k alone goes towards the price of the nails.
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Yes, that makes sense. Just out of curiosity, why is the case that the South African currency depreciates so much in the recent months ?
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Yes, that makes sense. Just out of curiosity, why is the case that the South African currency depreciates so much in the recent months ?
I thought you said you were educated at a top German business school.
http://lmgtfy.com/?q=why+is+the+south+african+rand+depreciating
Let's keep pertinent questions related to LL for Dr.Birkholtz?
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I thought you said you were educated at a top German business school.
http://lmgtfy.com/?q=why+is+the+south+african+rand+depreciating
Let's keep pertinent questions related to LL for Dr.Birkholtz?
Spoil sport I was planning to ask Dr Birkholtz about his ideas for resolving conflict in the Middle East.
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No worries.
I am no economist - thank goodness! But currencies in the developing world are volatile. Mostly issues of confidence in the politicians and their policies. Couple that to global concerns and people moving money to safe havens. Lastly, if the politicians do stupid things like firing a perfectly good finance minister, things sometimes go a little pear shaped.
Peace in the Middle East? Now that might take a little longer...
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No, I don't think peace in the Middle East is ever happening. There have always been wars over there, and the constitution of the countries there (that is, the Quran), calls for more war and violence.
Anyway, I sent you an email to (franz.birkholtz@walkamile.co.za) regarding the surgery that I am seriously considering with you and I look forward to discuss the details :)
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Good honest doctor. Not a salesman like many others in this forum. He tells the truth, he is honest and caring
It's a pity he works so far..
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Hello Dr. Franz,
I have sent you two emails with regard to internal femur lengthening. Have you received it yet? I really want to get it done, but I need those question answered first. Please let me know, it's been two weeks. Thanks
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Hi,
We have been in contact I believe?
Anyway, if we haven't, please send another mail.
Rgds,
F
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I was asked by some members to update our prices as the exchange rate make it more favorable than before.
We are now able to provide self-catered accommodation in addition to the other services for the following prices:
Precice 2 femoral lengthening package 42K USD
External fixators only 20K USD
LON/LATP 28K USD
This includes hospital, surgeon, aneasthetist, implants, physio in and out of hospital, accommodation after surgery, wheelchair, crutches/walker, medication within reason, follow-up xrays etc. Ie full package, only food is excluded outside of hospital.
There has to be benefits to a weaker currency!
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"medication within reason" I love it ;D
Could you elaborate a bit further on what kind of accommodation that is?
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IMO people considering the doctor in Spain for his price should consider Birkholtz instead. He is in the same price range. Monegal's price is a little cheaper but doesn't include very expensive physio out of hospital, very expensive accommodation after surgery, wheelchair, medication and Xrays. IMO Birkholtz is a very good option because he is honest, professional and caring and has a very nice personality. It's a pity he works in Africa.
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"medication within reason" I love it ;D
Could you elaborate a bit further on what kind of accommodation that is?
It would typically be a selfcatering apartment (ground level) in a safe and secure gated community close to the hospital.
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It's a pity he works in Africa.
What do you mean with that comment.?
SA is his country and thats where he works. Simple as that. You do realize that part of the affordable price is the fact that the SA currency is weak. Accordingly, his price would have been much higher had he worked in another country. He could probably work in the Netherlands, do you think if he goes there it would be the same price ? :)
As I wrote at the thread about Dr. Mitkovic, there are historic and economic and social factors why a country is..well fked up. And that does not mean that brilliant people are not born in these countries every day. In the choice of doctors, what is important is the experience and the technology of the doctor. If these are top, unless the country is in very bad situation, like in a civil war where it is dangerous to go, I see no problem. And I dont think SA is in such shape ;) I went there for the World Cup 6 years ago and I felt totally safe and had the time of my life.
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Hi guys,
We've looked at the numbers again. There is currently a lot of volatility in the international currency exchange rates. For this reason we have decided to change our costing model so that the quoted price is in South African Rand (ZAR). We pay the subcontractors in Rand so it makes sense to peg the price locally. This will obviously make our prices more competitive to some people and less so to others.
Secondly, we have started a second office at the brand new state of the art Mediclinic Midstream Hospital with fantastic facilities. We will be offering our CLL services at this hospital. It is more upmarket and discreet. The price quoted is for a private room in this facility (flat screen tv, private bathroom etc).
Remember that although we are getting progressively more known for internal lengthening with Precice, we have had many years of experience with the Ilizarov method, Taylor Spatial Frame, Truelok and Truelok Hex frames as well as other techniques. Therefore we can offer a high level of expertise and care should you require external fixator based treatment.
Lastly, we have decided to include all medical related costs into our package price estimates, but to leave accommodation costs out for now. The issue with accommodation is that the cost can vary widely depending on the option chosen. We can however put you in touch with relevant facilities that provide accommodation services.
The package includes:
- all hospital fees
- surgeon, assistant and anaesthetic fees
- prosthesis (implant) fees
- multidisciplinary team support
- physio daily in hospital and 3-5 days per week as outpatient
- regular doctor and nursing follow ups
- xray follow ups
- walking frame and wheelchair rental
For Precice 2 femorals it works out to 550K ZAR. Current exchange rate = 45800 USD.
Externals only: 300K ZAR. Current exchange rate = 25000 USD.
LON/LATP: 400K ZAR. Current exchange rate = 33000 USD.
I hope this clears up some confusion.
I searched and couldn't find the post, but the accomodation included is 90 days (3 months) right?
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Jip, couple of day before. 5 days in hospital and the rest of the 90 days until the visa expires.
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Jip, couple of day before. 5 days in hospital and the rest of the 90 days until the visa expires.
Is food included for 3 months? If not, what are food prices like in SA?
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Dr Birkholtz, I am interested in doing this with you.
I have the funds at the time but I just need to know, is Precise 2 a faster way of doing CLL and is there a risk of knee problems still?
I want to know how long this would take from beginning to end so that I can walk relatively normal through the airport to fly to Canada.
Is it easier to get visas for medical reasons if I'm Canadian.
Would I be able to stay in the guest house for the consolidation phase as well?
Thanks for your time, I am very impressed by you regularly answering everyone's questions.
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Dr Birkholtz, I am interested in doing this with you.
I have the funds at the time but I just need to know, is Precise 2 a faster way of doing CLL and is there a risk of knee problems still?
I want to know how long this would take from beginning to end so that I can walk relatively normal through the airport to fly to Canada.
Is it easier to get visas for medical reasons if I'm Canadian.
Would I be able to stay in the guest house for the consolidation phase as well?
Thanks for your time, I am very impressed by you regularly answering everyone's questions.
The Precice also has the potential to cause knee pain. Healing times will be similar. The big advantage of Precice lies in eliminating the need for external fixation.
Walking unaided after LON may take somewhere between 4 and 6 months after surgery.
A general visitors visa is valid for 90 days. It can usually be extended upon request with medical reports.
Yes accommodation is around 10K zar per month. Breakfast and dinner can be provided at around 170zar(10usd) per day.
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Hi Dr Birkholtz, I've had a browse through the thread but I couldn't see anything, so apologies if I'm asking repeated questions! Also apologies if this should be in the general question thread, but I decided on here as these are specifically towards your practice as I'm 70% certain if I do decide this is right for me, I would like it to be with you - despite a fear of flying!
So I arrive in South Africa and have the operation on my femurs with Precise installed.
- Is 6cm the maximum you would be willing to do for this, and on average what would be the time taken to lengthen 6cm?
- At what stage would it be possible to weight-bear (presuming under 140lbs) after the operation, what level of functionality would be expected during lengthening, and would pre operation fitness levels have any impact on this?
- After lengthening, presuming there are no complications, what would the best and worst cases be for the recovery period to take in order to be able to:
a. walk unaided?
b. return to fairly sedentary work?
c. partake in strenuous activity, e.g. long distance running, contact sports, weight lifting etc.
- If the Precise device was to fail for any reason, what would the protocol be?
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(http://i1296.photobucket.com/albums/ag19/Stadiometer/Screen%20Shot%202016-03-08%20at%201.59.58%20PM_zpsysszuldd.png)
https://www.youtube.com/watch?v=CVM89fxZ34M
https://www.youtube.com/watch?v=cBZ1MVSVhuw
https://www.youtube.com/watch?v=UVeI9GPnRK0
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There's where I do my physio and mostly everything that needs to be done. I was obviously operated there also
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Thank you Dr. Franz,
My question is what do you think about salamehfix?
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I wonder which is the actual cost for each item Precice, LON?
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(http://i67.tinypic.com/15xts00.jpg)
(http://i64.tinypic.com/30rw48k.png)
(http://i68.tinypic.com/23r61xg.png)
(http://i68.tinypic.com/2emk4g9.png)
(http://i68.tinypic.com/2iqcuio.png)
(http://i63.tinypic.com/2zsnrsp.png)
(http://i67.tinypic.com/33zfepc.jpg)
(http://i66.tinypic.com/ndo700.jpg)
Email: franz.birkholtz@walkamile.co.za
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https://www.youtube.com/watch?v=CVM89fxZ34M
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https://www.youtube.com/watch?v=cBZ1MVSVhuw
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https://www.youtube.com/watch?v=UVeI9GPnRK0
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Good to hear about dr. Franz again.
Doe i'm bit worried about current situation in SA.
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Right now I'm deciding between Birkholtz and Parihar for internals.
Wasn't his precise more expensive before? $41K isn't too bad :o
Thanks for the info.
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Yeah this is really great to hear thank you for the update! Seems like Parihar/Birkholtz are a pretty great option for internals with very well-trained physicians but a much more feasible price.
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Out of touch, his internals are still in the same range of price, but if you read carefully will realize that the package doesnt include pshysio, accomodation and everyday food, that is the reason because the price was quoted as 52k USD.
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^
Ah, I forgot that his old package had physio included along with accommodation.
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Just want to chime in. I had a clinic consult with Dr Franz about 3 years ago in SA. Here are my impressions:
- He doesn't do touting (does not advertise boastfully)
- His practice is busy with non CLL cases so I guess that's why he's not desperate advertising for CLL; and that's the main disadvantage I guess, he doesn't have a lot of CLL cases/experiences than other doctors here and so some patients may still be reluctant to choose him
- He is very realistic, and won't give you unrealistic centimetre goals; after x-ray measurements he tells me realistic goals with priority on my safety but still open to adjustments if my body would allow
- If I have funds and time, would still do CLL with him. I just hope he still accepts CLL when I get the funds
- I'm not saying SA is completely safe (and for sure SA is one of the most violent countries in recent years) but I'd be more scared walking around USA (than in SA) knowing guns are freely available (in fact in 2012 figure, USA and SA are #1 and #2 in highest gun-related deaths) LINK (http://"https://businesstech.co.za/news/government/91284/south-africa-is-the-second-worst-country-for-gun-deaths-in-the-world/")
- Another thing to consider is how much patients are protected in SA when there's a dispute; in USA and most Western countries, patients are more reassured.
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Reply| DeleteJunk|
Re: COST OF BILATERAL FEMUR LENGHTHENING SURGERY?
FB
Franz Birkholtz <franz.birkholtz@walkamile.co.za>
Reply|
Yesterday, 05:54
Some additional info I receive from Dr Birkholz. I think he would be a good choice, just a shame that he has taken out accommodation and PT from quote. I think he is trying to give his patients more flexibility, better hotel and more PT if you can afford it.
