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[ForcedPuberty]

so I had a discussion with  my doctor about this so called alleged ability to be able to lengthen more when you do internal.

at the moment my doctor states adamantly that external femurs should be maximum of 5cm.

so I had an in depth discussion about internal femurs and presented the ideas of what this forumn believes.


but in regards to this femur debate. my doctor tells me that the ASAMI board is discussing it next meet. but as you lengthen internally your knees become closer and closer together. when you lengthen externally this does not happen.

below is a leg representation of bone structure
   ______
  _______      hip section
  _______
   \       /   femur section slanted
    \     /
     l    l     tibia section straight
     l    l

the more you lengthen femurs(internally) the closer your knees come to each other, this will seriously alter biomechanics. if you lengthen to much you will have to get a reduction. this is why I would never get internal. internal is not superior, it causes lasting changes. the average person who does internal according to my doctor will need an average of 2.8 surgeries.

the price does not represent superior methodology. if you want to be safe and have the same type of body when you finish then do not get internal as you will be different when you are finished biomechanically speaking compared to a normal person.

I think external femurs is superior to internal femurs because you lengthen your height while not changing your body structure. when you finish lengthening externally your knees are not closer together, the distance between them remains the same as before surgery. and my doctor said that 5cm is the safe range for internal femurs also. 
   

[Taller]

What about the permanent loss of knee range of motion often associated with external femurs, especially monorails?

[Overdozer]

What about the permanent loss of knee range of motion often associated with external femurs, especially monorails?

There is no permament loss of ROM with external femurs - many studies exist - it's only temporary and is simply a cause of long immobilization caused by wires and half-pins that prevent knee flexion, as they go through muscles.

However, the main problem with Ilizarov femoral lengthening is the discomfort. Immediately after the surgery your knee flexion is limited to 60-90 degrees (pins going through the soft tissue) and in the proccess of lengthening it decreases to 30-60 degrees. Knee extension also suffers, but the same way as with internals, you can work it out. Now imagine having 2 huge frames around your femurs and at the same time having a maxium of 40 degrees knee flexion. Lengthening even just one femur at a time limits you much more than lengthening femurs bilaterally with internals: sitting, laying, sleeping - everything suffers.

The biomechanics thing is also true. I've read a Kurgan (Ilizarov Centre) article about it, which claimed that lengthening femurs internally, without fixing the mechanical axis, leads to arthritis in the long run. For that very reason they claimed that lengthening femurs externally is superior to internal methods. However, it should be taken with a grain of salt, as they don't have any real data to back it up. Also keep in mind that the femur angle is individual - is it known to depend on the pelvis width - women generally have bigger femur angle. The more the angle, the more your feet are going to 'move in'. Lets say you lengthen 10 cms and your femur angle is 45 degrees (in theory), that means only 50% of the length gained will transfer vertically, meaning you'll only grow by 5 cms. That also means the other 5 cms will transfer horizontally, moving your feet and altering the mechanical axis significantly. Which in the end will cause increased pressure and stress to your knees and quite likely lead to problems with your knees. Now obviously femur is rarely rotated at 45 degrees, I was just trying to explain how it works.

(I've lengthened 7.5 cms on my femur externally)

[Uppland]

Yeah I've heard this as well but I only though it meant you'd get less height for your clicks. Was planning on doing 6,5CM to get an actual 6CM height increase.

Didn't know about the biomechanical issues at all, thanks for telling. Is internals really that bad though? Several people on has done it and it seems like a lot of them recover pretty well.

What method would you guys recommend for a 6CM gain?

[Overdozer]

Yeah I've heard this as well but I only though it meant you'd get less height for your clicks. Was planning on doing 6,5CM to get an actual 6CM height increase.

Didn't know about the biomechanical issues at all, thanks for telling. Is internals really that bad though? Several people on has done it and it seems like a lot of them recover pretty well.

What method would you guys recommend for a 6CM gain?

Internal is still the best method for lengthening femurs. Like I said, you simply won't survive lengthening femurs bilaterally with externals, and if you do it 1 after 1 with pure externals it'll take 2 years at the very least. With internals you're mostly done after like 4-5 months. I think the importance of correcting the mechanical axis is highly exaggerated for one simple reason - someone who's naturally tall and has naturally long femurs will have the same mechanical axis as if you imagine he lengthened his femurs. Honestly, I'd disregard the 'mechanical axis problem' completely, I think it's made out of dust.

[Uppland]

Internal is still the best method for lengthening femurs. Like I said, you simply won't survive lengthening femurs bilaterally with externals, and if you do it 1 after 1 with pure externals it'll take 2 years at the very least. With internals you're mostly done after like 4-5 months. I think the importance of correcting the mechanical axis is highly exaggerated for one simple reason - someone who's naturally tall and has naturally long femurs will have the same mechanical axis as if you imagine he lengthened his femurs. Honestly, I'd disregard the 'mechanical axis problem' completely, I think it's made out of dust.

