Thanks again for contacting Dr. Paley, Sean. That was a helpful reply. It followed mostly along what I expected him to say: internal LL is faster, safer, more reliable, etc. But it's good to hear it direct from a guy with so much experience/expertise. I think he does have an arrangement with Precise. He installed the first Precise nails in existence, and I presume he's worked with them to create the device. He may even own some of the invention, though I really don't know and don't care too much. I trust Paley is saying what he truly believes. He seems like a very ethical man who is committed to getting the best results for his patients.
I've been thinking continually about all of this and I have a number of further thoughts.
Tibial Lengthening and the Anatomical AxisI've looked at it in more detail, and it appears the angulation of the tibias in a healthy anatomically correct person are far more vertical than I was giving them credit for. For example, in this xray here, we see the tibias are practically perfectly vertical. The only abnormality to them is that they have a somewhat "S" shaped curvature. But from direct top to bottom it is virtually perfectly vertical. The femurs by contrast are on an approximately 7-9° angle.
Here's another interesting xray of a person with bow legs (perhaps much like YellowSpike was preop), which was fixed via a high tibial osteotomy. I find it interesting, because they probably could have gotten close to the same correction from an internal femur lengthening. But the point is, in the post op xray, the tibias are now almost perfectly vertical, as it seems they probably ought to have been. The femurs appear to be post op at approximately 5°.
The verticality of normal tibias is important because it means that well done internal tibias should properly preserve the anatomical axis of the hips/knees/ankles. It would therefore not be necessary to use Ilizarovs to keep the alignment.
I am fixated on maintaining alignment for a number of reasons which should be obvious but I'll touch on later. Internal tibias (for myself) may then be a favorable approach. Uppland, you say knee pain is a real possibility with internal tibias. The question is exactly why, and whether this is due to soft tissue pain which may resolve with physio or bone damage/deformity that is permanent. Further questions I want to answer include:
- How slow will an internal tibia be?
- Would an internal Guichet tibia be better than an internal Precise tibia, since Guichet is more weight bearing?
- How exactly is the rod drilled into the tibia? If it is inserted in any way that damages the articular surface of the tibia, that's going to be the fastest way to knee arthritis, so then this option becomes less appealing.
- Does the lack of a full nail through the fibula predispose the fibula to deformity during this procedure that could lead to ankle arthritis long term?
Internal vs External FemursI looked at Bluebarbie's thread and honestly I'm sorry to say I am horrified at what has been done to her. I think her thread is a perfect (unfortunate) example of why monorails shouldn't be used. The surgeons have installed the monorails on a massive angle in one of her legs, and now they have no way to correct this. They have told her "it will be fixed when the nail is inserted". But in the meantime she is developing bone callous which will start consolidating. There is no controlled or accurate way they will be able to fix this misalignment during the nailing process. What they are telling her makes no sense.
She's wealthy. If I was her, I'd be sending my xrays to Paley or Guichet and asking them what they can do to fix it ASAP, perhaps in this case via external Ilizarov. I don't mean to sound cynical or unsupportive but I think she looks like she's getting butchered, and if she doesn't do something soon she will regret it. I'm going to tell her that too.
Ilizarov externals have so many adjustable attachments to the bone it can shift the bone in almost any direction to correct misalignments like what Barbie's going through now. So for her now that might actually be a good corrective option.
But reviewing threads from people who have had them for primary lengthening in Russia, China, etc. I am beginning to understand better why the modern surgeons are less eager to rely on them. Bluecrimson in his thread was saying it can take up to 2 years to get back to "normal" from what he's seen.
They do seem to perform external femur Ilizarovs at the Ilizarov Scientific Centre in Russia. If I were to get Ilizarovs, I presume that's where I'd get them. But if the surgeons control the axis during such Ilizarovs by serial xray and approximation, it becomes such an almost artistic endeavor since it depends so much on the skill and attentiveness/awareness of the surgeon. That can be dangerous, which is probably part of why Paley doesn't want to touch them unless to correct deformity.
http://www.dailymail.co.uk/health/article-1039416/Tall-order-The-bizarre-Russian-clinic-offers-leg-lengthening-surgery-STAND-pain.htmlPaley's Pending Study:I agree with Sean that Paley's not saying the axis deviation doesn't happen. Rather, he's saying it's a "nonissue". Like everyone else, I am eager to see what he plans to publish to show this. I expect it will be reassuring. However, I don't think he will be able to truly prove that this deviation is is a nonissue. The Precise is too new a device. The only way to prove it's a nonissue would be to follow a cohort of Precise femur lengthened patients for 20 years and then show they don't have increased arthritis or knee pain rates. No one can do that though because the technique hasn't existed long enough.
What I'm guessing he's going to be publishing instead is a comparison of maybe 20 patients lengthened by tibial Ilizarov to 20 patients lengthened by internal Precise femur and show that the knee pain, stiffness, and range of motion is not significantly different between both groups after 1-2 years or so. That would be useful to see, but it still wouldn't completely put to rest concerns about the genu valgum deviation of internal femurs.
A genu valgum deformity/deviation will put increased stress on the lateral compartments of the knee and ankle. As theuprising phrased it, this is again a matter of fundamental geometry. The only way to know what the long term effects are is to wait 20 years. But we shouldn't even need to do that. Most orthopedic surgeons can tell you that genu varum puts you at risk for medial compartment arthritis, and genu valgum puts you at risk for lateral compartment arthritis. I simply can't see a way around this. The weight bearing through the two knee compartments needs to be balanced to maintain the longest duration of joint health.
As I've said, I really want to be taller. But personally I'm not yet so desperate I'm willing to take the risk that an axis deviation could lead to knee/ankle/hip problems in the long run. Right now, I'm putting my hopes into the possibility of Guichet/Paley tibial internals. I'm looking into more detail at the operative techniques linked here:
http://ellipse-tech.com/precice-physicians/
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Topic: How LL (inevitably?) misaligns joints, creates x-legs, and causes joint pain (Read 42635 times)