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[RealLostSoul]

Hi guys in my ever ongoing research about LL I asked myself the question, when the procedure of LL does not alter your mechanical axis (assuming you didn't get butchered and the nail is placed properly etc.) are you still at risk for early arthritis due to increased pressure (or whatever) stemming from an abnormal ratio of the tibia/femur in and of itself?

My assumption is you start at let's say ~0.8 tibia/femur and do 8cm femur lengthening. Now your new ratio will be 0.7 or potentially even lower (like 0.6), a lot of people are afraid that this will cause aesthetic probems (bad proportions) but what is imo a million times more important is your health after this.
We know that if your mechanical axis drifts off, leading to unequal pressure on the knee joint, it definitely causes arthritis (which btw is a pretty terrible thing and should definitely be avoided, especially if you are younger than 60). However, does a femur lengthening of ~8cm, if done correctly, meaning no misalignement of the mechanical axis, in and of itself causes arthritis due to a lower tibia/femur ratio?


tldr, if you lengthen your femur for 8cm, do you have to do tibias as well to avoid arthritis or is arthritis only a problem if you get a mechanical axis misalignement?

[Tartar]

I replied to this months ago. I copy and paste.
Arthrosis in LL can be promoted ("due" is a too strong word) by: -joint pressure, which however decreases gradually anyway; -after a tibial lenghtening (probably beacuse an increased mechanical lever, but this is my thought based on statistics); -due to deformity of the knee. Lengthening over the anatomical axis with a nail leads to a valgus deviation BUT:
-The deviation got is very light
-You have to consider that everyone has a different "starting point"; someone has a slightly valgus knee at the beginning, others can have a slightly varus knee at the beginning.

This is my thought

[RealLostSoul]

I replied to this months ago. I copy and paste.
Arthritis in LL can be promoted ("due" is a too strong word) by: -joint pressure, which however decreases gradually anyway; -after a tibial lenghtening (probably beacuse an increased mechanical lever, but this is my thought based on statistics); -due to deformity of the knee. Lengthening over the anatomical axis with a nail leads to a valgus deviation BUT:
-The deviation got is very light
-You have to consider that everyone has a different "starting point"; someone has a slightly valgus knee at the beginning, others can have a slightly varus knee at the beginning.

This is my thought

Did you reply to me/a comment of mine back then? If so I am sorry I didn't see..
Anyways, thanks for your thoughts I agree. Kinda sucks that I already have a (very light) valgus starting point but I am doing femurs first regardless.
Why and when do you think the joint pressure decreases?

[Tartar]

Did you reply to me/a comment of mine back then? If so I am sorry I didn't see..
Anyways, thanks for your thoughts I agree. Kinda sucks that I already have a (very light) valgus starting point but I am doing femurs first regardless.
Why and when do you think the joint pressure decreases?

No it wasn’t an answer to you, it was an older topic, I simply copied it because I remember I had written something about before.
A valgus can be avoided, if you already have a slight one, the increase of the deviation can be avoided by an external method or even with a retrograde access of the nail (from the knee) if the deformity is light.
For what concern the joint pressure, it reduces but I think the timing is quite variable. It’s related to the muscle hyperplasia and the tendons release.  Unfortunately there are not many studies about it, such as there are not many about the muscle growth after lengthening.
Anyway I’ve never thought about the arthrosis as one of the main problem of this surgery, it’s a very reasonable risk in my opinion.

[RealLostSoul]

No it wasn’t an answer to you, it was an older topic, I simply copied it because I remember I had written something about before.
A valgus can be avoided, if you already have a slight one, the increase of the deviation can be avoided by an external method or even with a retrograde access of the nail (from the knee) if the deformity is light.
For what concern the joint pressure, it reduces but I think the timing is quite variable. It’s related to the muscle hyperplasia and the tendons release.  Unfortunately there are not many studies about it, such as there are not many about the muscle growth after lengthening.
Anyway I’ve never thought about the arthritis as one of the main problem of this surgery, it’s a very reasonable risk in my opinion.

Ah I see, okay good I will ask my future surgeon about it, however I kinda want to avoid retrograde nailing because of the knee pain risk. Externals isn't an option for me, especially for femurs. I will discuss it with my doctor.
Hmm interesting hypothesis, so avoiding a tendon release (like EU doctors do) could actually be a good thing in that regard? Muscle hyperplasia should only happen if you cut fascies open right? People that don't have any fasciotomy often say they even atrophied quite a lot.

