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[Franz]

Hi Dr Birkholtz,

When you first obtained access to the Precice nail, was a representative from Ellipse sent by the company to be present during the surgeries? If so, how long does that continue until Ellipse decides that a representative doesn't need to be there for the surgery every time you use it on a patient?

Good question. This differs from country to country. Ellipse was bought out by Nuvasive, so they now distribute globally. In South Africa the company sells their products through a distributor. On initial launch there was an intensive training programme. Even now we have a representative in theatre with every case. Most importantly to ensure that there is optimal safety and attention to detail. It facilitates communciation and eliminates errors. I see everyone in the surgical team as equally important. The surgeon is strengthened by the team around him or her.

[Franz]

Hello Dr. Franz,

I really appreciate that you have offered to help us understand the limb lengthening process through your experience

I would like to ask about the prospects of a patient who chooses to undergone a 8.0 cm lengthening using external fixators, followed by intramedullary nailing; LATN. For a person who does such an amount of lengthening:
1) How long would a he be needing to use a wheelchair after the surgery?
2) Is weight bearing possible right after the surgery?
3) How long would one have to use crutches after 'graduating' from the wheelchair

It depends a little on the segment, whether tibial or femoral. 8cm is an extreme distance, and would be something I would discourage greatly.
In principle crutch walking could start within days after surgery. As with any lengthening, consolidation takes around 1.5 months per cm lengthened. This is approximately the time till full unassisted weight bearing as well.

[Alu]

Dr,

If I may ask about your record, how many CLL have you preformed? How many non-CLL surgeries have your preformed? Of those how many were using the Precice nail?

I see you don't offer Internal Tibia lengthening, is there a particular reason why? (Like lack of confidence to do so, perhaps you feel the alternatives are safer?)

Have you heard about about news relating to Ellipse's upgraded Precice 2 and when it's coming out? What are your views on it?

[yyes]

50mm lengthening:
10 days lag period, 50 days distraction period. Ie 2 months till length is achieved. Bone consolidation typically takes another 4 months. Ie by six months full unaided weight bearing should be OK. Return to sport the six-nine months after that, depending on the type of sport.

Ballpark is around 18 months.

Thank you for responding Dr. All this information is so invaluable to us.

I guess my final question would be:

What would you say to the people that are considering you as an option but are afraid to do so because of the crime rate in South Africa? How concerned should we be?

[onemorefoot]

Some months ago some user here wrote about Precice3, they are creating a cobalt nail, which can be almost full Weight bearing, the question here is if P2 Will go Out of the market like Precice1?? Or just will be an option(mainly because there are very Slim people), also the cost!!

[alps]

Hi doctor.

do blood vessels get smaller in diameter after lengthening? have there been any studies regarding this?

also, do you know of research material we can go through to understand the impact of lengthening of nerves and blood vessels? Most of the papers I find on Google, decide the outcome of a surgery based on how a patient feels, but not quantitatively. Is there research done that quantitatively compares the before - after states of lengthening? (like an EMG test before and after)

[Franz]

Dr,

If I may ask about your record, how many CLL have you preformed? How many non-CLL surgeries have your preformed? Of those how many were using the Precice nail?

I see you don't offer Internal Tibia lengthening, is there a particular reason why? (Like lack of confidence to do so, perhaps you feel the alternatives are safer?)

Have you heard about about news relating to Ellipse's upgraded Precice 2 and when it's coming out? What are your views on it?

Hi,

I do not specifically count my numbers. Lengthening and limb reconstrction surgeries more than 2000. CLL with Precice around 10. Other non-CLL Precice around 20.

The imformation leaflet is somewhat misleading. Sorry about that. Tibial Precice is offered for the same package as femorals. Confidence is not an issue. Anterior knee pain risk with Precice still about the same as for LON. Weight bearing with LON better than Precice. COst significantly higher with Precice. Therefore I am probably a bit biased to prefer LON. :-)

[Franz]

Thank you for responding Dr. All this information is so invaluable to us.

I guess my final question would be:

What would you say to the people that are considering you as an option but are afraid to do so because of the crime rate in South Africa? How concerned should we be?