Thanks but I guess I'll ask my doctor of choice about it just to be safe.

[Medium Drink Of Water]

Internal is still the best method for lengthening femurs. Like I said, you simply won't survive lengthening femurs bilaterally with externals, and if you do it 1 after 1 with pure externals it'll take 2 years at the very least. With internals you're mostly done after like 4-5 months. I think the importance of correcting the mechanical axis is highly exaggerated for one simple reason - someone who's naturally tall and has naturally long femurs will have the same mechanical axis as if you imagine he lengthened his femurs. Honestly, I'd disregard the 'mechanical axis problem' completely, I think it's made out of dust.

That tall person would have a wider hip base, so he'd have a natural mechanical axis.  Otherwise all tall people would be walking around knock-kneed.

[Puertoricanwasp123]

Lets say you lengthen 10 cms and your femur angle is 45 degrees (in theory), that means only 50% of the length gained will transfer vertically, meaning you'll only grow by 5 cms. That also means the other 5 cms will transfer horizontally, moving your feet and altering the mechanical axis significantly. Which in the end will cause increased pressure and stress to your knees and quite likely lead to problems with your knees.

So will a patient with a 45 degrees be lengthened until they vertically grow to a desired height or will they have to settle with less gains?

[Uppland]

So will a patient with a 45 degrees be lengthened until they vertically grow to a desired height or will they have to settle with less gains?

They will have to settle I think.

[Puertoricanwasp123]

They will have to settle I think.

How about correcting the 45 degrees then the height surgeries later?

[Uppland]

How about correcting the 45 degrees then the height surgeries later?

I don't know much about leg anatomy but I suspect that might be dangerous. I.e the femur bone might be supposed to have a certain angle, it could also be a very invasive surgery to do.

You will have to ask a doctor about your femur angle. A decent rule of thumb to improve safety is to stick to a conservative goal. For example if you're shooting for a gain of 10CM it should be safer (better recovery, less chance of complications) to lenghten your femur 6CM and then your tibia 4CM instead of doing it all in one segment.

[Dr Monegal]

Hi FP

I beg you to read carefully before you start to argue and missprestige doctors and techniques as usual. The use of internal devices can lead to the kind of deviations you refer when lenthenning strictly on the anatomical axis of the Femur. This happens mainly when performing antegrade techniques as it does Not allow any correction at all.

LL we do care about this issues and we do plan our cases. That is exactly one of the reasons why I prefer Fitbone over others like Precice. The implant is Not strictly placed in the canal...it s placed in order to achieve a correction on the mechanical axis so it is close to perdection. We use the "reverse Planning method" published by Rainer Baumgart after more than 500 procedures. You can find a Link and a presentation below. And We Also use powerful Tools as computer assisted Planning to simulate How the bone will behave on the procedure.

Ex fix usually Leads to varus femur and tibia valga for many reasons i can explain you such as a Bad positionning of pins, pin losening (caused by local infection), excentric forces applied on pins, bad allignment of the rod, progressively stiffness of the callus... So it is dangerous to post that ex fix is safer.

You can Also find a paper from Dror Paley in which he advices the use of a nail (LON) as it is much safer than ex fix itself.

I decide to write because it is very Important that all the information you give about the different techniques has to be backgrounded by some professional supervision and/or Medical publications.
My advice as a doc for both tibias and femurs is internal by far.
But i trully appreciate that you posted this issue of malalignment. Planification is extremely important. LL is Not easy and it is vital to plan every case individually.


http://www.llrs.org/PDFs/Annual%20Meeting%20Presentations/Friday%20Meeting/8.Dahl.pdf
http://www.ncbi.nlm.nih.gov/m/pubmed/19685230/

[Uppland]

Great to have you back on the forum Dr. Monegal, we've been missing your insight since you left.

What can we, as patients, do to avoid any harmful deviations?

Also, this might be beyond your professional curtesy so don't feel preassured to answer,  but I am considering hiring Dr. Jean-Marc Guichet, what is your professional opinion on him as a surgeon?

[Puertoricanwasp123]

I don't know much about leg anatomy but I suspect that might be dangerous. I.e the femur bone might be supposed to have a certain angle, it could also be a very invasive surgery to do.

For example if you're shooting for a gain of 10CM it should be safer (better recovery, less chance of complications) to lenghten your femur 6CM and then your tibia 4CM instead of doing it all in one segment.