Thank you for quote. May I ask some additional questions.
1.Can I have an approximate price for all other aspects not covered in quote. Accommodation, further x-rays, physical therapy. Basically anything else that you can
* Accommodation ranges widely depending on level but starts at around 800$ a month. Xrays are included for three months. As in the document physio after hospital is around $55 per hour. Recommended three times a week.
think of based on your experience of patients completing this process.
2. Do you test the functionality of the nail during initial surgery?
*yes and we replace a nonfunctional nail straightaway at no extra cost.
3. What would be my position if nail failed. Would I be responsible for the cost of a further surgery to replace the nail and the cost of the nail?
*if a nail breaks (highly unlikely) replacement with a trauma nail will be done. Cost will be shared. Hospital and nail costs for patients account. Around 8000$
4. What are the scars like with this surgery?
*2cm incision where nail is inserted on side of hip. 4 stab incisions for locking screws. 2cm incicision lateral above knee for ITB release.
5. Do you advise weight bearing during lengthening or would i be in a wheelchair for all of that time?
*check document. Upon discharge you will aready be weight bearing on a walking frame. Double leg stance.
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Hi everyone,
Since I am being swamped by emails, I thought it may be a good idea to open this thread again for questions and answers. In this way I can answer once for everyone's benefit. Please keep it civil and to the point.
Ground rules: no trolling, no badmouthing of eachother or other doctors. My intention here is to provide information. For real medical advice you need to see your local CLL doctor. There are fantastic docs out there who can look after you well.
I will endeavour to answer speedily and accurately, but bear in mind this happens inbetween normal patient care, so answers may take a while.
Fire away!
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Sorry to hear that, Dr. Franz. I have just one little doubt, before a tibial lengthening is not recommended to use heels more than 2 cm, right? In the unfortunated case that some people have used high heels( up to 4 cm) for a long time, would you recommend a percutaneous achilles tendon lengthening prior to the tibia surgery??
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Interesting question. :-)
I personally don't think that having worn heels is necessarily a contra-indication. It really depends more on your current flexibility and stretching routine during and after lengthening. I almost never perform the achilles lengthening at the beginning, but tend to add it to the exfix removal procedure at the end if it is deemed necessary.
Hope this helps?
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Thank you very much for your time, Dr.
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Dr. Birkholtz, thank you for returning to the forum! I would certainly appreciate your take on the following questions:
1) Do you believe that a biceps femoris release is required for femoral lengthening? Some Drs perform it as a precautionary measure, some do not - I would love your opinion on this, and specifically, what the tradeoffs are in performing/not performing the release?
2) What do you consider a "safe" lengthening amount for close to full return to athletic activity? Reading through literature, you and other Drs have stated 5 cms, possibly 6 cms. Are there specific medical/physiological reasons as to why this is considered a "safe" length, and/or is there more leeway between a person of, say, 168 cms in stature vs one of 178 cms in stature (leaving aside the why the taller person would seek the procedure)?
The latter seems to be a pretty common question on the board, I'm not sure I've seen it answered in great detail.
Your time here is very much appreciated. I am actually glad you are being bombarded by inquiries :), based on your reputation, you seem to be a terrific surgeon and clinician, and I hope your CLL practice continues to blossom. TIA.
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Dr.Birkholtz
Thank you very much for your contribution to this forum.
Would the benefits outweigh the risks of nail removal, femur PRECICE2 in particular?
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Dr Birkholtz
I am looking my femurs internally . I am looking to lengthen 2 inches.
How long would it take to recover from the day of surgery all the way to doing sports again specifically soccer and basketball. And would I be able to go back to 100 percent athletic abilities?
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Thank you very much for your time, Dr.
No worries
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Dr. Birkholtz, thank you for returning to the forum! I would certainly appreciate your take on the following questions:
1) Do you believe that a biceps femoris release is required for femoral lengthening? Some Drs perform it as a precautionary measure, some do not - I would love your opinion on this, and specifically, what the tradeoffs are in performing/not performing the release?
2) What do you consider a "safe" lengthening amount for close to full return to athletic activity? Reading through literature, you and other Drs have stated 5 cms, possibly 6 cms. Are there specific medical/physiological reasons as to why this is considered a "safe" length, and/or is there more leeway between a person of, say, 168 cms in stature vs one of 178 cms in stature (leaving aside the why the taller person would seek the procedure)?
The latter seems to be a pretty common question on the board, I'm not sure I've seen it answered in great detail.
Your time here is very much appreciated. I am actually glad you are being bombarded by inquiries :), based on your reputation, you seem to be a terrific surgeon and clinician, and I hope your CLL practice continues to blossom. TIA.
Hi, thanks for the kind words.
Biceps femoris lengthening is not something I do often and my suspicion is that with my conservative lengthening goals, we probably need it less often than with surgeons who routinely push to 8cm. ITB release, on the other hand, is something I think is essential in nail based femoral lengthening. This helps nail elongation and does not seem to cause any long-term effects.
The issue with a discussion around safe lengthening amounts is that the complications as well as athletic ability are so variable per patient and that many individual factors contribute. As a rule, we start seeing more complications of regenerate delayed unions, deformities, muscle contractures etc after around 5 cm. That is where that comes from. Of course the athletic recovery is dependent on a number of factors like: -pre-surgery athletic ability ; -lengthening amount (this affects the lever arms and mechanics, as well as muscle tightness) ; -muscle tightness and contracture which is also is indirectly related to lengthening amount ; -alignment after lengthening ; and postoperative rehabilitation.
In general, we can probably ironically get a bit more length safely in a patient with a longer starting height than in someone who starts out shorter. It is a precentage equation. So, again, the guys who need the most length are ironically again the guys in whom we can probably safely add less. Just life, I guess?
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Dr.Birkholtz
Thank you very much for your contribution to this forum.
Would the benefits outweigh the risks of nail removal, femur PRECICE2 in particular?
Good question. We simply do not know what the long-term effects of those magnets are. Furthermore MRI is impossible with those nails in.
For these reasons it is advisable to have them removed. The issue is that it is surgery again and that it may well end up with slightly larger scars as well. Ironically the wounds used to remove the nails are typically larger than to insert them.
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Dr Birkholtz
I am looking my femurs internally . I am looking to lengthen 2 inches.
How long would it take to recover from the day of surgery all the way to doing sports again specifically soccer and basketball. And would I be able to go back to 100 percent athletic abilities?
50mm lengthening:
10 days lag period, 50 days distraction period. Ie 2 months till length is achieved. Bone consolidation typically takes another 4 months. Ie by six months full unaided weight bearing should be OK. Return to sport the six-nine months after that, depending on the type of sport.
Ballpark is around 18 months.
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Hello doctor Franz.
I wanted to ask, is there a reason that both you and dr.Rozbruch now more "easily" accept people taller than below the 3%? Before, only a handful of docs accepted people of certain heights (my 5'7 included) but now it seems doctors are more open to do the operation on taller folks (I presume based on the risk/reward ratio).
Basically, what I am asking is if the new methods really did "revolutionized" LL in terms of safety? Did the precise nail really made the procedure much more safer, thus making more doctors feel more comfortable doing this procedure on even taller (sane minded) folks?
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Hi Dr. Franz, thanks so much for answering our questions. I'm interested in your quote about the ITB release. What exactly is an ITB release? What happens to the band after? Does it go back to normal?
ITB release, on the other hand, is something I think is essential in nail based femoral lengthening. This helps nail elongation and does not seem to cause any long-term effects.
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Hello doctor Franz.
I wanted to ask, is there a reason that both you and dr.Rozbruch now more "easily" accept people taller than below the 3%? Before, only a handful of docs accepted people of certain heights (my 5'7 included) but now it seems doctors are more open to do the operation on taller folks (I presume based on the risk/reward ratio).
Basically, what I am asking is if the new methods really did "revolutionized" LL in terms of safety? Did the precise nail really made the procedure much more safer, thus making more doctors feel more comfortable doing this procedure on even taller (sane minded) folks?
Good observation. I think you are hitting the nail on the head (excuse the pun). As techniques and technologies evolve, surgical indications also evolve.
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Good observation. I think you are hitting the nail on the head (excuse the pun). As techniques and technologies evolve, surgical indications also evolve.
So indeed we can safely say that LL is much more safer today than even 5 years ago?
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Hi Dr Birkholtz,
When you first obtained access to the Precice nail, was a representative from Ellipse sent by the company to be present during the surgeries? If so, how long does that continue until Ellipse decides that a representative doesn't need to be there for the surgery every time you use it on a patient?
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Hi Dr. Franz, thanks so much for answering our questions. I'm interested in your quote about the ITB release. What exactly is an ITB release? What happens to the band after? Does it go back to normal?
The iliotibial band (itb) is a connective tissue band on the outside of the thigh. It crosses over the knee as well. As opposed to tendons, the itb cannot really be stretched too much. Because of that, it is often a major resistive force to distraction and can cause nails to malfunction and also can cause a flexion contracture of the knee. This is the reason we advocate releasing it routinely. It is not really a very complicated procedure. A small slit is made in the itb. That allows it to stretch. It then heals up with a form of scar tissue. Interestingly scar tissue is made up mostly of collagen, a protein that also makes up most of the itb. Recovery is essentially complete.
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So indeed we can safely say that LL is much more safer today than even 5 years ago?
Absolutely
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Hello Dr. Franz,
I really appreciate that you have offered to help us understand the limb lengthening process through your experience
I would like to ask about the prospects of a patient who chooses to undergone a 8.0 cm lengthening on both tibias using external fixators, followed by intramedullary nailing; LATN. For a person who does such an amount of lengthening:
1) How long would a he be needing to use a wheelchair after the surgery?
2) Is weight bearing possible right after the surgery?
3) How long would one have to use crutches after 'graduating' from the wheelchair
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Hi Dr Birkholtz,
When you first obtained access to the Precice nail, was a representative from Ellipse sent by the company to be present during the surgeries? If so, how long does that continue until Ellipse decides that a representative doesn't need to be there for the surgery every time you use it on a patient?
Good question. This differs from country to country. Ellipse was bought out by Nuvasive, so they now distribute globally. In South Africa the company sells their products through a distributor. On initial launch there was an intensive training programme. Even now we have a representative in theatre with every case. Most importantly to ensure that there is optimal safety and attention to detail. It facilitates communciation and eliminates errors. I see everyone in the surgical team as equally important. The surgeon is strengthened by the team around him or her.
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Hello Dr. Franz,
I really appreciate that you have offered to help us understand the limb lengthening process through your experience
I would like to ask about the prospects of a patient who chooses to undergone a 8.0 cm lengthening using external fixators, followed by intramedullary nailing; LATN. For a person who does such an amount of lengthening:
1) How long would a he be needing to use a wheelchair after the surgery?
2) Is weight bearing possible right after the surgery?
3) How long would one have to use crutches after 'graduating' from the wheelchair
It depends a little on the segment, whether tibial or femoral. 8cm is an extreme distance, and would be something I would discourage greatly.
In principle crutch walking could start within days after surgery. As with any lengthening, consolidation takes around 1.5 months per cm lengthened. This is approximately the time till full unassisted weight bearing as well.