Good question.
There are areas where it is really unsafe as in almost any country in the developing world. The hospitals an environments where I live and work are probably safer than a lot of big cities in the US. Be that as it may, the best would probably be to schedule a short holiday and combine that with a consultation and planning visit.

[Franz]

Some months ago some user here wrote about Precice3, they are creating a cobalt nail, which can be almost full Weight bearing, the question here is if P2 Will go Out of the market like Precice1?? Or just will be an option(mainly because there are very Slim people), also the cost!!

In my experience products generally tend to take a lot longer to get to market than the rumour mill would suggest. Whether the company will kee the price similar and whether they will withdraw the 'older' models I don't know.

Remember that the Synoste Chrome Cobalt nail is also on the horison.

[Franz]

Hi doctor.

do blood vessels get smaller in diameter after lengthening? have there been any studies regarding this?

also, do you know of research material we can go through to understand the impact of lengthening of nerves and blood vessels? Most of the papers I find on Google, decide the outcome of a surgery based on how a patient feels, but not quantitatively. Is there research done that quantitatively compares the before - after states of lengthening? (like an EMG test before and after)

Interesting question. I suspect that there are not many such studies as the groups per centre are relatively small. Also, proper assessment would require biopsy which is obviously too invasive. There are some studies on animals. In broad terms the muscle and vessels also grow with the bone and end up being of a similar structure than originally. Some of us are looking into getting better outcomes data through ongoing research.

[YourSpaceBoyfriend]

Good question.
There are areas where it is really unsafe as in almost any country in the developing world. The hospitals an environments where I live and work are probably safer than a lot of big cities in the US. Be that as it may, the best would probably be to schedule a short holiday and combine that with a consultation and planning visit.

What about staying in a hospital for lengthening phase?

Seriously i'm hearing tons of horrifying stories from SA...

[onemorefoot]

I have Been trying to figure Out if with LON method a monolateral fixators can be an option, can the nail inside help to prevent misalignments or the fixator is as important as the nail.

[YourSpaceBoyfriend]

What about staying in a hospital for lengthening phase?

Seriously i'm hearing tons of horrifying stories from SA...

I mean in the hotel*

[jbc]

Dr. Birkholtz, thank you for taking the time to diligently answer so many questions. It is incredibly appreciated.

One last question from me: how much blood loss do you generally see in operating theatre from CLL procedures (femoral) done with the Precise nail? In your experience, do they generally require blood transfusions? If so, how safe are the blood banks in SA relative to US/EU in terms of risk of infection/disease from blood transfusions?

TIA and best regards!

[Franz]

What about staying in a hospital for lengthening phase?

Seriously i'm hearing tons of horrifying stories from SA...

As the accommodation is not directly part of the package, it is your choice to decide where to stay during lengthning.
If it were me, I would consider the Irene Country Lodge. Excellent, safe, good food and amenities, beautiful gardens and centrally located close to shops, malls, hospitals etc. I think they have a reduced rate for extended stays.

[Franz]

I have Been trying to figure Out if with LON method a monolateral fixators can be an option, can the nail inside help to prevent misalignments or the fixator is as important as the nail.

It is definitely an option. To a large extent the nail will prevent malalignment. Cost in our setting for tibial lon with circular would be the same though, so probably better to go for circular.

[Franz]

Dr. Birkholtz, thank you for taking the time to diligently answer so many questions. It is incredibly appreciated.

One last question from me: how much blood loss do you generally see in operating theatre from CLL procedures (femoral) done with the Precise nail? In your experience, do they generally require blood transfusions? If so, how safe are the blood banks in SA relative to US/EU in terms of risk of infection/disease from blood transfusions?

TIA and best regards!

As a rule, because we use percutaneous techniques and have relatively low transfusion triggers, the need for blood transfusion is the exception.

You can visit the South African National Blood Transfusion Service's website for more info. It is one of the oldest blood bank services in the world and is regarded as exceptional in terms of international safety standards. www.sanbs.org.za

Intra-operative blood loss between 300 and 500 mls at the most. There can be further ongoing loss into the 'third space'. Most healthy adults can withstand losses of around three times this much without the need for transfusion.

[applesandoranges]

Thank you for your responses so far 

[onemorefoot]

Oh okay, thanks .

[Jack1066]

Hey, thanks for your time Dr. Birkholtz, this thread has been an interesting read.