My un-revokeable plan is one segment (femur/femoral region for the following reason) and I will experiment with 2 inch tall sandals so I can once again return to the beach without all the worries of modern life. If elevator shoes are too much of a burden then I might return to the surgeon for the tibias.

To answer you now, 5cm on both segments is more even than 6cm here and 4cm though I was raised with inches in school.

(Welcome back Monegal keep it up)

[Uppland]

My un-revokeable plan is one segment (femur/femoral region for the following reason) and I will experiment with 2 inch tall sandals so I can once again return to the beach without all the worries of modern life. If elevator shoes are too much of a burden then I might return to the surgeon for the tibias.

To answer you now, 5cm on both segments is more even than 6cm here and 4cm though I was raised with inches in school.

(Welcome back Monegal keep it up)

5CM is generally considered safe, I wouldn't worry too much if I were you. Can your proportions handle 10CM though? I've studied mine carefully and I wouldn't add more than 8CM personally.

[Puertoricanwasp123]

5CM is generally considered safe, I wouldn't worry too much if I were you. Can your proportions handle 10CM though? I've studied mine carefully and I wouldn't add more than 8CM personally.

I use large shirts like every average person, the pants though had to be cut smaller so as long as I reach the average pants size I will be alright and fooling a wife will be easy with large shirt plus average pants in the laundry.

[Overdozer]

My advice as a doc for both tibias and femurs is internal by far.

Dr. Monegal, can you comment on the following study, which claims 47% mean incidence of (chronic) anterior knee pain after intramedullary nailing of tibia and 18.6% mean incidence after IM nailing of femur? Can this be avoided?
http://www.bjj.boneandjoint.org.uk/content/88-B/5/576

[Uppland]

Dr. Monegal, can you comment on the following study, which claims 47% mean incidence of (chronic) anterior knee pain after intramedullary nailing of tibia and 18.6% mean incidence after IM nailing of femur? Can this be avoided?
http://www.bjj.boneandjoint.org.uk/content/88-B/5/576

Dr. Monegal seems to have left. He's like a medical information ninja, coming at us with actually qualified oponions when we least expect it -but when we need it the most.

Not the hero the forum deserves, but he's the one we need right now.

[Puertoricanwasp123]

Dr. Monegal seems to have left.

I see his online icon green.

[galaxy1]

medical information ninja, lol
Now I'm afraid to do all external, but I know he is referring to femurs specifically.

[Puertoricanwasp123]

medical information ninja, lol
Now I'm afraid to do all external.

Don't let anyone discourage you if there's a bright side it's that externals have been in the market for several decades.

[Overdozer]

medical information ninja, lol
Now I'm afraid to do all external.

Keep in mind that many surgeons have their own opinions on the matter. They just can't argue because they don't visit the forums. Also keep in mind that cosmetic LL surgeries, just like any other cosmetic surgeries, are a business.

[galaxy1]

Don't let anyone discourage you if there's a bright side it's that externals have been in the market for several decades.

Every method will have it's pros and cons. I would have concerns with bone growth in using internal methods and because of my age it's not a concern I should take lightly.

[ForcedPuberty]

I beg you to read carefully before you start to argue

I did not read anything. I had a 1 hour discussion with my surgeon in my home.

my doctor discussed the reverse Planning method during this hour, and he said that it is irrelevant as a safe approach because of the retrograde insertion and the massive statistical outcome of permanent knee pain. (you beat me to it exclide I was going to post that study)

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

1460 patients, mean follow-up was 23.9 months,  permanent knee pain: 47.4%

You can Also find a paper from Dror Paley in which he advices the use of a nail (LON) as it is much safer than ex fix itself.

im not sure how this is relevant to knock knees discussion, but either way paley has sent an email saying that for tibia certain styles of monorail are superior to internal devices. although I concede that paley prefers internal for femur.

I decide to write because it is very Important that all the information you give about the different techniques has to be backgrounded by some professional supervision and/or Medical publications.

its funny because I was medically supervised by a doctor who invents/develops limb lengthening devices when we had this discussion. and you have now a study with 1460 patients with an almost 50% permanent knee pain complication rate.

[Dr Monegal]

Hi guys
Regarding anterior knee pain. This is an issue that you Are all aware of.
I trully think that entry Point of the nail is a critical Point and patellar tendon spreading is one of main reasons apart from soft tissue stretching and malalignment outcome.

You might see a great difference when performing tibiae and this is caused because most of the procedures are performed through patellar tendon whereas in femur most are performed throught the piriformis fosae (antegrade).

To avoid that when performing tibiae We can chose a Suprapatellar Approach.

http://www.ncbi.nlm.nih.gov/m/pubmed/24694557/

Check that link wich might be usefull.