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Dr,
If I may ask about your record, how many CLL have you preformed? How many non-CLL surgeries have your preformed? Of those how many were using the Precice nail?
I see you don't offer Internal Tibia lengthening, is there a particular reason why? (Like lack of confidence to do so, perhaps you feel the alternatives are safer?)
Have you heard about about news relating to Ellipse's upgraded Precice 2 and when it's coming out? What are your views on it?
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50mm lengthening:
10 days lag period, 50 days distraction period. Ie 2 months till length is achieved. Bone consolidation typically takes another 4 months. Ie by six months full unaided weight bearing should be OK. Return to sport the six-nine months after that, depending on the type of sport.
Ballpark is around 18 months.
Thank you for responding Dr. All this information is so invaluable to us.
I guess my final question would be:
What would you say to the people that are considering you as an option but are afraid to do so because of the crime rate in South Africa? How concerned should we be?
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Some months ago some user here wrote about Precice3, they are creating a cobalt nail, which can be almost full Weight bearing, the question here is if P2 Will go Out of the market like Precice1?? Or just will be an option(mainly because there are very Slim people), also the cost!!
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Hi doctor.
do blood vessels get smaller in diameter after lengthening? have there been any studies regarding this?
also, do you know of research material we can go through to understand the impact of lengthening of nerves and blood vessels? Most of the papers I find on Google, decide the outcome of a surgery based on how a patient feels, but not quantitatively. Is there research done that quantitatively compares the before - after states of lengthening? (like an EMG test before and after)
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Dr,
If I may ask about your record, how many CLL have you preformed? How many non-CLL surgeries have your preformed? Of those how many were using the Precice nail?
I see you don't offer Internal Tibia lengthening, is there a particular reason why? (Like lack of confidence to do so, perhaps you feel the alternatives are safer?)
Have you heard about about news relating to Ellipse's upgraded Precice 2 and when it's coming out? What are your views on it?
Hi,
I do not specifically count my numbers. Lengthening and limb reconstrction surgeries more than 2000. CLL with Precice around 10. Other non-CLL Precice around 20.
The imformation leaflet is somewhat misleading. Sorry about that. Tibial Precice is offered for the same package as femorals. Confidence is not an issue. Anterior knee pain risk with Precice still about the same as for LON. Weight bearing with LON better than Precice. COst significantly higher with Precice. Therefore I am probably a bit biased to prefer LON. :-)
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Thank you for responding Dr. All this information is so invaluable to us.
I guess my final question would be:
What would you say to the people that are considering you as an option but are afraid to do so because of the crime rate in South Africa? How concerned should we be?
Good question.
There are areas where it is really unsafe as in almost any country in the developing world. The hospitals an environments where I live and work are probably safer than a lot of big cities in the US. Be that as it may, the best would probably be to schedule a short holiday and combine that with a consultation and planning visit.
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Some months ago some user here wrote about Precice3, they are creating a cobalt nail, which can be almost full Weight bearing, the question here is if P2 Will go Out of the market like Precice1?? Or just will be an option(mainly because there are very Slim people), also the cost!!
In my experience products generally tend to take a lot longer to get to market than the rumour mill would suggest. Whether the company will kee the price similar and whether they will withdraw the 'older' models I don't know.
Remember that the Synoste Chrome Cobalt nail is also on the horison.
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Hi doctor.
do blood vessels get smaller in diameter after lengthening? have there been any studies regarding this?
also, do you know of research material we can go through to understand the impact of lengthening of nerves and blood vessels? Most of the papers I find on Google, decide the outcome of a surgery based on how a patient feels, but not quantitatively. Is there research done that quantitatively compares the before - after states of lengthening? (like an EMG test before and after)
Interesting question. I suspect that there are not many such studies as the groups per centre are relatively small. Also, proper assessment would require biopsy which is obviously too invasive. There are some studies on animals. In broad terms the muscle and vessels also grow with the bone and end up being of a similar structure than originally. Some of us are looking into getting better outcomes data through ongoing research.
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Good question.
There are areas where it is really unsafe as in almost any country in the developing world. The hospitals an environments where I live and work are probably safer than a lot of big cities in the US. Be that as it may, the best would probably be to schedule a short holiday and combine that with a consultation and planning visit.
What about staying in a hospital for lengthening phase?
Seriously i'm hearing tons of horrifying stories from SA...
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I have Been trying to figure Out if with LON method a monolateral fixators can be an option, can the nail inside help to prevent misalignments or the fixator is as important as the nail.
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What about staying in a hospital for lengthening phase?
Seriously i'm hearing tons of horrifying stories from SA...
I mean in the hotel*
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Dr. Birkholtz, thank you for taking the time to diligently answer so many questions. It is incredibly appreciated.
One last question from me: how much blood loss do you generally see in operating theatre from CLL procedures (femoral) done with the Precise nail? In your experience, do they generally require blood transfusions? If so, how safe are the blood banks in SA relative to US/EU in terms of risk of infection/disease from blood transfusions?
TIA and best regards!
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What about staying in a hospital for lengthening phase?
Seriously i'm hearing tons of horrifying stories from SA...
As the accommodation is not directly part of the package, it is your choice to decide where to stay during lengthning.
If it were me, I would consider the Irene Country Lodge. Excellent, safe, good food and amenities, beautiful gardens and centrally located close to shops, malls, hospitals etc. I think they have a reduced rate for extended stays.
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I have Been trying to figure Out if with LON method a monolateral fixators can be an option, can the nail inside help to prevent misalignments or the fixator is as important as the nail.
It is definitely an option. To a large extent the nail will prevent malalignment. Cost in our setting for tibial lon with circular would be the same though, so probably better to go for circular.
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Dr. Birkholtz, thank you for taking the time to diligently answer so many questions. It is incredibly appreciated.
One last question from me: how much blood loss do you generally see in operating theatre from CLL procedures (femoral) done with the Precise nail? In your experience, do they generally require blood transfusions? If so, how safe are the blood banks in SA relative to US/EU in terms of risk of infection/disease from blood transfusions?
TIA and best regards!
As a rule, because we use percutaneous techniques and have relatively low transfusion triggers, the need for blood transfusion is the exception.
You can visit the South African National Blood Transfusion Service's website for more info. It is one of the oldest blood bank services in the world and is regarded as exceptional in terms of international safety standards. www.sanbs.org.za
Intra-operative blood loss between 300 and 500 mls at the most. There can be further ongoing loss into the 'third space'. Most healthy adults can withstand losses of around three times this much without the need for transfusion.
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Thank you for your responses so far :)
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Oh okay, thanks .
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Hey, thanks for your time Dr. Birkholtz, this thread has been an interesting read.
If you know anything about other LL doctors and also don't mind sharing your thoughts on them, what are your opinions on Dr. Mitkovic in Nis, Serbia?
Also, what things do you usually recommend your patients do to prepare in the months leading up to the surgery? Stretches, exercises, diet, supplements?
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Greetings Dr Birkholtz. Primarily, I'd like to thanks your contributions to this thread in shedding light on certain hazy issues found within the limb lengthening world. It is refreshing to see a weighted opinion from a professional. If you may, would you please answer the following queries -
1) Is the placement of the break relevant in regards to recovery or even the look of the soft tissue surrounding it? For example, if one was to break and lengthen the center of the calf muscle vs just above the ankle.
2) I have noticed many issues with gait are often blamed on soft tissue. While this is an issue, I often think that minor misalignment may factor strongly into this, especially when viewing video footage where genu valgum (which I assume is different when the bone misaligns than simply being 'knock kneed') is present to some degree. Do you believe this is possible? Can genu valgum be corrected in its entirety an osteotomy or a 'guiding plate'? Can it be avoided in the current form of leg lengthening?
3) Soft tissue is one of the largest issues in regards to limb lengthening. Is there a medical consensus on why soft tissue doesn't adapt the same way it does during natural bone growth? We are all aware that after growth plates fuse no more growth can occur even under the same hormonal conditions but why does the same issue of growth of soft tissue occur where they technically have no 'end point' similar to plate fusion? Could one not accurately reproduce the hormonal conditions in soft tissue growth to mimic that found in natural growth? I believe I have read some studies that refer to issues with cell reproduction of soft tissue in regards to this.
4) A second question regarding soft tissue, after leg lengthening, does the body ever truly recover to the stretching even several years after combined with consistent physical therapy (if lengthened to reasonable standards rather than over lengthening leading to plastic deformation which I assume is permanent), creating new tissue as found in someone with legs of that natural length or does the body just adapt and become more flexible rather than truly recovering, with the soft tissue always being stretched to accommodate the new bone?
5) What are your thoughts on maintaining the ratio naturally found prior to leg lengthening? For example, lengthening both segments by 10% meaning they maintain the ratio or is falling in a biomechanically sound ratio just as acceptable?
6) Is there truly such thing as 100% recovery in regards to cosmetic leg lengthening when the soft tissue is stretched any amount reasonable or not or will it always limit maximum athletic potential even if its imperceptible?
7) What do you believe is the future of cosmetic leg lengthening? Personally, statistical evidence and measurements of patients would be the most important at this point. If I were to go forward with this surgery, I'd hope to do so in a decades time which by then I hope there have been improvements, with as much knowledge as possible and with a reputable surgeon such as yourself.
Thank you in advance for taking the time to read and hopefully reply to these questions. Regards.
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Good question. This differs from country to country. Ellipse was bought out by Nuvasive, so they now distribute globally. In South Africa the company sells their products through a distributor. On initial launch there was an intensive training programme. Even now we have a representative in theatre with every case. Most importantly to ensure that there is optimal safety and attention to detail. It facilitates communciation and eliminates errors. I see everyone in the surgical team as equally important. The surgeon is strengthened by the team around him or her.
I like this about Precice. There have been some problems with Fitbone and the representatives didn't come or came very late and patients had to have many surgeries like Helloworld and Musicmaker. In Penguinn's case with Precice everything was fixed during the initial surgery. Precice isn't perfect but it's the best one in the market.
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Hey, thanks for your time Dr. Birkholtz, this thread has been an interesting read.
If you know anything about other LL doctors and also don't mind sharing your thoughts on them, what are your opinions on Dr. Mitkovic in Nis, Serbia?
Also, what things do you usually recommend your patients do to prepare in the months leading up to the surgery? Stretches, exercises, diet, supplements?
I prefer not to comment on other doctors out of professional courtesy. It is certainly not up to me to evaluate whether a doctor is good or safe. I hope you understand.
I am a firm believer that the two most important preparations are flexibility and mindset. Improving flexibility and core strength is key. This is achieved through regular pilates or yoga, supplemented by a stretching programme.
Mindset is a little more difficult. I think regular sessions of meditation and/prayer (depending on your personal beliefs) will serve to calm and centre the spirit. This is needed to endure the sometimes brutal process that lies ahead.
Lastly a good balanced diet with ample amounts of protein and vegetables will provide the building blocks needed for recovery. Think of what you would ideally want to feed a healthy growing child.
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Dr Birkholtz,
Based off your experience would you be able to answer the following questions
1. How long does one have to stay in Africa before being able to travel back home
2. How long before someone makes a recovery. My definition of a recovery is the ability to walk without any help and the ability to walk completely normal without a limp of any kind.
This is assuming that the patient does internals.