If you know anything about other LL doctors and also don't mind sharing your thoughts on them, what are your opinions on Dr. Mitkovic in Nis, Serbia?

Also, what things do you usually recommend your patients do to prepare in the months leading up to the surgery? Stretches, exercises, diet, supplements?

[682]

Greetings Dr Birkholtz. Primarily, I'd like to thanks your contributions to this thread in shedding light on certain hazy issues found within the limb lengthening world. It is refreshing to see a weighted opinion from a professional. If you may, would you please answer the following queries -

1) Is the placement of the break relevant in regards to recovery or even the look of the soft tissue surrounding it? For example, if one was to break and lengthen the center of the calf muscle vs just above the ankle.

2) I have noticed many issues with gait are often blamed on soft tissue. While this is an issue, I often think that minor misalignment may factor strongly into this, especially when viewing video footage where genu valgum (which I assume is different when the bone misaligns than simply being 'knock kneed') is present to some degree. Do you believe this is possible? Can genu valgum be corrected in its entirety an osteotomy or a 'guiding plate'? Can it be avoided in the current form of leg lengthening?

3) Soft tissue is one of the largest issues in regards to limb lengthening. Is there a medical consensus on why soft tissue doesn't adapt the same way it does during natural bone growth? We are all aware that after growth plates fuse no more growth can occur even under the same hormonal conditions but why does the same issue of growth of soft tissue occur where they technically have no 'end point' similar to plate fusion? Could one not accurately reproduce the hormonal conditions in soft tissue growth to mimic that found in natural growth? I believe I have read some studies that refer to issues with cell reproduction of soft tissue in regards to this.

4) A second question regarding soft tissue, after leg lengthening, does the body ever truly recover to the stretching even several years after combined with consistent physical therapy (if lengthened to reasonable standards rather than over lengthening leading to plastic deformation which I assume is permanent), creating new tissue as found in someone with legs of that natural length or does the body just adapt and become more flexible rather than truly recovering, with the soft tissue always being stretched to accommodate the new bone?

5) What are your thoughts on maintaining the ratio naturally found prior to leg lengthening? For example, lengthening both segments by 10% meaning they maintain the ratio or is falling in a biomechanically sound ratio just as acceptable?

6) Is there truly such thing as 100% recovery in regards to cosmetic leg lengthening when the soft tissue is stretched any amount reasonable or not or will it always limit maximum athletic potential even if its imperceptible?

7) What do you believe is the future of cosmetic leg lengthening? Personally, statistical evidence and measurements of patients would be the most important at this point. If I were to go forward with this surgery, I'd hope to do so in a decades time which by then I hope there have been improvements, with as much knowledge as possible and with a reputable surgeon such as yourself.

Thank you in advance for taking the time to read and hopefully reply to these questions. Regards.

[notimportant]

Good question. This differs from country to country. Ellipse was bought out by Nuvasive, so they now distribute globally. In South Africa the company sells their products through a distributor. On initial launch there was an intensive training programme. Even now we have a representative in theatre with every case. Most importantly to ensure that there is optimal safety and attention to detail. It facilitates communciation and eliminates errors. I see everyone in the surgical team as equally important. The surgeon is strengthened by the team around him or her.

I like this about Precice. There have been some problems with Fitbone and the representatives didn't come or came very late and patients had to have many surgeries like Helloworld and Musicmaker. In Penguinn's case with Precice everything was fixed during the initial surgery. Precice isn't perfect but it's the best one in the market.

[Franz]

Hey, thanks for your time Dr. Birkholtz, this thread has been an interesting read.

If you know anything about other LL doctors and also don't mind sharing your thoughts on them, what are your opinions on Dr. Mitkovic in Nis, Serbia?

Also, what things do you usually recommend your patients do to prepare in the months leading up to the surgery? Stretches, exercises, diet, supplements?

I prefer not to comment on other doctors out of professional courtesy. It is certainly not up to me to evaluate whether a doctor is good or safe. I hope you understand.

I am a firm believer that the two most important preparations are flexibility and mindset. Improving flexibility and core strength is key. This is achieved through regular pilates or yoga, supplemented by a stretching programme.
Mindset is a little more difficult. I think regular sessions of meditation and/prayer (depending on your personal beliefs) will serve to calm and centre the spirit. This is needed to endure the sometimes brutal process that lies ahead.