Hmm I think premature arthritis would indeed suck a lot. If you get it at around age 40 or even earlier. You have to keep in mind you will need an artifical knee / partial implant for a long time and those implants tend to function only for some time until they need to be exchanged. I wouldn't want to undergo a lot of surgeries when I am old, with each one having a risk of infection etc.
Of course it is not an immediate problem of LL.

[Tartar]

I don't think any doctor will be very clear about these topics since there are not many studies.
IT band release is essential since there's no other way to release a structure made by fibrous tissue only. Otherwise you'd be crooked soon.
Hyperplasia is not a bad thing, I mean that the number of muscolar cells should increase.
Probably you think about the massive thickening of the calves often reported in tibia lenghtening; even if it is sometimes called "hyperplasia" I don't know actually if it is hyperplasia, hypertrofia or simply an increased blood pressure due to the gravity. Hyperplasia should be, for the most, promoted by muscle traction along its axis, such as during a normal child growth.
Anyway a so premature arthrosis I don't think has been reported; Paley himself said that it is not a relevant problem. Actually I've read a single paper about premature arthrosis, and it was related to tibia lenghtening only, not femur.
In my opinion this last problem is related predominantly to tibia lenghtening due to a bigger lever between anckle and knee.

[RealLostSoul]

How do you explain the people who successfully do 8+cm then? There are indeed some who have done 8.5 , 9 , 10 or even 11 cm who recover WITHOUT It band release. Apo for example had a huge duckass at like 10cm femurs but after 10 weeks in consolidation phase it was almost gone completely. This makes me really question it. Ofc if everyone was crooked as you said it would be a huge fraud from Betz/EU doctors but this isn‘t the case actually. For sure there are bad cases but a lot of good ones too.

For me a thickening of my muscles (enlarging it a lot) would suck since I am a a lanky type person and wouldn‘t want thick legs at all. With femur this is rarely the case. You meant hyperplasia in terms of adaptation of the muscles, yea that‘s for sure. I was talking about the calf/tibia thing, I was told it‘s because if you do a prophylactic fasciotomy like every dr should do the muscle quills out a bit and thus the fascies is larger when it repairs itself.

Yea maybe but isn’t this for all tall people the case? Because they have natural long tibias and yet they aren’t destined to become arthritis. Maybe they have a higher chance? And if so, getting it at 70 is different than getting it at 35

[Tartar]

How do you explain the people who successfully do 8+cm then? There are indeed some who have done 8.5 , 9 , 10 or even 11 cm who recover WITHOUT It band release. Apo for example had a huge duckass at like 10cm femurs but after 10 weeks in consolidation phase it was almost gone completely. This makes me really question it. Ofc if everyone was crooked as you said it would be a huge fraud from Betz/EU doctors but this isn‘t the case actually. For sure there are bad cases but a lot of good ones too.

For me a thickening of my muscles (enlarging it a lot) would suck since I am a a lanky type person and wouldn‘t want thick legs at all. With femur this is rarely the case. You meant hyperplasia in terms of adaptation of the muscles, yea that‘s for sure. I was talking about the calf/tibia thing, I was told it‘s because if you do a prophylactic fasciotomy like every dr should do the muscle quills out a bit and thus the fascies is larger when it repairs itself.

Yea maybe but isn’t this for all tall people the case? Because they have natural long tibias and yet they aren’t destined to become arthritis. Maybe they have a higher chance? And if so, getting it at 70 is different than getting it at 35

I explain simple that is not something always strictly necessary but it's something that many times lead to problems that can't be solved otherwise and there's not a real reason why you should not to it since it just fibros tissue not connected to muscles and it heals perfectly after a while. It's nowhere something like the ATL. Otherwise you should do another surgery just to cut it. Not worth it. Recently I've even read a girl complaining because Betz refused to do it and she was crooked after more than 1 year.
Actually I don't know other doctors than Betz not doing the IT release during the first surgery, even in Europe.
I don't think there could be a thickening other than in tibias since it's due to blood accumulation gravity-related, anyway I thoiìught you were interested in femur from your previous message. I know that compressive stocks work very well to avoid any thickening. Fasciotomy is generally done for a compartimental syndrome and it's pretty gory by the way. Probably some kind of fascial release could be performed but I'm not informed about its extent and indication for LL.
Taller people have a bigger surface of the tibia compared to the shorter ones. That's the main difference mechanically. LL should leads to a minor contact surface for a certain lever. But, I repeat, this last one is just an assumption of mine.

