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[limbusername]

Hello,

I've been reading about the high risk of permanent knee pain from internal tibia lengthening. 

First, it seems there's a good deal of uncertainty about the risk.  Intramedullary rods are said to cause permanent knee pain in 73% of cases, but I've seen threads here which quote Dr Birkholtz saying the number is more like 25%.  Monegal said (here: http://www.limblengtheningforum.com/index.php?topic=1091.0) that

"Chronic knee pain in 25% of cases? That s well beyond the numbers in medical publications.
Try to insert nail throught a suprapatellar approach to prevent patellar tendon spreading and your numbers will go down almost to 0%".

Paley told the patient in this thread: http://www.limblengtheningforum.com/index.php?topic=237.54 that his numbers are more like 10% if that.  Apparently he makes the incision higher up on the knee, avoiding the sensitive tissues? 

I imagine a reason for CLL knee complications being lower is that 73% is that the study that gave the 73% number was done 20 years ago and, at least in the West, surgical techniques have probably improved in response to the study.

But are the rate of complications actually lower?  There's a whole lot of anecdotal stuff around here on the risk of knee complications.  I know several users here suffer from them, so they definitely happen, but I can't find any solid numbers as to their frequency and likelihood.  Does anyone have any?  Specifically, can anyone provide details on Paley's method and stats on his track record with permanent knee complications, since he's the doctor I'd probably go with?

Second, and I haven't seen this question posted so let me know if it has been, could potential knee issues resulting from the tibial surgery be themselves treated with another surgery?  The people experiencing the pain say that it's at its worst when kneeling, which indicates damage to the patellar tendon.  This is basically the same as a condition called Jumper's Knee, in which the patellar tendon is torn through over-exertion.  That condition IS treatable, so in theory the post-lengthening knee pain should be as well.  Do any CLL patients who had the knee pain complication have experience with having it remedied surgically?

Thanks a lot.   

[ForcedPuberty]

im confused. the last post in that monegal thread linked a medical article with numbers.

but I can't find any solid numbers as to their frequency and likelihood.  Does anyone have any?

did you even bother to read the thread that you posted?

the last post on the thread was:

found the rate for LON patella chronic pain. in an accredited study.



Quote

Tibial nailing.
In this group, 11 retrospective11,22,45,47,48,50,62,63,65,66,70 and nine prospective studies1,5,8,12,52,64,67–69 had a total of 1469 fractures. Of the 1460 patients, 629 had symptoms of anterior knee pain independent of the approach used. The mean follow-up was 23.9 months (7.267 to 5765). The mean incidence of anterior knee pain at the end of the follow-up was 47.4%




http://www.bjj.boneandjoint.org.uk/content/88-B/5/576

so a sample size of 1460 is fairly significant. 47.4% at 2 years later had anterior knee pain.

I recommend external humerus and not LON until further research has been conducted on LON humerus.

[ForcedPuberty]

that's not a small study with 20 patients.....

[limbusername]

im confused. the last post in that monegal thread linked a medical article with numbers.

did you even bother to read the thread that you posted?

the last post on the thread was:

Well yeah.  Monegal claimed that a 25% incidence of anterior knee pain was "well beyond" the numbers in medical publications, which would go down to almost 0 if the right approach was used.  The medical publication in the link showed 47% incidence no matter what approach was used, literally the exact opposite of what Monegal said.  This is the kind of contradictory information I'm trying to sort out.  How do we reconcile what Monegal and Paley say with what the studies say?  Are they lying?  The study is 8 years old.  Is it out of date?  Or is IM nail insertion in a CLL context somehow different from insertion in an injury context?

[ForcedPuberty]

good point. a lot of conflicting information. I tend to trust clinical studies over doctors opinions tbh.

[limbusername]

I'm tempted to lean that way too, to be on the safe side, but maybe we're inferring things from the study that we shouldn't be.  For instance, the studies were done on surgeries that took place more than a decade ago, and the nails used weren't Precice nails.  Maybe that makes a difference, who knows?  It would explain why Monegal, Birkholtz, and Paley all report a lesser incidence of long-term complications. 

The fact that Paley is an American doctor is encouraging too, considering the amount of legal pressure exerted on American doctors to avoid any semblance of malpractice.  The massive class action lawsuit and possible prosecution he would be hit with for underestimating the risk of permanent complications would make doing so a poor long-term strategy   So maybe Paley does really have better numbers than the studies indicate.

If I could get a tibial lengthening done with Paley with less than a 10% chance of a permanent complication, and have the ability to fix the complication if it did arise, I'd be happy indeed.