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[An_Apple_A_Day]

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

[handy]

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?

[Franz]

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.

[An_Apple_A_Day]

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?

[BilateralDamage]

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.

[Medium Drink Of Water]

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?

[KiloKAHN]

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. 

[Franz]

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!

[Franz]

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?

[KiloKAHN]

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 ). 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.

[An_Apple_A_Day]

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.

[Franz]

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 ). 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...

[Rivers]

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.

[Bruno Mars]

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.

[An_Apple_A_Day]

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?

[Franz]

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!

[Franz]

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.

[Machine]

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

[Bruno Mars]

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?

[Claude]

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.

[ThePlague]

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

[Franz]

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.

[Franz]

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.

[Franz]

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.

[Franz]

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! 

[KiloKAHN]

When did you first develop an interest in orthopedics? What aspect of being an orthopedic surgeon do you like most?

[Franz]

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.

[Bruno Mars]

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.

[KiloKAHN]

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.
=====

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?

[Disobedient]

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

[alps]

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?