[RealLostSoul]

I explain simple that is not something always strictly necessary but it's something that many times lead to problems that can't be solved otherwise and there's not a real reason why you should not to it since it just fibros tissue not connected to muscles and it heals perfectly after a while. It's nowhere something like the ATL. Otherwise you should do another surgery just to cut it. Not worth it. Recently I've even read a girl complaining because Betz refused to do it and she was crooked after more than 1 year.
Actually I don't know other doctors than Betz not doing the IT release during the first surgery, even in Europe.
I don't think there could be a thickening other than in tibias since it's due to blood accumulation gravity-related, anyway I thoiìught you were interested in femur from your previous message. I know that compressive stocks work very well to avoid any thickening. Fasciotomy is generally done for a compartimental syndrome and it's pretty gory by the way. Probably some kind of fascial release could be performed but I'm not informed about its extent and indication for LL.
Taller people have a bigger surface of the tibia compared to the shorter ones. That's the main difference mechanically. LL should leads to a minor contact surface for a certain lever. But, I repeat, this last one is just an assumption of mine.

I agree with the IT band dilemma. It's my biggest con with Betz. Ik it won't do much harm to cut it, without it it's like you said more of a gamble. You can be fine but you can end up needing it later (which is dumb tbh, ofc it's not a big surgery but unecessary). I know that case too but I also know for example tallertree who had an excellent recovery for an insane 9cm. Other surgeons that don't do it are Guichet and Monegal I think.
Yea I am interested in femur surgery. Not going with tibias. I probably will not even do them in the future, it depends on how I will feel after femur. So you are sure that for femur surgery there will not be a thickening? That's good news.
Yes the prophylactic cut is done in the calf (I think) with tibia LL to prevent compartment syndrome as it's devastating. Deffo one of the worse complications you can have. a full fasciotomy leaves you with a huge scar on the leg (almost the whole lower leg gets cut open, you need to release 4 muscle compartments which can be reached from one incision but that incision.. well you have seen images).
Never heard of the compression socks lol, do you get them all the time for tibia ll?

Interesting idea I think this is a good question to ask an expert. Is the caput tibiae larger (wider) in tall people and is it bad for the joints to lengthen the legs out of their natural size and will the joints adapt (you know like people with arthritis get extra bone formations near their joint region to adapt to the force of missing cartilage)?

[Body Builder]

I agree with the IT band dilemma. It's my biggest con with Betz. Ik it won't do much harm to cut it, without it it's like you said more of a gamble. You can be fine but you can end up needing it later (which is dumb tbh, ofc it's not a big surgery but unecessary). I know that case too but I also know for example tallertree who had an excellent recovery for an insane 9cm. Other surgeons that don't do it are Guichet and Monegal I think.
Yea I am interested in femur surgery. Not going with tibias. I probably will not even do them in the future, it depends on how I will feel after femur. So you are sure that for femur surgery there will not be a thickening? That's good news.
Yes the prophylactic cut is done in the calf (I think) with tibia LL to prevent compartment syndrome as it's devastating. Deffo one of the worse complications you can have. a full fasciotomy leaves you with a huge scar on the leg (almost the whole lower leg gets cut open, you need to release 4 muscle compartments which can be reached from one incision but that incision.. well you have seen images).
Never heard of the compression socks lol, do you get them all the time for tibia ll?

Interesting idea I think this is a good question to ask an expert. Is the caput tibiae larger (wider) in tall people and is it bad for the joints to lengthen the legs out of their natural size and will the joints adapt (you know like people with arthritis get extra bone formations near their joint region to adapt to the force of missing cartilage)?

I never did and "prophylactic" cut on tibia nor most LLers had.
Compartment syndrome is a bad complication but unusual too. If you lengthen slow and not more than your limits most LLers won't have any problem to need fasciotomies, tendon lengthenings etc for tibias.
For femurs itb release is a must though as it has only benefits and no risk so all the respectable doctors do it.

