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[Franz]

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?

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.

[Franz]

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!)

[Franz]

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.

[Dingo]

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.

[Disobedient]

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

[ThePlague]

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

[Arche]

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 

[inquisitivemind]

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?

[Polycrates.]

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

[Medium Drink Of Water]

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:

[Franz]

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.

[Smallguy]

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,

[Franz]

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

[KiloKAHN]

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?

[Franz]

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.

[Franz]

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.

[Franz]

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.

[BilateralDamage]

Wooo, the king is back!

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.

[Franz]

Wooo, the king is back!

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!

[Franz]

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!

[BilateralDamage]

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.

[Medium Drink Of Water]

What is inside my bones now, where the internal nails used to be?

[Smallguy]

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?

[JP]

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

[Übermensch]

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

[Daylight]

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!!!

[Franz]

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.

[Franz]

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.

[Franz]

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.

[Franz]

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.

[OverrideYouGenetics]

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?"