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[An_Apple_A_Day]

Well at the risk of looking like a class A tit & eating humble pie (I'm used to it by now!) I'd like to take the opportunity to thank you for your contributions Franz.

I would also like to ask you typically in your opinion what kinda of recovery one can hope to achieve if they are conservative with lengthening (say 5cm?).

From my understanding of the process muscles lengthen through serial sarcomere synthesis as appose to the muscles simply stretching.

Do you see people a few years down the line?  What is there recovery like?  You mentioned arthritis what is the mechanism of this the surgical trauma, the actual increased length of the limb or both?

Sorry for my crudeness about your country earlier.  Like I said I was perhaps ignorant.

[handy]

Dr. Birkholtz-

Thank you for posting and answering questions on this forum. Can you please elaborate on your following quote.

potential increased arthritis risk after CLL.

During my consultation with Dr. Rozbruch in New York I asked about this question and he told me that cosmetic limb lengthening itself does not pose a risk for developing arthritis. The risk of arthritis comes from the surgeon not taking the proper precautions in aligning the axis of the joints during surgery and monitoring any changes during lengthening. He also said that 5cm is the safest amount to lengthen but up to 8cm does not increase the risk of arthritis. Going beyond 8cm increases the risk of arthritis because of the change in the ratio on the lengthened bone and excess pressure on the joints.

Do you share the same opinion as Dr. Rozbruch?

[handy]

Dr. Birkholtz-

Would you also please give your opinion on what happens to the soft tissues (muscles, ligaments, nerves etc.) in the leg during lengthening. Do they simply stretch or are they building new tissue to support the increased length? How long do you estimate for recovery time after lengthening?

What is your opinion on returning to 100% or close to 100% athletic ability after lengthening? Is it possible up to 5cm and can a patient lengthen beyond 5cm and still return to or close to 100% athletic ability?

What is your opinion on the cosmetic or aesthetics of lengthening? How much can a patient lengthen on each bone segment and still look in proportion to the rest of their body before their legs start to look too long for their torso and arms?

Thank you again for posting on this forum and I look forward to your answers.

[Franz]

Hi guys,
It looks like we've opened a real can of worms! Firstly let me just state that any advice I give on a forum like this cannot constitute professional medical advice, and should be seen as general comments

[Franz]

Let me try and batch the answer to encompass all your comments. Distraction osteogenesis creates new bone, but also new soft tissues. Unfortunately this happens at different rates for different tissues. Muscles tend to go slowe than bone, so theres probably a combination of new muscle formation and stretching, hence the joint contracture risk.

[Franz]

Functional recovery is multifactorial but we expect high levels of recovery in lengthenings between 5 and 10 cm.
Cosmetically 10cm still keeps people in proportion.
I would aim for 5-6 cm on femur and 4-5 cm on tibia.
Arthritis is probably due to malalignment, but also increased joint pressures.
This seems to be related to the extent of the lengthening as well.
Hope this answers most of the questions?

[An_Apple_A_Day]

Thanks for the reply.  I assume you mean 5-10 cm you are referring to both segments, not 5-10 cm on one limb?

[Franz]

Yep the 5 could be one segment, but 10 definitely two.

[Metanoia]

Dear Dr. Birkholtz,
could you please explain what malalignment means?

Thank you very much in advance

[Franz]

Dear Dr. Birkholtz,
could you please explain what malalignment means?

Thank you very much in advance

Apologies. Sometimes we use technical terms without explaining their meaning.
Malalignment simply means when a joint's normal direction of action is changed, or pushed out of alignment. This could be the result of surgery, where the joint is now not 'straight' anymore. This means the forces go through the joint at an abnormal angle and can cause arthritis.

[BilateralDamage]

Everyone,

I have been emailing with Dr. Birkholtz and he's answered a ton of questions I've thrown at him.  I'm really impressed with the answers he's given so far, and I'll paste his responses here in no particular order.  I AM NOT being paid to promote him, or have any deal with him whatsoever- one of the answers he gives even shows he is against doing this sort of practice.


How many cases of Cosmetic Leg Lengthening have you done?
I perform legengthenings for non-cosmetic reasons all the time (appprox 100-200 per year), and am comfortable with distraction osteogenesis as a technique. I arranged to have Precice brought into our country recently, and because I believe that standard exfix techniques have a risk profile too high for CLL, we've not done many CLLs. In fact only 2, one LON tibia (6cm) and one bilat LRS femurs (5cm limited due to knee stiffness). With Precice I believe we can now safely offer CLL widely.

What were the outcomes of the 2 CLL surgeries you did?
My 2 CLLs: LON tibias 6 cm and very happy. femoral LRS, frames came off recently, so too soon to tell.

How much would it cost for bilateral femur lengthening using PRECICE?  What would this pricing include?
Pricing for CLL in our unit is 40K euro for bilat femoral Precice. This includes everything except complications, incl meals and accommodation for 4 weeks. (See forum for details).  Physio is included and they will provide you with a home programme.

How much does PRECICE removal cost?  What about PRECICE nail replacement?
Ballpark figure for Precice removal would be around 4K euro. Should a precice have to be replaced it would cost approx 15K.

How much is a consultation?  Would it be possible to send you x-rays and then consult with you over a skype call instead of flying out to SA for only a consultation?
I will not charge you anything for an email or skype consultation. We will definitely need to see xrays for measurement purposes. These should be done according to a standardised protocol which we can send through via email.