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Greetings Dr Birkholtz. Primarily, I'd like to thanks your contributions to this thread in shedding light on certain hazy issues found within the limb lengthening world. It is refreshing to see a weighted opinion from a professional. If you may, would you please answer the following queries -
1) Is the placement of the break relevant in regards to recovery or even the look of the soft tissue surrounding it? For example, if one was to break and lengthen the center of the calf muscle vs just above the ankle.
Yes,absolutely. The choice of osteotomy site will determine the rate and quality of bone growth, as well as the final appearance of the limb. As a general rule, the preference in the femur is proximal. In the tibia we also prefer proximal as that creates the most reliable bone formation.
2) I have noticed many issues with gait are often blamed on soft tissue. While this is an issue, I often think that minor misalignment may factor strongly into this, especially when viewing video footage where genu valgum (which I assume is different when the bone misaligns than simply being 'knock kneed') is present to some degree. Do you believe this is possible? Can genu valgum be corrected in its entirety an osteotomy or a 'guiding plate'? Can it be avoided in the current form of leg lengthening?
Genu valgum is, as you rightly put, a knock-kneed alignment of the limb. It is accepted that the term applies to the more severe cases which would be pathological and may cause long-term issues like arthritis. It is possible to control for and prevent malalignment. With some techniques like Ilizarov only and Monolateral only techniques, it is easier to develop malalignments. The surgeon can usually pre-empt and treat this if they are experienced.
3) Soft tissue is one of the largest issues in regards to limb lengthening. Is there a medical consensus on why soft tissue doesn't adapt the same way it does during natural bone growth? We are all aware that after growth plates fuse no more growth can occur even under the same hormonal conditions but why does the same issue of growth of soft tissue occur where they technically have no 'end point' similar to plate fusion? Could one not accurately reproduce the hormonal conditions in soft tissue growth to mimic that found in natural growth? I believe I have read some studies that refer to issues with cell reproduction of soft tissue in regards to this.
The main difference in soft tissue adaptation to growth during normal growth vs CLL growth, is the rate at which it occurs. It seems like one of the ways that soft tissue adapts to growth is because of a constant distraction force which triggers gene expression and provides soft tissue growth. In normal growth, this rate of elongation is quite slow and as a result the tissues grow at the optimal rate and can 'keep up'. In limb lengthening we have to speed up the process because the bone will consolidate prematurely if we stretch too slowly. If we could drop distraction rates down to 0.1-0.3mm per day, we will probably have soft tissues that will adapt better. In addition there is probably some form of genetic trigger that switches off after normal adolescent growth, similar to a growth plate closing. Lastly, the predominant protein in soft tissue is collagen. It does become less supple as time goes on, and this is a result of aging. This causes more resistance to stretching as well.
4) A second question regarding soft tissue, after leg lengthening, does the body ever truly recover to the stretching even several years after combined with consistent physical therapy (if lengthened to reasonable standards rather than over lengthening leading to plastic deformation which I assume is permanent), creating new tissue as found in someone with legs of that natural length or does the body just adapt and become more flexible rather than truly recovering, with the soft tissue always being stretched to accommodate the new bone?
Although distraction histiogenesis does cause new tissue to form (ie grow properly), there is an element of elongation through stretching. One of the reasons why realistic lengthening goals should be borne in mind.
5) What are your thoughts on maintaining the ratio naturally found prior to leg lengthening? For example, lengthening both segments by 10% meaning they maintain the ratio or is falling in a biomechanically sound ratio just as acceptable?
As you know, the ration is around 80% and is probably best to try and maintain that as far as possible. Unfortunately logistics and money usually allows only one segment of lengthening, which means deviating from this ratio. For the majority of us, I do not believe that this will translate on its own into worse biomechanics and sporting function. If you happen to be at the top end of your sporting game, it may be different.
6) Is there truly such thing as 100% recovery in regards to cosmetic leg lengthening when the soft tissue is stretched any amount reasonable or not or will it always limit maximum athletic potential even if its imperceptible?
I think that with current technologies available, athletic potential is definitely affected regardless of lengthening amount. Whether it is noticeable in an individual would depend on factors like pre-op status, flexibility, genetics, lengthened amount, technique etc etc.
7) What do you believe is the future of cosmetic leg lengthening? Personally, statistical evidence and measurements of patients would be the most important at this point. If I were to go forward with this surgery, I'd hope to do so in a decades time which by then I hope there have been improvements, with as much knowledge as possible and with a reputable surgeon such as yourself.
I suspect we will very soon start meddling with growth genes during childhood and adolescence and be able to switch these on and off in patients with proven expected shorter stature. Would we be playing God?
Thank you in advance for taking the time to read and hopefully reply to these questions. Regards.
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Dr Birkholtz,
Based off your experience would you be able to answer the following questions
1. How long does one have to stay in Africa before being able to travel back home
2. How long before someone makes a recovery. My definition of a recovery is the ability to walk without any help and the ability to walk completely normal without a limp of any kind.
This is assuming that the patient does internals.
For internal femurs it is recommended to stay in the area for around 90 days.
Weight bearing without crutches between 6 and 9 months. 'Full recovery' at 12-18 months.
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Thank you very much for your time and answers Dr Birkholtz, it's much appreciated.
If we could drop distraction rates down to 0.1-0.3mm per day, we will probably have soft tissues that will adapt better.
Perhaps technology will advance to the point where some system can be put in place to stretch soft tissue prior to any surgery over the course of a year or so at a much slower rate meaning that the tissue will have been stretched at a much more reasonable speed and amount and be already be at the correct length for the increase in bone, delay union to lengthen at a slower rate (which would present it's own issues) or use stem cell/hormonal therapy to repair the damaged tissue. The future can't arrive soon enough.
Would we be playing God?
This all depends on perception I believe. In my opinion, no more so than being able to to switch off genetic signals that may result in disease or disability, of course one could argue that height itself is not in the same realm as those issues.
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Dear Dr Franz,
I'd like to ask a question regarding nerve sensations during limb lengthening:
1) If a patient feels a shooting pain, which is thought to be caused by a nerve, should lengthening be stopped or is it safe to continue?
2) If a patient feels numbness and a tingling sensations at places like the sole of the foot, should lengthening be stopped or is it safe to continue?
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Hi,Dr. Franz
Would you operate one leg and some time after the second leg?? When you have a discrepancy of 6-7 cm, is Safe for the supone the use of some extra length on the shoe?
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Dear Dr Franz,
I'd like to ask a question regarding nerve sensations during limb lengthening:
1) If a patient feels a shooting pain, which is thought to be caused by a nerve, should lengthening be stopped or is it safe to continue?
2) If a patient feels numbness and a tingling sensations at places like the sole of the foot, should lengthening be stopped or is it safe to continue?
This is a difficult question to answer, as I do not have the full context of the patient. In broad terms, if this were my patient, we would slow the rate of distraction down. It is extremely important that these symptoms be discussed with the treating surgeon as soon as possible.
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Hi,Dr. Franz
Would you operate one leg and some time after the second leg?? When you have a discrepancy of 6-7 cm, is Safe for the supone the use of some extra length on the shoe?
I guess the question is whether one leg can be done and then the second leg later?
I am hesitant to do this, as this will leave the patient with a 6cm leg length discrepancy after the first surgery. If, for some reason the patient cannot return, it would be permanent.
It is also significantly more expensive than simultaneous bilateral surgery.
Another alternative would be cross-over surgery, where one femur and the opposite tibia are done at the same time. Once femur can take weight, the opposite combo of segments can be done. In this way, the LON leg becomes the stong one taking most of the weight.
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Hello Dr Birkholtz, I hope you are having a good day in South Africa. Truly a beautiful country.
If you would humor me, I would like to ask some questions.
1) In your personal opinion and speaking very generally (every case is unique of course), if a man in peak physical fitness, young, flexible and dedicated to PT (Apologies, this sounds very odd) underwent the procedure, lengthened a reasonable amount of 3-4CM per segment for a total of 6-8CM gain and no complication arose, would you expect the patient to recover to a point where they were physically able to run/casually play sports to an acceptable standard?
2) I often see safety limits given as an absolute number. Would % not be more accurate, for example would 5CM on a short tibia be a much more difficult prospect than on a much larger tibia? Or are general safety limits just that, general and should be advised on a case by case situation? Do you have an upper limit you personally advise? Is it true plastic deformation occurs when the soft tissue cannot stretch anymore and is damaged more and more by further lengthening?
3) I see you stated that it is much safer to undergo cosmetic limb lengthening surgery now than 5 years ago, do you anticipate that such advancements in safety and results will carry on in the next decade? I assume this is because developments in orthopedic correction of deformity are technically the same developments that would be applied to cosmetic lengthening correct?
4) Is it true that the soft tissue isn't that much of an issue in deformity correction because the body has usually created the correct amount of soft tissue for a longer limb? I wouldn't think this is the case for Achondroplasia and the soft tissue would be relative to limb length, yet they seem to lengthen very high amounts and don't appear to run into major issues - why is this?
5) Do you like biltong?
Regards.
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I guess the question is whether one leg can be done and then the second leg later?
I am hesitant to do this, as this will leave the patient with a 6cm leg length discrepancy after the first surgery. If, for some reason the patient cannot return, it would be permanent.
It is also significantly more expensive than simultaneous bilateral surgery.
Another alternative would be cross-over surgery, where one femur and the opposite tibia are done at the same time. Once femur can take weight, the opposite combo of segments can be done. In this way, the LON leg becomes the stong one taking most of the weight.
.
Very good option, I think 11-12 cm is still a safe amount doing this un Cross way. Would the price be exactly half of the original in each technique? More or less 35k USD.
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I forgot to ask one thing: talking about subsidence, is it only a problem with pure external or there is still a chance using an hybrid method( LON, LATN)? I have read diaries of patients using pure external and lose like 1.5 cm, I hope this is not the case with hybrids.
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I forgot to ask one thing: talking about subsidence, is it only a problem with pure external or there is still a chance using an hybrid method( LON, LATN)? I have read diaries of patients using pure external and lose like 1.5 cm, I hope this is not the case with hybrids.
Conceivably, once the nail or plate is locked, the only way the bone can shorten is by the nail or plate bending or failing.
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Hello Dr Birkholtz, I hope you are having a good day in South Africa. Truly a beautiful country.
If you would humor me, I would like to ask some questions.
1) In your personal opinion and speaking very generally (every case is unique of course), if a man in peak physical fitness, young, flexible and dedicated to PT (Apologies, this sounds very odd) underwent the procedure, lengthened a reasonable amount of 3-4CM per segment for a total of 6-8CM gain and no complication arose, would you expect the patient to recover to a point where they were physically able to run/casually play sports to an acceptable standard?
2) I often see safety limits given as an absolute number. Would % not be more accurate, for example would 5CM on a short tibia be a much more difficult prospect than on a much larger tibia? Or are general safety limits just that, general and should be advised on a case by case situation? Do you have an upper limit you personally advise? Is it true plastic deformation occurs when the soft tissue cannot stretch anymore and is damaged more and more by further lengthening?
3) I see you stated that it is much safer to undergo cosmetic limb lengthening surgery now than 5 years ago, do you anticipate that such advancements in safety and results will carry on in the next decade? I assume this is because developments in orthopedic correction of deformity are technically the same developments that would be applied to cosmetic lengthening correct?