Lastly a good balanced diet with ample amounts of protein and vegetables will provide the building blocks needed for recovery. Think of what you would ideally want to feed a healthy growing child.

[yyes]

Dr Birkholtz,

Based off your experience would you be able to answer the following questions

1. How long does one have to stay in Africa before being able to travel back home

2. How long before someone makes a recovery. My definition of a recovery is the ability to walk without any help and the ability to walk completely normal without a limp of any kind.

This is assuming that the patient does internals.

[Franz]

Greetings Dr Birkholtz. Primarily, I'd like to thanks your contributions to this thread in shedding light on certain hazy issues found within the limb lengthening world. It is refreshing to see a weighted opinion from a professional. If you may, would you please answer the following queries -

1) Is the placement of the break relevant in regards to recovery or even the look of the soft tissue surrounding it? For example, if one was to break and lengthen the center of the calf muscle vs just above the ankle.

Yes,absolutely. The choice of osteotomy site will determine the rate and quality of bone growth, as well as the final appearance of the limb. As a general rule, the preference in the femur is proximal. In the tibia we also prefer proximal as that creates the most reliable bone formation.

2) I have noticed many issues with gait are often blamed on soft tissue. While this is an issue, I often think that minor misalignment may factor strongly into this, especially when viewing video footage where genu valgum (which I assume is different when the bone misaligns than simply being 'knock kneed') is present to some degree. Do you believe this is possible? Can genu valgum be corrected in its entirety an osteotomy or a 'guiding plate'? Can it be avoided in the current form of leg lengthening?

Genu valgum is, as you rightly put, a knock-kneed alignment of the limb. It is accepted that the term applies to the more severe cases which would be pathological and may cause long-term issues like arthritis. It is possible to control for and prevent malalignment. With some techniques like Ilizarov only and Monolateral only techniques, it is easier to develop malalignments. The surgeon can usually pre-empt and treat this if they are experienced.

3) Soft tissue is one of the largest issues in regards to limb lengthening. Is there a medical consensus on why soft tissue doesn't adapt the same way it does during natural bone growth? We are all aware that after growth plates fuse no more growth can occur even under the same hormonal conditions but why does the same issue of growth of soft tissue occur where they technically have no 'end point' similar to plate fusion? Could one not accurately reproduce the hormonal conditions in soft tissue growth to mimic that found in natural growth? I believe I have read some studies that refer to issues with cell reproduction of soft tissue in regards to this.

The main difference in soft tissue adaptation to growth during normal growth vs CLL growth, is the rate at which it occurs. It seems like one of the ways that soft tissue adapts to growth is because of a constant distraction force which triggers gene expression and provides soft tissue growth. In normal growth, this rate of elongation is quite slow and as a result the tissues grow at the optimal rate and can 'keep up'. In limb lengthening we have to speed up the process because the bone will consolidate prematurely if we stretch too slowly. If we could drop distraction rates down to 0.1-0.3mm per day, we will probably have soft tissues that will adapt better. In addition there is probably some form of genetic trigger that switches off after normal adolescent growth, similar to a growth plate closing. Lastly, the predominant protein in soft tissue is collagen. It does become less supple as time goes on, and this is a result of aging. This causes more resistance to stretching as well.

4) A second question regarding soft tissue, after leg lengthening, does the body ever truly recover to the stretching even several years after combined with consistent physical therapy (if lengthened to reasonable standards rather than over lengthening leading to plastic deformation which I assume is permanent), creating new tissue as found in someone with legs of that natural length or does the body just adapt and become more flexible rather than truly recovering, with the soft tissue always being stretched to accommodate the new bone?

Although distraction histiogenesis does cause new tissue to form (ie grow properly), there is an element of elongation through stretching. One of the reasons why realistic lengthening goals should be borne in mind.

5) What are your thoughts on maintaining the ratio naturally found prior to leg lengthening? For example, lengthening both segments by 10% meaning they maintain the ratio or is falling in a biomechanically sound ratio just as acceptable?