[Tartar]

I agree with the IT band dilemma. It's my biggest con with Betz. Ik it won't do much harm to cut it, without it it's like you said more of a gamble. You can be fine but you can end up needing it later (which is dumb tbh, ofc it's not a big surgery but unecessary). I know that case too but I also know for example tallertree who had an excellent recovery for an insane 9cm. Other surgeons that don't do it are Guichet and Monegal I think.
Yea I am interested in femur surgery. Not going with tibias. I probably will not even do them in the future, it depends on how I will feel after femur. So you are sure that for femur surgery there will not be a thickening? That's good news.
Yes the prophylactic cut is done in the calf (I think) with tibia LL to prevent compartment syndrome as it's devastating. Deffo one of the worse complications you can have. a full fasciotomy leaves you with a huge scar on the leg (almost the whole lower leg gets cut open, you need to release 4 muscle compartments which can be reached from one incision but that incision.. well you have seen images).
Never heard of the compression socks lol, do you get them all the time for tibia ll?

Interesting idea I think this is a good question to ask an expert. Is the caput tibiae larger (wider) in tall people and is it bad for the joints to lengthen the legs out of their natural size and will the joints adapt (you know like people with arthritis get extra bone formations near their joint region to adapt to the force of missing cartilage)?

I didn't know about Guichet but it doesn't surprise me since it uses almost the same nail. Anyway they are pretty ancient techniques. I don't like the nail.
No way any thickening for femur.
For the tibial thickeing I don't really know, it's a patients complain about tibia but I'm not very informed about it, if you like you can find even dr Lee talking about it in his youtube channel. I don't really have never thought a lot about it.
The bone formation aroung the arthrosis or generally arthritic regions should be actually considered more as an unavoidable process due to the bone friction...missing cartilage leads to bone damage and remodeling.

[RealLostSoul]

I never did and "prophylactic" cut on tibia nor most LLers had.
Compartment syndrome is a bad complication but unusual too. If you lengthen slow and not more than your limits most LLers won't have any problem to need fasciotomies, tendon lengthenings etc for tibias.
For femurs itb release is a must though as it has only benefits and no risk so all the respectable doctors do it.

Well if I remember correctly Paley does a small (I think 1cm incision) cut on the calf to reduce the risk. This is the reason why people get thicker lower legs after LL. We are not talking about chronic compartment syndrome which is a different story. Accute compartment syndrome shouldn't happen once you already start lengthening but in the days after the surgery trauma.
Agree the risks of ITB release is none if done properly....

I didn't know about Guichet but it doesn't surprise me since it uses almost the same nail. Anyway they are pretty ancient techniques. I don't like the nail.
No way any thickening for femur.
For the tibial thickeing I don't really know, it's a patients complain about tibia but I'm not very informed about it, if you like you can find even dr Lee talking about it in his youtube channel. I don't really have never thought a lot about it.
The bone formation aroung the arthrosis or generally arthritic regions should be actually considered more as an unavoidable process due to the bone friction...missing cartilage leads to bone damage and remodeling.

Yes in arthritis it's due to a negative effect but maybe in LL you get a remodelled tibia head too because of altered forces? This question can easily be answered by looking at longterm before and after xrays (I kinda doubt this is true though tbh).
Do you have a link to that dr lee video that would be sweet? ty

e:/ yes , if you check Paleys site under "additional costs" etc. he says for tibia LL he does anterior compartment release to prevent compartment syndrome. So I think that's pretty reasonable and should be considered (same safety measurement as that small tube that blows out the fat and stuff when drilling the IM canal, or heparin after the surgery, etc.)

[Tartar]

I don't really remember which video could it be...himself said it and it was asked at least once to one of the interviewed patient, those video are nice and informative and they last few minutes so if you like watch them.
I'll check the Paley additional procedure in his website.

[MakeMeTallAF]

There are so many drugs on trial for arthritis right now, I really don't think this is a big concern. I would be surprised if arthritis isn't cured within the next 20 years. Some large companies are already in phase 2/3 trials I think, like Samumed for example.

[Serilium]

being obesity and inactive causes 20x more chance arthritis than a 2 degree shift from LL ever will