4) Is it true that the soft tissue isn't that much of an issue in deformity correction because the body has usually created the correct amount of soft tissue for a longer limb? I wouldn't think this is the case for Achondroplasia and the soft tissue would be relative to limb length, yet they seem to lengthen very high amounts and don't appear to run into major issues - why is this?
5) Do you like biltong?
Regards.
The short answer to all your questions, especially number five is YES. :-)
1) Yes, but it does depend on the individual circumstances.
2) Again, yes. To be 100% safe, the limit is 0cm lengthening. But life is not absolute and everything is a balancing act of benefit vs risk. My suggestion is to choose a good surgeon and then follwo his/her advice re safe limits. Personally I am comfortable with a risk-benefit ratio of around 5.5cm for femorals and 4.5-5cm for tibials. If the patient's starting height is more, maybe these numbers can be increased somewhat.
3) There is constant invention of new techniques and devices and development of existing ones. Technologies like Precice represent somewhat of a Revolution in thinking (disruption of the market). What will logically follow for the next few years will be gradual evolution of the system until the next revolution takes place.
4) Generally contractures in post-traumatic deformity is less of an issue. Achondroplasia is an interesting one. It is a condition that has its origins in abnormal collagen. You will recall that collagen also makes up most of the muscle and tendon structures. Because of this, these patients have much more supple soft tissues that allow tremendous amounts of lengthening quite safely.
5) Again Yes. Biltong is difficult to describe. It is a salt cured air dried meat, not dissimilar to Jerky or even Bresaola. But it needs to be experienced locally to really appreciate it. If you have gout, South Africa is maybe not the best place to visit! Barbecue, red meat, wine and beer is pretty much part of life down here.
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.
Very good option, I think 11-12 cm is still a safe amount doing this un Cross way. Would the price be exactly half of the original in each technique? More or less 35k USD.
Yes around there.
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Hi Dr.Fraz
I underwent limb lengthening in India and did 6.3 CM using LON in tibias.
It's been 8 months since first surgery and 5 months since frame removal. I have equinus in my right foot. I have been doing stretchings and physiotherapy daily. I don't see any improvement in ballerina. I thought of undergoing ATL surgery.
But, the experience of few patients who underwent ATL is bad. I am confused now.
I consulted couple of doctors too and some say I have to go for ATL to fix the issue.
One of doctor says, he will put fixator on me to correct the equinus foot. But, I spoke to one patient who also had fixator with Dr.Paley for correcting his Equinus. The patient says that the fixator fixed only like 60%. He says he still have tightness and he has to stretch it every morning. He is considering to go for another surgery if necessary to fix the equinus.
I heard from both the forums that ATL causes permanent weakness and even Dr. Paley says not to go for it. Few doctors say it is ok to go for it. There is one LL vetaran "Body Builder" who went for ATL and says not to go for it. His doctor seems to have over lengthened his tendon. Now, he is planning for another surgery to shorten it. He advises LL patient against ATL.
I have to take decision to go for either fixator (or) ATL.
Fixator:
It may not completly correct the issue. 2 surgeries again.
ATL:
It will correct the Equinus. But, leaves tendon permanently weak.
Could you please give me your advise ?
Thanks in advance.
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Hope you are not having very busy day , doctor:
In case of delayed consolidation what can be done?
some doctors say that ATL is not a good option becuase it has permanent bad effects on the tendon, but others say that is not wrong , in your opinion which position is more correct :)?
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With regards to the two posts on Achilles tendon lengthening in this thread:
Achilles tendon lengthening is probably the best way to het rid of of improve a resistant ballerina foot. Correction with a frame post-CLL has a chance of recurrence. It is very useful for other indications of equinus contracture.
Equinus contracture after CLL can he devastating. Not performing TAL because of fear of weakening is nonsensical. If you remain with the contracture the function is nonexistent anyway.
My advice: get checked out by experienced surgeon and then follow their advice.
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Dr Birkholtz,
When it comes to the Safest procedure, in your opinion which one is it?
Initially I was under the impression that it was precise in the fémurs. Lately I have been seeing that the best option are externals not only for long term safety reasons but also for aesthetic and athletic reasons.
What are your feelings when it comes to these two methods?
Sometimes I know that doctors can have biases when it comes to their preferred methods but biases out of the way and considering aesthetic and athletic goals what is the best option for a patient?
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With regards to the two posts on Achilles tendon lengthening in this thread:
Achilles tendon lengthening is probably the best way to het rid of of improve a resistant ballerina foot. Correction with a frame post-CLL has a chance of recurrence. It is very useful for other indications of equinus contracture.
Equinus contracture after CLL can he devastating. Not performing TAL because of fear of weakening is nonsensical. If you remain with the contracture the function is nonexistent anyway.
My advice: get checked out by experienced surgeon and then follow their advice.
Dr Birkholz.
I've done atl and i have a reduction of plantar flexion in my both feet but especially in the left one where I had more equinus and my tendon lengthened more.
Also, the tension is really bad and the feeling of walking is not as it used to be.
Also, from the most patients who did atl I heard about the same symptoms. So how can you say that the fear of weakening is nonsensical while I live with tis weakening every day after I did atl?
I am really asking about your opinion because you are a respectable doctor.
Finally on he other month I am planing to do an achilles tendon shortening surgery to get back most of the tension and the power I lost due to tendon lengthening.
Do you think that this new surgery won't improve my current situation?
Finally, isn't tendon overlengthening a very usual complication of atl? If yes (and thats what I think it happened with my case), how can a doctor be sure which length he should give to the achilles tendon after atl so as to not have a big loss of power and tension?
Because if there is no way to measure precisely what length you should give to the tendon then the risk of overlengthening is another one major reason to avoid atl in my opinion.
I would like to hear your opinion with much interest.
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Hi Dr. Franz,
It's quite well known that femur lengthening can correct varus deformity slightly. If a patient with a varus deformity undergoes femur lengthening and has no complications during lengthening, do you think he'll be better off physically than before surgery?
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Hi Dr Franz,
Thank you for being so active in the thread and community. I have learned a lot just by reading your answers to different patients here. However, I have a couple of questions that I couldn't find answers from your previous threads. It would be great if you could address my concerns and hopefully educate others as well.
1, I read around and hear other patients said that LON and LATN has higher rate of getting knees pain than doing external only, is that true?
2, I am 165 cm and thinking about lengthening 4cm on tibia and 5 cm on Femur. I am thinking of using external fixator only (Ilizarov Apparatus). Can I do both tibia and femur at the same time to reduce the total duration of the treatment? If so, how long will it take and what are the disadvantages of doing so? How long will the fixator stay on?
3, I have bow legs and I would like to correct my bow leg while doing the LL, will this an option and will this have a higher chance of complication than doing them separately?
4, I know you have the price mentioned earlier, but I just want to get the most updated figure. How much will it cost to do 4cm on tibia and 5 cm on Femur using external fixator only?
Thank you Dr Franz.
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Hi Dr. Birkholtz,
I continue to be grateful to you for being so thorough with your responses, and the time you are giving to inform this audience. I have two questions that relate to your specific practice:
In the literature Stadiometer posted here from you, there is a mention of a 7-day step down program from the hospital. I think this is a huge difference maker of your practice and approach to this procedure in relation to other Drs., and I'd like to expand on this a bit. Specifically:
- Is it essentially a transition period after the 4-5 day post-operative period so the patient can be more or less self-sufficient once they leave the hospital and go to whatever secondary lodging they choose (guesthouse, etc.?)
- If that is the case, do you believe a personal caretaker is required after the 7 day period (counting about 11-12 days total post surgery)?
- If a personal caretaker is still required, are such folks readily available in SA?
Additionally, I really believe in post-operative physical therapy. From a surgery I had for a sports-related injury, great PT made a huge difference in my recovery. If I wanted to purchase additional PT sessions, and/or do PT 7 days a week, would this be possible (or recommended by you)?
Many thanks in advance!!
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In case delayed consolidation, would you recommend the insertion of nails? Which is the common protocol here?
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Dr Birkholtz, somebody posted the comment below in another thread concerning yourself,
Dr. Birkholtz (Orthopedic surgeon) should be able to clear this up. However, I continue to believe they're 2 different doctors. I do admit to this being a really strange coincidence, however, the qualification and graduation dates don't match. Their professional organizations (Association of Plastic and Reconstructive Surgeons of South Africa and Health Professions Council of South Africa, respectively) should be able to verify this as well.
In addition to that, I guess someone can just call the hospital where Dr. Birkholtz (Orthopedic Surgeon) works and ask :)
https://goo.gl/TL2Scs
First one (plastic surgeon):
I am a South African trained plastic and reconstructive surgeon, and a full member of the Association of Plastic and Reconstructive Surgeons of South Africa.
I completed my pregraduate studies at the University of Pretoria in 1992. I then worked for three years in Namibia, where I gained valuable surgical experience. It was during this time that I had the honour of working with Prof Alistair Lamont. He introduced me to the fascinating discipline of plastic and reconstructive surgery.
I started my plastic surgery training at the University of Pretoria in 1996 and completed my specialization in 2001. During this five year period, I had extensive exposure to and developed a keen interest in micro vascular reconstruction as well as cosmetic surgery.
I have been in full time private practice at the Kloof Medi Clinic in Pretoria since 2003. I am still involved at the Pretoria Academic Hospital on a session basis and have been a guest lecturer at the University of Zurich for the past two years.
The discipline of plastic and reconstructive surgery has its roots in the time of the great world wars. During this period surgeons had to develop and come up with ingenious methods of reconstructing all the disfigured soldiers. This is a far cry from the modern concept of plastic surgery being portrayed by Hollywood.
Second one (Orthopedic surgeon):
Dr Birkholtz qualified from the University of Pretoria as a medical doctor in 1997 and comes from a family of doctors. He started his post-graduate career in Orthopaedic Surgery in 2000. During his time as a registrar (resident), he created the Limb Reconstruction Unit at the Pretoria Academic Hospital (later Steve Biko Academic Hospital). During this time he developed his skills and understanding of the Ilizarov method and limb lengthening and reconstruction surgery in general. He also developed a keen interest in complex trauma. He qualified as an orthopaedic surgeon in 2006 and holds both the MMed (Orth) degree from the University of Pretoria and the FCOrth(SA) qualification from the College of Orthopaedic Surgeons of South Africa. He is fully registered with the Health Professions Council of South Africa. The private practice was started in 2006 and rapidly developed into a highly renowned practice both locally and internationally, especially catering for complex trauma and limb reconstruction cases. With the addition of Dr De Lange, the practice was turned into the Walk-A-Mile Centre and has continued to grow from strength to strength.
Could you please clarify to put to rest some of the more imaginative minds on this forum, thank you.
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Hi Dr. Franz,
can you please give us a list of credible research papers to read to understand the nature of LL? We've seen papers on outcomes of LL based on clinical examinations and statements made by patients, but is there more granular research that we should know of? For example, lesions in nerves, deterioration of muscles, effect on blood vessel diameter to name a few (from my non-medical head). I think that's the only way we undecided prospective CLL patients we can quantify the odds of a good outcome.
Also, a lot of published research is on animals. Is there a way to extrapolate the results to humans?
Thank you
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Dr Birkholtz, somebody posted the comment below in another thread concerning yourself,
Could you please clarify to put to rest some of the more imaginative minds on this forum, thank you.