As you know, the ration is around 80% and is probably best to try and maintain that as far as possible. Unfortunately logistics and money usually allows only one segment of lengthening, which means deviating from this ratio. For the majority of us, I do not believe that this will translate on its own into worse biomechanics and sporting function. If you happen to be at the top end of your sporting game, it may be different.

6) Is there truly such thing as 100% recovery in regards to cosmetic leg lengthening when the soft tissue is stretched any amount reasonable or not or will it always limit maximum athletic potential even if its imperceptible?

I think that with current technologies available, athletic potential is definitely affected regardless of lengthening amount. Whether it is noticeable in an individual would depend on factors like pre-op status, flexibility, genetics, lengthened amount, technique etc etc.

7) What do you believe is the future of cosmetic leg lengthening? Personally, statistical evidence and measurements of patients would be the most important at this point. If I were to go forward with this surgery, I'd hope to do so in a decades time which by then I hope there have been improvements, with as much knowledge as possible and with a reputable surgeon such as yourself.

I suspect we will very soon start meddling with growth genes during childhood and adolescence and be able to switch these on and off in patients with proven expected shorter stature. Would we be playing God?

Thank you in advance for taking the time to read and hopefully reply to these questions. Regards.

[Franz]

Dr Birkholtz,

Based off your experience would you be able to answer the following questions

1. How long does one have to stay in Africa before being able to travel back home

2. How long before someone makes a recovery. My definition of a recovery is the ability to walk without any help and the ability to walk completely normal without a limp of any kind.

This is assuming that the patient does internals.

For internal femurs it is recommended to stay in the area for around 90 days.
Weight bearing without crutches between 6 and 9 months. 'Full recovery' at 12-18 months.

[682]

Thank you very much for your time and answers Dr Birkholtz, it's much appreciated.

If we could drop distraction rates down to 0.1-0.3mm per day, we will probably have soft tissues that will adapt better.

Perhaps technology will advance to the point where some system can be put in place to stretch soft tissue prior to any surgery over the course of a year or so at a much slower rate meaning that the tissue will have been stretched at a much more reasonable speed and amount and be already be at the correct length for the increase in bone, delay union to lengthen at a slower rate (which would present it's own issues) or use stem cell/hormonal therapy to repair the damaged tissue. The future can't arrive soon enough.

Would we be playing God?

This all depends on perception I believe. In my opinion, no more so than being able to to switch off genetic signals that may result in disease or disability, of course one could argue that height itself is not in the same realm as those issues.

[NeedForSpeed]

Dear Dr Franz,

I'd like to ask a question regarding nerve sensations during limb lengthening:

1) If a patient feels a shooting pain, which is thought to be caused by a nerve, should lengthening be stopped or is it safe to continue?

2) If a patient feels numbness and a tingling sensations at places like the sole of the foot, should lengthening be stopped or is it safe to continue?

[onemorefoot]

Hi,Dr. Franz
Would you operate one leg and some time after the second leg?? When you have a discrepancy of  6-7 cm, is Safe for the supone the use of some extra length on the shoe?

[Franz]

Dear Dr Franz,

I'd like to ask a question regarding nerve sensations during limb lengthening:

1) If a patient feels a shooting pain, which is thought to be caused by a nerve, should lengthening be stopped or is it safe to continue?

2) If a patient feels numbness and a tingling sensations at places like the sole of the foot, should lengthening be stopped or is it safe to continue?

This is a difficult question to answer, as I do not have the full context of the patient. In broad terms, if this were my patient, we would slow the rate of distraction down. It is extremely important that these symptoms be discussed with the treating surgeon as soon as possible.

[Franz]

Hi,Dr. Franz
Would you operate one leg and some time after the second leg?? When you have a discrepancy of  6-7 cm, is Safe for the supone the use of some extra length on the shoe?

I guess the question is whether one leg can be done and then the second leg later?

I am hesitant to do this, as this will leave the patient with a 6cm leg length discrepancy after the first surgery. If, for some reason the patient cannot return, it would be permanent.

It is also significantly more expensive than simultaneous bilateral surgery.

Another alternative would be cross-over surgery, where one femur and the opposite tibia are done at the same time. Once femur can take weight, the opposite combo of segments can be done. In this way, the LON leg becomes the stong one taking most of the weight.