PS: i am Not a ninja...just trying to help you guys out There

[Dr Monegal]

There you go FP

You carry on with your cruisade to criticise and try to pull down any single comment We post here.
Go and di whatever. You Are posting a review of articles in which it does Not say a word about malalignment outcome, damage on the patellofemoral surfaces, meniscus or tibial plateau.

As far as I read this is a review of intramedullary nailing (Not Limb lengthening) and in most cases (probably all from traumatic aethiology) there might have been several colateral injuries like soft tissue injuries, joint injuries, shortenning, axial deviations...

But well done. You carry on with your useless point.

Let me ask you a question. What the hell Are you doing in this forum? I thought this Was suposed to be a experience sharing and supporting tool to help people to decide best option for themselves. You carry on posting whatever...and I am Not sure if you already had any experience on you...but after your words i am Not quite sure LL is the best option for you.
Confidence is very relevant for us the surgeons. And you don t seem to Feel confident enought tongo for it. Just think about it.

[galaxy1]

Keep in mind that many surgeons have their own opinions on the matter. They just can't argue because they don't visit the forums. Also keep in mind that cosmetic LL surgeries, just like any other cosmetic surgeries, are a business.

True. It's well known that internals will not be compatible for every one person. The method that one chooses to lengthen is very individual to each person.

[ForcedPuberty]

But well done. You carry on with your useless point

correction, my surgeons points.

Let me ask you a question. What the hell Are you doing in this forum? I thought this Was suposed to be a experience sharing and supporting tool to help people to decide best option for themselves.

second correction, this thread was started by me due to a 1 hour discussion with my surgeon who invents/develops limb lengthening devices, that 1 hour discussion was the very reason for this thread being created, to tell me that I dare not post the express view point of my surgeon that he stated during that 1 hour would just be ludicrous. the actual topic here is the 1 hour discussion. so I am completely relevant. you are just being a bully because I am not a doctor.

You carry on with your useless point

also please don't call my surgeon and his points useless. its not very nice.

And you don t seem to Feel confident enought tongo for it. Just think about it.

I am already undergoing limb lengthening. so this quote is irrelevant. however you are correct I don't need LL, my life was already amazing, this is just an improvement because perhaps 10-20% of girls who are attractive have height requirements, although I have enough other characteristics to date those girls already. and I don't really care to spend my money on anything else.

To avoid that when performing tibiae We can chose a Suprapatellar Approach.

I concede that does look promising, however it is 36 patients, not 1,460 patients. so your study although looking promising is inconclusive.

please don't bully me because I am not a surgeon. my opinion is valid because it is not my opinion. it is a surgeons opinion. don't shoot the messenger.

[Dr Monegal]

Sorry for the word useless. This Was Not referred to the knee pain issue it Was referred to your initial argument about malalignment regarding femoral internals.

First I never bully anyone...neither patients Nor doctors. Someone asked me about Guichet and I Did not mention a word.
I never give opinions on others procedures.
I remain respectfull to all of you guys.

So you Did Not towards me in the past. But I do Not give any relevance to it.

Your study is from 1990 to 2005 based on trauma cases. Obviously medicine and surgical techniques have there own evolution. But a paper in Orthopaedics is no longer relevant after 3 years in most cases. In the USA procedures of tibia nailing Are electively performed suprapatellar..you know why? To prevent knee pain and other issues.

But it s ok. Feel free to post your thoughts, This is  why this forum Was created.
I never missrespect you, and you Did this towards me and other users recently. And this pisses me off.

By the way I wish you the best in your lengthening procedure. Probably externals after your words.
And keep in mind that LL is Not easy neither with internals Not with externals.
But As I told you I wish you early recovery, excellent outcome and make your expectancies be fully satisfied as This is a brave decission.

[ForcedPuberty]

Sorry for the word useless. This Was Not referred to the knee pain issue it Was referred to your initial argument about malalignment regarding femoral internals.

correction. my doctors initial argument about malalignment regarding femoral internals.

But it s ok. Feel free to post your thoughts, This is  why this forum Was created

correction. my doctors thoughts.

this entire thread is just me posting what my doctor told me. if you don't like my doctors opinion feel free to keep telling me that im preposterous.

[Freewill]

i totally agree with Dr Monegal . If really anyone is concerned about difference in opinions of surgeons or the surgery then LL is not for such people , just follow your heart , trust your heart and go for it , whatever be the result you will be happy for it for the Fact that you listened to your heart "WILL" and not to the will of someone else mind. if you layout all the "IF" and "BUT" of any task you want to do , you will simply end up doing nothing just NOTHING. regarding Femoral LL i would go with Internals , after reading dairies of Hannah, Shy Shy , Apo and many others , i think they gained the height they wanted and they are living normal life. 

* Looks like someone expects to become spiderman or Mister Fantastic after LL *  ugghhh