Hehe, responded in that thread. (Still chuckling, though!)
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Dr Birkholtz,
When it comes to the Safest procedure, in your opinion which one is it?
Initially I was under the impression that it was precise in the fémurs. Lately I have been seeing that the best option are externals not only for long term safety reasons but also for aesthetic and athletic reasons.
What are your feelings when it comes to these two methods?
Sometimes I know that doctors can have biases when it comes to their preferred methods but biases out of the way and considering aesthetic and athletic goals what is the best option for a patient?
I think cost and logistics aside, a combination of femoral internals and tibial externals in two phase is probably the best.
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Dr Birkholz.
I've done atl and i have a reduction of plantar flexion in my both feet but especially in the left one where I had more equinus and my tendon lengthened more.
Also, the tension is really bad and the feeling of walking is not as it used to be.
Also, from the most patients who did atl I heard about the same symptoms. So how can you say that the fear of weakening is nonsensical while I live with tis weakening every day after I did atl?
I am really asking about your opinion because you are a respectable doctor.
Finally on he other month I am planing to do an achilles tendon shortening surgery to get back most of the tension and the power I lost due to tendon lengthening.
Do you think that this new surgery won't improve my current situation?
Finally, isn't tendon overlengthening a very usual complication of atl? If yes (and thats what I think it happened with my case), how can a doctor be sure which length he should give to the achilles tendon after atl so as to not have a big loss of power and tension?
Because if there is no way to measure precisely what length you should give to the tendon then the risk of overlengthening is another one major reason to avoid atl in my opinion.
I would like to hear your opinion with much interest.
I am sorry if I gave offence. It was not my intention.
My point was that a permanent equinus contracture is probably worse to live with than some weakening of the triceps surae (achilles).
It is difficult to judge lengthening during surgery.
As far as I am aware, the results of Achilles shortening surgery are not very good.
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Hi Dr. Franz,
It's quite well known that femur lengthening can correct varus deformity slightly. If a patient with a varus deformity undergoes femur lengthening and has no complications during lengthening, do you think he'll be better off physically than before surgery?
No. Slight varus does not translate into poorer physical function. The only potential issue is degenerative changes in the long term.
Lengthening will almost always diminish your physical ability (even if slightly).
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Hi Dr Franz,
Thank you for being so active in the thread and community. I have learned a lot just by reading your answers to different patients here. However, I have a couple of questions that I couldn't find answers from your previous threads. It would be great if you could address my concerns and hopefully educate others as well.
1, I read around and hear other patients said that LON and LATN has higher rate of getting knees pain than doing external only, is that true?
2, I am 165 cm and thinking about lengthening 4cm on tibia and 5 cm on Femur. I am thinking of using external fixator only (Ilizarov Apparatus). Can I do both tibia and femur at the same time to reduce the total duration of the treatment? If so, how long will it take and what are the disadvantages of doing so? How long will the fixator stay on?
3, I have bow legs and I would like to correct my bow leg while doing the LL, will this an option and will this have a higher chance of complication than doing them separately?
4, I know you have the price mentioned earlier, but I just want to get the most updated figure. How much will it cost to do 4cm on tibia and 5 cm on Femur using external fixator only?
Thank you Dr Franz.
Hi,
Thanks for the kind words.
1. Yes, approximately 20-25% rate of knee pain in literature. This is probably lower with newer nailing techniques like suprapatellar nailing.
2. I do not perform exfix lenghtening for CLL on the femur. On the tibia the fixator stays on for 1.5-2 months per cm lengthened.
3. Bowleg correction is easy to do with a hexapod fixator like the TSF or TLHex, both of which I have vast experience in. This is best combined with the lengthening procedure.
4. External only tibia with bowleg correction is the cost of exfix only tibial lengthening as explained in the pdf brochure posted earlier in this thread.
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Hi Dr. Birkholtz,
I continue to be grateful to you for being so thorough with your responses, and the time you are giving to inform this audience. I have two questions that relate to your specific practice:
In the literature Stadiometer posted here from you, there is a mention of a 7-day step down program from the hospital. I think this is a huge difference maker of your practice and approach to this procedure in relation to other Drs., and I'd like to expand on this a bit. Specifically:
- Is it essentially a transition period after the 4-5 day post-operative period so the patient can be more or less self-sufficient once they leave the hospital and go to whatever secondary lodging they choose (guesthouse, etc.?) Yes absolutely
- If that is the case, do you believe a personal caretaker is required after the 7 day period (counting about 11-12 days total post surgery)? Normally not
- If a personal caretaker is still required, are such folks readily available in SA? Yes. Anything is available in SA (sometimes at a price ;-) )
Additionally, I really believe in post-operative physical therapy. From a surgery I had for a sports-related injury, great PT made a huge difference in my recovery. If I wanted to purchase additional PT sessions, and/or do PT 7 days a week, would this be possible (or recommended by you)? PT is essential in a good outcome. The physios can typically provide extra sessions during the week. Weekends would be difficult, but again, maybe two days rest out of every 5 of active PT is not a bad idea.
Many thanks in advance!!
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In case delayed consolidation, would you recommend the insertion of nails? Which is the common protocol here?
I am not sure I follow the question. Do you mean with exfix lengthening?
Then we tend to default to submuscular plating and frame removal.
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Hi Dr. Franz,
can you please give us a list of credible research papers to read to understand the nature of LL? We've seen papers on outcomes of LL based on clinical examinations and statements made by patients, but is there more granular research that we should know of? For example, lesions in nerves, deterioration of muscles, effect on blood vessel diameter to name a few (from my non-medical head). I think that's the only way we undecided prospective CLL patients we can quantify the odds of a good outcome.
Also, a lot of published research is on animals. Is there a way to extrapolate the results to humans?
Thank you
Unfortunately literature on CLL is quite sparse and on lengthening in general also. Animal studies should not be extrapolated to humans generally.
There is good ongoing research on muscle and bone lengthening.
I understand that you want to undescore your decisions based on scientific evidence. As a scientist myself, I respect that desire. The sad truth is that no paper with quantify the risk in your individual case, as it depends on too many factors: genetics, surgeon, unforeseen complications, starting height, lengthening goals, lengthening techniques, physio etc etc. Very difficult to standardise these factors to study them scientifically.
Apologies for the fuzzy answer, though.
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I am sorry if I gave offence. It was not my intention.
My point was that a permanent equinus contracture is probably worse to live with than some weakening of the triceps surae (achilles).
It is difficult to judge lengthening during surgery.
As far as I am aware, the results of Achilles shortening surgery are not very good.
In the only study about AT shortening, the results were quite successful as all patients said they feeling their gait normal again and the push off power restored to more than 80% compared to the uninjured foot.
Do you know something else or have a personal experience that AT shortening surgery didn't work?
Thank you for your time dr Birkholz and your precious contribution on this forum.
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I mean if delayed consolidation happens, which are the possible options that can be done.
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Dr Birkholtz, thank you for your providing further advice to the forum, it is invaluable and we all appreciate it. I have been reading some research as of late and am confident certain complementary therapies will be approved for orthopedic use to benefit soft tissue adaptation in the near future or be adopted/recommended in the field. Unfortunately, there appears to be much research on the actual distraction and surgical procedure but very little soft tissue tolerance and adaption, long term consequence, statistics and issues apart from invasive and questionable soft tissue release - do you find this to be true? I have great interest in preventing or managing soft tissue damage as the actual distraction seems 'relatively' straightforward for satisfactory results with a competent surgeon and opinions remain relatively in line with one another, opinions on managing soft tissue vary greatly.
Anyway, I have several questions I wish to ask your opinion on;
A) Rate of Lengthening?
I have read some interesting studies on the effects of lengthening rate and the impact on muscular structure and soft tissue damage. As you had said, it would be unwise to extrapolate animal studies to humans but many complications and bad outcomes appear to be at the very least, impacted by excessive lengthening. For some reason, lengthening rate appears to have increased from the recommended 0.5/6mm daily, I have seen examples of up to 2mm daily and I do not believe that soft tissues can adapt to such a rate causing further damage.
Besides the inconvenience and excess time taken, from a purely theoretical point, would the optimal rate of lengthening not be the absolute lowest possible (<0.5mm) split into smaller amounts (5x daily - people have reported less pain with lengthening split - opinion?) throughout the day without risking pre-consolidation and other issues? This of course would be made more difficult with excessive lengthening but with conservative amounts of ~4cm would it not be beneficial? I genuinely believe rate of lengthening plays a massive part to recovery and potential damage. Could it theoretically also be beneficial to split the process into 2 procedures on a single segment with a year recuperation in between for adaptation, for example with the goal of an inch for each process resulting in 2 inches?
What I find very interesting is something that you have mentioned previously, that cell division actually occurs, myogenesis happens to some degree as a reaction to lengthening. As I understand this, this is true adaptation to the new length, at least some of the muscle cells are actually created to compensate for the length of bone rather than stretching - could there be an optimal rate in which myogenesis occurs and damage is prevented? Could this be the key at this moment in time to achieving the best recovery?
We used an experimental rabbit model of leg lengthening to study the morphology and function of muscle after different distraction rates. Lengthening was in twice-daily increments from 0.4 to 4 mm per day. New contractile tissue formed during lengthening, but some damage to the muscle fibres was seen even at rates of less than 1 mm per day; abnormalities increased with larger rates of lengthening. There was proliferation of fibrous tissue between the muscle fibres at distraction rates of over 1 mm per day.
Active muscle function showed adaptation when the rate was 1.0 mm per day or less, but muscle compliance was normal only after rates of 0.4 mm per day. Muscle responded more favourably at rates of distraction slower than those shown to lead to the most prolific bone formation. At present the rate of distraction in clinical practice is determined mainly by factors which enhance osteogenesis. Our study suggeststhat it may be advisable to use a slower rate of elongation in patients with poor muscle compliance associated with the underlying pathology; this will allow better accommodation by the contractile and connective tissues of the muscles.
B) Strong Muscles or Weak Muscles?
Most doctors advise that a prospective patient be physically fit (as is advised for all surgeries). Many then seem to concentrate on femur/hamstring/calf hypertrophy and strengthening. Are excessively strong and hypertrophied muscles detrimental to lengthening as stiff muscular structures are or is there no appreciable difference as long as a good level of flexibility is maintained? Would a prospective patient be better spending time on extra flexibility and cardiovascular health in an attempt to minimize hypertrophy? I ask this as I read a PubMed study on the application of Botulinum Toxin A being used during distraction to limit damage to tendons and soft tissues through the weakening of the muscular structures, it seemed to have a notable beneficial effect - what is your opinion on this? This also leads on to...
C) Physical Therapy?
It seems to me physical therapy is important for 3 main reasons; 1) To encourage blood flow and healthy bone regrowth 2) To maintain flexibility as supple muscles lengthen much easier than stiff ones minimizing complications such as equinus 3) To prevent major atrophy leading a poor physical condition upon consolidation which will take substantial time and effort to solve but is fully reversible.
This makes me wonder if the excessive physical therapy - hours of hard pedaling on a stationary bike could be detrimental to lengthening and further damage recently stretched tissues prior to an adaptation by exercising them excessively, making the muscles stiff and misplacing the body's much needed reserves for healing and adaptation. It would seem better to attempt to retain some muscular strength and improve blood flow through limited steady, slow pace stationary bike but to focus mostly on flexibility, relaxing the muscles rather than excessive contractions and and use and weight bearing when possible leading.
