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[BilateralDamage]

a welcome distraction during LL

Nice pun there. 

[Wannabegiant]

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.

[Franz]

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

[Franz]

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.

[Wannabegiant]

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..

[Adriano]

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?

[Franz]

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...

[Daylight]

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.

[Franz]

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...

[KiloKAHN]

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.

[Franz]

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

[BilateralDamage]

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...

[Blackhawk]

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. 

[Polycrates.]

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...

[theuprising]

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.

[mediocre]

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. 

[Dingo]

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.

[theuprising]

Also do patients have a choice of spinal anesthetic or is it only general available?

Thanks again Dr B

[Franz]

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.

[Polycrates.]

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.

[rickybobby]

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!!

[paco1]

hello doctor Frank,
what method do you prefer for lengthening 5,5 cm in tibias? LON or LATN.

[handy]

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.

[Polycrates.]

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.

[Rivers]

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.

[Franz]

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.

[Franz]

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.

[Franz]

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.

[Franz]

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.

[Franz]

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!

[rickybobby]

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?