D) Massage and Timing of Lengthening?
Another study I read was on the benefits of massage and hyperbaric oxygen therapy, though I'll not ask about the latter! Carrying on from the previous two questions, what is your opinion on the benefits of massage therapy to aid in ensuring the muscles are supple and reducing stiffness while increasing blood flow during lengthening? I see very little people mention it and I believe it could be highly beneficial. To follow on from this, does the timing of lengthening matter or is it negligible in the grand scheme of the process? - For example, massage and warming up for blood flow and suppleness prior to using the Precice device rather than lengthening a 'cold' and stiff muscle?
E) Soft Tissue Damage - Linear or Exponential?
Soft tissue has its elastic limits before plastic deformation and major damage occur. From what you have witnessed, where does this occur? Beyond 10% of initial length or is it once again individual? Is this why the 5cm rule exists as it appears to be the upper limit before major soft tissue damage and complication? Now to the main question, would I be correct in think that damage is not linear and is exponential in nature? For example, lengthening to to the elastic limit is generally safer than lengthening beyond that limit at which damage occurs, that lengthening from 5cm (hypothetically the elastic limit) is less damaging than from 5cm to 6cm and beyond that, the damage compounds which each centimeter lengthened.
F) The True Physical Potential After Lengthening
As I understand it, the nature of lengthening and the soft tissue damage is different than most other injuries as they don't change the length of the soft tissue permanently, are there any injuries similar to that of limb lengthening? Many athletes suffer from permanent and debilitating injuries from bad breaks, completely torn cuffs and muscles, snapped tendons that need reattaching etc. many of these injuries can be worked around even if they are never quite as good as before, unfortunately some end sporting careers as they can no longer compete in the top 1 or 2% but by normal standards still remain incredibly fit and athletic, much more than the general population. In your opinion, is there anyway this could be possible with limb lengthening? That through physical therapy and rehabilitation the injury could be almost imperceptible or is the damage to soft tissue just too big of a hit to be able to function to anywhere near the initial level even with perfect conditions and minor lengthening? As much I am an optimist, I fear it may be the latter as I realize that with most injuries, the tissue isn't permanently stretched and in a weakened state, the muscle unable to truly contract to the same degree due to the change of distance between insertion points - almost to the point of your new 'normal' length being similar to standing on your tip toes or beyond prior to lengthening, would this be accurate?
G) The Future
With improvements being made in every aspect, from distraction technology such as that of Precise and its upcoming iteration, studies into stem cell therapy and cartilage regrowth to studies into complementary therapies and the usage of things such as botox to prevent the damage initially, do you believe the success and ease of orthopedics and by extension limb lengthening will improve substantially within the next few decades?
H) Ultrasound Bone Healing
Do you have experience or an opinion on 'at home' ultrasound devices for consolidation such as the Exogen device?
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I mean if delayed consolidation happens, which are the possible options that can be done.
Sorry, I didnt mention external fixators, I forgot delayed consolidation with internal nails :)
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Hi Dr. Franz
Some Asians have short arms, how do you look at arm Lengthening？
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:)
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hello！Dr Franz Birkholtz！
Please allow me to introduce myself first.
My name is Lin Tao, is a Chinese, male.
I'd like to go to you for cosmetic lengthening， and I have known your information for a long time. I would like to confirm the following, get your reply, no accident I will go to South Africa to visit you in October。
1.My height is 165-166 cm, I hope to get 6-7CM gain. Will you allow me to undergo surgery?
2.I wish to undergo surgery on my thighs and use PRECICE . how much is the cost? What items does the cost contain?
3.How many patients have you operated for cosmetic Limb Lengthening so far?Is there a failure case?If so, can you specifically say it?
4.I have 6 years of smoking history.Does this affect the postoperative recovery?
5.I am a Chinese, my spoken English is not particularly good, Do I need to carry a translation for surgery? How should I solve the problem of language barrier?
6.How is the settlement during recovery? What is the approximate cost of accommodation?
7.Safety is my number one concern.I hope you can give me some advice.You can also send me your information about cosmetic lengthening.
Forgive my English,Looking forward to your reply.
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:)
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Thanks Dr. for answering our questions. I want to have limb lengthening surgery in next one year. I have been researching from last 4 years. My tibia and femur are pretty much well proportioned (one not relatively shorter then other), I want to have exactly 3 inches (not a mm less not a mm more :)). My problem is that I cannot spend more than 55-56k USD (all included) and cannot take break from (normal office desk job) work for more than 3 months. I can walk with a walker/crutches though while working. How do you so see it becoming possible (e.g. internal vs external, tibia vs femur)? also if 3 months is too aggressive a goal (given 3 inch target) then what would be a more reasonable target for walking (with aid) - 5 months? 6 months? Also, given good tibia femur ratio, which segment should I lengthen. plz provide your expert input. Thanks.
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Dear sweetone6. I have answered you via email.
Best regards.
PS, you are welcome to post the answers if you wish. For confidentiality reasons I answered you privately.
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Thanks Dr. for answering our questions. I want to have limb lengthening surgery in next one year. I have been researching from last 4 years. My tibia and femur are pretty much well proportioned (one not relatively shorter then other), I want to have exactly 3 inches (not a mm less not a mm more :)). My problem is that I cannot spend more than 55-56k USD (all included) and cannot take break from (normal office desk job) work for more than 3 months. I can walk with a walker/crutches though while working. How do you so see it becoming possible (e.g. internal vs external, tibia vs femur)? also if 3 months is too aggressive a goal (given 3 inch target) then what would be a more reasonable target for walking (with aid) - 5 months? 6 months? Also, given good tibia femur ratio, which segment should I lengthen. plz provide your expert input. Thanks.
Hi
7.5 cm is a sizeable goal best achieved with two segments to preserve the ratio. With a limited budget and time constraints, a single femoral Precice lengthening will give you the best bang for your buck. I do think your target will then have to be adjusted to 6-6.5cm though.
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Hi
7.5 cm is a sizeable goal best achieved with two segments to preserve the ratio. With a limited budget and time constraints, a single femoral Precice lengthening will give you the best bang for your buck. I do think your target will then have to be adjusted to 6-6.5cm though.
Thanks for the reply dr. , much appreciated.
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Any updates on pricing or anything else, Dr. Birkholtz?
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Dr. Birkholtz, I have sent you a message and I have couple of questions came to mind,
1) Can I lengthen in my country (Canada) if I did Precice 2? And come back after 2-3 months? Is this possible? I would do the X-rays in Canada and send it by email. If there is complications, then I would fly to SA to fix it.
2) I'm also around 60Kg (132Lbs) of weight and 165cm tall so if Precice 2 can handle 75lbs load bearing each leg, then can I walk (with crouches ofcourse) safely while lengthening?
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Does anyone know what happened to Dr. Birkholtz? I had him picked out as my LL doctor and now it seems he has disappeared.
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Does anyone know what happened to Dr. Birkholtz? I had him picked out as my LL doctor and now it seems he has disappeared.
He hasn't disappeared, he's just not as active on the forums. You can still reach out to him and his team here (http://www.walkamile.co.za/contact-walk-a-mile-centre-for-advanced-orthopaedics.php).
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Thank you Android. I will try that. I have tried other emails but nothing seems to work.
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Thank you Android. I will try that. I have tried other emails but nothing seems to work.
I reached out fairly recently via that form and was able to get in touch with the receptionist. Good luck!
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Hello Dr. Franz!
Here are some questions.
1) Does a quadrilateral lenghtening of 8cm (4cm tibia and 4 cm femur) have better recuperation than a 6cm femur?
2) As a smoker that I am, how much time before the surgery do you recommend to stop?
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Hi everyone,
Apologies for the silence. I have decided to limit my time on the forums as it really sucks up a lot of time... (I think everyone will agree with this :-) )
To answer a few questions:
1) Yes, I still do CLL.
2) My preferred technique is still Precice femorals with an ideal upper limit of 6.5cm for safety reasons.
3) Our updated pricing is available from my receptionist, Tessa at reception@walkamile.co.za
4) Smoking is a contra-indication to CLL. You need to be an ex-smoker if you want to embark on CLL. Probably at least 3 months clear.
5) With regards to quadrilateral lengthening: I personally think the risk of doing all 4 segments in 1 go is too much.
6) I have performed humerus lengthening for CLL with Precice. Forearm lengthening not safe.
Hope this helps.
Btw, my receptionist is probably the best first contact, as she tends to answer emails more diligently than I do!
Otherwise, welcome to try franz.birkholtz@walkamile.co.za
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Hi everyone,
Apologies for the silence. I have decided to limit my time on the forums as it really sucks up a lot of time... (I think everyone will agree with this :-) )
To answer a few questions:
1) Yes, I still do CLL.
2) My preferred technique is still Precice femorals with an ideal upper limit of 6.5cm for safety reasons.
3) Our updated pricing is available from my receptionist, Tessa at reception@walkamile.co.za
4) Smoking is a contra-indication to CLL. You need to be an ex-smoker if you want to embark on CLL. Probably at least 3 months clear.
5) With regards to quadrilateral lengthening: I personally think the risk of doing all 4 segments in 1 go is too much.
6) I have performed humerus lengthening for CLL with Precice. Forearm lengthening not safe.
Hope this helps.
Btw, my receptionist is probably the best first contact, as she tends to answer emails more diligently than I do!
Otherwise, welcome to try franz.birkholtz@walkamile.co.za
Hello doctor Franz. If you ever read this, could you tell me what do you see as the ideal upper limit for tibial lengthening?
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(http://i64.tinypic.com/33wwg9e.jpg)
Excludes daily physiotherapy after release from hospital.
Conversion to U.S. Dollar 5-February-2018:
R 580,000 = $48,360
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Has anyone been in contact with Dr. Franz recently? Am interested in getting ll done with him, sent an email but no response
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Has anyone been in contact with Dr. Franz recently? Am interested in getting ll done with him, sent an email but no response
As Dr. Franz recommended I'd reach out Tessa, his receptionist, if you haven't already: reception@walkamile.co.za
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As Dr. Franz recommended I'd reach out Tessa, his receptionist, if you haven't already: reception@walkamile.co.za
Yeah I actually emailed her first before emailing him. Maybe they're busy recently, hopefully he gets back to me soon.
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Hi,
My upper safe limits are 6.5 for femurs and 5-5.5 for tibias.
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I need you to be around during the distraction phase, as this is the risky phase where I need to keep a close eye for your safety.
All our patients walk with crutches during distraction, but you may need to use a double leg stance if you are on the heavier side. Our physios are really good at helping in this regard.
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Yes, unfortunately very busy atm. I suspect I might have answered you by email earlier tonight.
If not, you are welcome to resend your query to my private email address fbirkholtz@gmail.com and I will endeavour to answer as soon as possible...
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Greetings. I would like to know if lymphedema and chronic venous insufficiency would preclude one from pursuing limb lengthening.
If yes, is it in all cases or depending on the gravity of these conditions?
For example, would lymphedema affecting only the feet preclude one from femur lengthening? One thing reading about lymphedema that caught my interest was how even minor injuries could turn into life threatening infections.
Also, with the surgery being invasive, am I right in assuming some damage to the lymph system and its components would be caused, worsening the condition?
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Greetings. I would like to know if lymphedema and chronic venous insufficiency would preclude one from pursuing limb lengthening.
If yes, is it in all cases or depending on the gravity of these conditions?
For example, would lymphedema affecting only the feet preclude one from femur lengthening? One thing reading about lymphedema that caught my interest was how even minor injuries could turn into life threatening infections.
Also, with the surgery being invasive, am I right in assuming some damage to the lymph system and its components would be caused, worsening the condition?
E-mail him your question.
franz.birkholtz [at] walkamile [dot] co [dot] za
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STRYDE availability to patients is undetermined....
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Hi all,
For those of you who have emailed me: apologies. Work and travel seems to be taking all my time. Hence the slow (no?) responses via email. Of course my current existing patients get first choice for my attention. Not really good for new business I guess. :-)
I have decided to also give you an alternative email address to contact us. Dr Marie-Marì Alberts is my Clinical Practice Manager and also assists me in the operating room with all my cases. We also see eachother daily, so she has a pretty direct line to me. Her email address is m3@walkamile.co.za
Meanwhile, I will try and continue my email sweep and hopefully respond to everyone’s emails in due course.
Best regards,
Franz
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Hi all,
For those of you who have emailed me: apologies. Work and travel seems to be taking all my time. Hence the slow (no?) responses via email. Of course my current existing patients get first choice for my attention. Not really good for new business I guess. :-)
I have decided to also give you an alternative email address to contact us. Dr Marie-Marì Alberts is my Clinical Practice Manager and also assists me in the operating room with all my cases. We also see eachother daily, so she has a pretty direct line to me. Her email address is m3@walkamile.co.za
Meanwhile, I will try and continue my email sweep and hopefully respond to everyone’s emails in due course.
Best regards,
Franz
Hi Dr. Birkholtz thanks for the update. I’ll email Dr. Alberts with my questions. I think the most common question is regarding when Stryde will be available in SA.
Hope everything is going well in your practice. Best wishes.
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Hi Dr. Birkholtz thanks for the update. I’ll email Dr. Alberts with my questions. I think the most common question is regarding when Stryde will be available in SA.
Hope everything is going well in your practice. Best wishes.
did you ever get to know when Stryde would be available?
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Dr. Birkholtz was the first surgeon in Africa to offer PRECICE, so it makes sense that he will be the first surgeon in Africa to offer STRYDE. Unfortunately, no date is available for STRYDE in Africa.
http://www.bizcommunity.com/Article/196/426/94291.html
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just wanted to say thanks to Leggs for continously polling different surgeons for STRYDE availability. good job
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Sure man, you're welcome.
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complications include leg amputation ???, I done LL in India with Dr Sarin you know the doctor everyone said is a butcher, I seen some complications that were fixed but leg amputation ?? ! Shouldn't an orthopedic surgeon be able to prevent this?
Anyway doc I done tibia lengthening around 5.5 to 6cms depending on compression , do you think another 4 cms on femurs using internal nails is risky? Like what are the chances of having to have my legs amputated ?
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bumping this, anyone heard anything about Stryde availability?
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August 2019
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August 2019
:(
is that a joke or real? i hope you dont joke about such things, alot of people are depending on the information
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Dr.B does't do LL anymore.
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^I also Read that in another thread. He doesnt do CLL anymore but not sure If true
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2018-10-15
Dear Prospective Patient,
After long hours of contemplation and soul-searching, I have decided not to offer Cosmetic Limb Lengthening at my
practice anymore. This may come as a shock to some of you and certainly will derail a lot of plans.
The decision was not taken lightly. The overriding reason for my decision is that it has become clear to me (based on
the complications I see from elsewhere), that the risk-benefit ratio of CLL swings firmly to the ‘risk’ side. In other
words, the potential complications are not worth the risk of permanent functional impairment. For this reason I can not
ethically continue to offer this surgery.
Ironically, once a complication is present, I can get involved morally, as this type of complication correction surgery
makes up the bulk of my work and here I can provide effective solutions for difficult problems. This swings the ethical
risk-benefit equation into the other direction.
My patients’ best interest and safety come first and for this reason the decision was taken and is also a final
decision. I will ask you to please respect this decision and also refrain from endless engagements and discussions
on online platforms, social media etc.
If, after weighing all the risks and benefits and you are still keen on pursuing CLL, PLEASE choose an ethical doctor
and choose someone with a solid track record, not only in CLL, but also in management of complications.
With my best regards,
Dr FF Birkholtz
2018-10-15
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Is this real? Can Dr. Frank himself come and tell this?
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It's true. You can send email to Dr.b's assistant(eception@walkamile.co.za).
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Hi Everyone,
This is true and I believe the letter is self-explanatory. My apologies for inconvenience caused.
Good luck on your journey.
FFB
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Sir,
Thanks for the reply.
If you could please tell the reason a bit more, would be so helpful for the prospective candidates.
In other words did you take the decision as you came to know about some unforeseen side effects of CLL which you were previously not aware of?
Or some sudden incident which caused you to take this?
Or is it a completely different reason?
But I guess it just can't be sudden change in mindset as you have successfully defended your choice by saying it's unethical to not do it than to do it as people will anyway get it done through some unqualified doctor. Also you were so active in replying to queries and were even assuring people that surgery has become less risky in last 5 years(So it should be more so after the invention of Stryde.)
Sir, for a prospective patient, it is vital to know why such a great doctor, who actually spearheaded CLL in a whole continent, backs off completely from the surgery and that too suddenly? Is there any bitter surprise in the offing for the people who are undergoing/planning to undergo through the surgery?
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Brave decision and to be honest probably the correct one too.
Look at what we, the LL community, have become. The entire purpose of this community is to provide safe height increase for those of us who struggle with height dysphoria.
But if you go to the Diaries section of this forum its infested with people lured into crappy surgeons. Diary writers stop posting as soon as complication occurs and just disappears.
These warnings falls on deaf ears as a new wave of members arrive, going to the same doctors with same outcomes. Its really sad. Atleast with the old forum we held doctors accountable before Apo/sysop took over. People went to Beijing, yes it was risky but we didnt have bad outcomes like today. This was for 10+ years ago!
As soon as apo took over he introducted ty butcheres like Dr. Sarin who made several patients cripple.
So this forum was created by people revolting to avoid such situations, and guess what. The same people (Sweden, 4cms etc) keep promoting the same doctor. Hiding and ignoring the sad sad devastating cases of the old patients.
This forum being unmoderated has created a climate for fake diaries, scammers and promoters.
e like Dr. parihar, Dr. srigari, dr.sarin, dr. solomin, dr. bagirov, dr. abu jamar, dr. salameh, dr.monegal (http://www.limblengtheningforum.com/index.php?action=profile;u=4540) (he only seems to fk up tibia, not femur though) + ++ the list is endless, should be all blocked and banned from this forum. every fking diary of these savages should be deleted.
When are we going to tell the newcomers on this forum that "its better to be short, than cripple"? Either save up money for proper surgeons or dont do it at all. Instead we promote LL at any cost. Some people even asking if they can do LL with $8000 budget? everyone knows how the story ends, but to my surprise what I see is other members recommending cheap crap surgeons in India and Russia. The blood is on your hand aswell.
Dr. Birkholtz, a respected surgeon, or for that sake any surgeon would not be wanted to be associated with the toxic culture we have going on here.
I salute you Birkholtz, you are well and truly a man worthy of the title surgeon. May you fix limb deformities for those people who cant even function properly. These are the people who need help!
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fk YOU Dr B
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Sir,
Thanks for the reply.
If you could please tell the reason a bit more, would be so helpful for the prospective candidates.
In other words did you take the decision as you came to know about some unforeseen side effects of CLL which you were previously not aware of?
Or some sudden incident which caused you to take this?
Or is it a completely different reason?
But I guess it just can't be sudden change in mindset as you have successfully defended your choice by saying it's unethical to not do it than to do it as people will anyway get it done through some unqualified doctor. Also you were so active in replying to queries and were even assuring people that surgery has become less risky in last 5 years(So it should be more so after the invention of Stryde.)
Sir, for a prospective patient, it is vital to know why such a great doctor, who actually spearheaded CLL in a whole continent, backs off completely from the surgery and that too suddenly? Is there any bitter surprise in the offing for the people who are undergoing/planning to undergo through the surgery?
Still waiting for your reply doctor. Please reply. It would be most helpful act one can do to any prospective candidate.
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Hi Everyone,
This is true and I believe the letter is self-explanatory. My apologies for inconvenience caused.
Good luck on your journey.
FFB
Thank you for confirming it, Dr. Birkholtz.
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That's a shame. Had a Skype consultation with the dr. Birkholtz and was highly impressed. Chose other options due to convenience but he really impressed me with his honesty, professionalism, and the fact he is the exact opposite of a salesman, which many ll doctors are.
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Brave decision and to be honest probably the correct one too.
Dr. Birkholtz, a respected surgeon, or for that sake any surgeon would not be wanted to be associated with the toxic culture we have going on here.
I salute you Birkholtz, you are well and truly a man worthy of the title surgeon. May you fix limb deformities for those people who cant even function properly. These are the people who need help!
+1000
This forum being unmoderated has created a climate for fake diaries, scammers and promoters.
e like Dr. parihar, Dr. srigari, dr.sarin, dr. solomin, dr. bagirov, dr. abu jamar, dr. salameh, dr.monegal (http://www.limblengtheningforum.com/index.php?action=profile;u=4540) (he only seems to fk up tibia, not femur though) + ++ the list is endless, should be all blocked and banned from this forum. every fking diary of these savages should be deleted.
No. Monegal fks up femur too. His worst case is Musicmaker a femur case
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Dear Dr. Franz
Sorry to hear you decide not to perform cll. But I really appreciate all you help us and you are so honest always telling us truth.
Could I ask you a question what do you think abou double cut with pure external in tibia(upper and lower in one surgery) according to the picture ?
Thanks
https://pan.baidu.com/s/12_z9bJD26PmiPITS7BwJVw
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I received this e-mail from Doctor Birkholtz:
2018-10-15
Dear Prospective Patient,
After long hours of contemplation and soul-searching, I have decided not to offer Cosmetic Limb Lengthening at my
practice anymore. This may come as a shock to some of you and certainly will derail a lot of plans.
The decision was not taken lightly. The overriding reason for my decision is that it has become clear to me (based on
the complications I see from elsewhere), that the risk-benefit ratio of CLL swings firmly to the ‘risk’ side. In other
words, the potential complications are not worth the risk of permanent functional impairment. For this reason I can not
ethically continue to offer this surgery.
Ironically, once a complication is present, I can get involved morally, as this type of complication correction surgery
makes up the bulk of my work and here I can provide effective solutions for difficult problems. This swings the ethical
risk-benefit equation into the other direction.
My patients’ best interest and safety come first and for this reason the decision was taken and is also a final
decision. I will ask you to please respect this decision and also refrain from endless engagements and discussions
on online platforms, social media etc.
If, after weighing all the risks and benefits and you are still keen on pursuing CLL, PLEASE choose an ethical doctor
and choose someone with a solid track record, not only in CLL, but also in management of complications.
With my best regards,
Sorry, I didn't read the thread before posting.