There has been a long ongoing debate in our forums of the healing time of PRECICE vs. Betzbone, Albizzia, etc.  Some arguments against PRECICE are the lack of weight-bearing it provides, which will slow down healing because you will most likely be confined to a wheelchair.  Some arguments against the Betzbone is the twisting motion of the rod, which seems to affect consolidation as well.  What is your take on this?  Which do you recommend more?
I think the controllability of the Precice is its key feature. I bieve that with IM nail lengthenings weight bearing is less important than the quality of the osteotomy in providing good regenerate. For this reason I think Precice is the superior product.

Do you work on minimizing scars?
We always operate in such a way as to minimize scars (subcut sutures where possible etc).

How do you prevent ballerina feet that usually comes from tibial lengthening?
Ballerina foot is a euphemistic term for a serious complication of equinus contracture. We have developed special orthotic devices to prevent this. Sometimes we include the foot into the exfix frame and occasionally we perform a percutaneous tendon achilles lengthening upon frame removal to correct this.

Do you have any pictures of your guesthouses I could look at?
Guesthouse price quoted is for a guest room next to the hospital in the office building where my office is situated. Of course accommodation in the area varies somewhat in terms of price and quality. My suggestion would be to use the rooms initially until a bit more mobile (4 wks incl in price) and then spend a couple more weeks in a local hotel or guesthouse with more amenities. The Centurion Hotel may work well for this. You can find them via Forever Resorts SA. This would be approx 100 euro per day for bed and breakfast.

Would it be possible to work out a discount from promoting your services on several different forums at all? sorry guys, I had to ask! 
Wrt endorsements diaries etc, I think we should be careful about linking endorsements to monetary value. I know other surgeons do that, but ethically I would prefer for my patients to endorse me(or criticize me) independently!

[KiloKAHN]

Dr Birkholtz, I'm curious to know whether you prefer LON or LATN for combination internal/external methods. Would you say one is "better" than the other for most cases?

[BilateralDamage]

Dr Birkholtz, I'm curious to know whether you prefer LON or LATN for combination internal/external methods. Would you say one is "better" than the other for most cases?

Something I want to know as well!  I know Dr. Donghoon Lee prefers LATN according to this post by Walk6 in his diary: "it offers a much quicker recovery time post-frame removal. He informed me that while the frames would stay on for a bit longer during LATN than LON, because there is no nail implanted during the actual lengthening and fixation process, the bone would be much stronger after the fixators are removed and hence recovery would be noticeably smoother for LATN.

[Franz]

Something I want to know as well!  I know Dr. Donghoon Lee prefers LATN according to this post by Walk6 in his diary: "it offers a much quicker recovery time post-frame removal. He informed me that while the frames would stay on for a bit longer during LATN than LON, because there is no nail implanted during the actual lengthening and fixation process, the bone would be much stronger after the fixators are removed and hence recovery would be noticeably smoother for LATN.

I think the two methods both work well. It needs to be done properly though. I would choose the surgeon and then go with the technique he or she advises.

[alps]

Dr Franz, and about the reaming, it creates an unnatural hole where the bone marrow should be, correct?
What happens to this after the rods are removed? Will the inner cavity created, not get filled up?
Is this not an issue either?

[Franz]

Dr Franz, and about the reaming, it creates an unnatural hole where the bone marrow should be, correct?
What happens to this after the rods are removed? Will the inner cavity created, not get filled up?
Is this not an issue either?

Hi there, again a good question.
In adults the long bones have very little functioning (blood-forming) marrow left, and it is basically a fat-filled cavity. Whereas this fat is not so important, what is important is that there are blood vessels that feed the bone itself in this cavity. Of course when we ream and stick a nail in there, it destroys some of the blood vessels. Hence some of the complications like delayed and non-unions we sometimes see with intramedullary nails. Once the nails are removed, the endosteal (marrow cavity surface) blood vessels are restored somewhat.
All of this is uncanny, but does not seem to translate into significant complications or problems in most individuals.
The more important potential risk involved with reaming is that of fat embolism. This is where fat is displaced into the blood stream during reaming and can cause significant respiratory problems. There are techniques to reduce this risk. Discuss this with your doctor, and if he does not know how to do this, look elsewhere. This complication can be fatal in rare instances.
The idea is not to scare you, but to give you as much info as you need to make safe decisions...
Hope this helps!
Warm regards.

[Machine]

Hi Dr Franz ,
I recently did LL with LON  on my tibia.. during my distraction phase i had swelling for almost 3 months on my left leg. The reason for the swelling was that my frame was installed on my left leg in a way that my calf  was pressed from below as i always use to put my leg on a soft pillow. So , calf is like a second heart that pumps blood for blood circulation and since my calf was pressed most of the time the swelling didnt went away ..

[Franz]

The problem is that any technique has its limitations and potential complications. It is important to have a surgeon who can prevent and manage complications well.
My adult patients spend around one and a half months per cm of length in a frame. In other words between six and nine months for 5 cms. This is a long frame time. I would not advocate this for femurs, as the risk of knee stiffness is very high.
For tibias ilizarov/Truelok/TSF frames work well and we encourage early full weight bearing on the frames.
The long frame times make LON and LATN attractive.
Apart from the reaming and potential infection risks, tibial nails have around a 50% chance of persistent knee pain. Only half of these patients improve when nails are removed.

[Machine]

What i mean to say is that i had swelling for 3 months on my left leg during LL through LON . Now its almost 9 months after surgery and i feel 70% numb. Is it normal?
When will i feel my skin again ?

[Franz]

What i mean to say is that i had swelling for 3 months on my left leg during LL through LON . Now its almost 9 months after surgery and i feel 70% numb. Is it normal?
When will i feel my skin again ?

Please bear in mind that ethically I can not dispense detailed medical advice via a forum like this without knowing your case in minute details. Hopefully what youre dealing with is a neurapraxia (stretching) of a nerve which can recover. It can take a long time in a lower limb (1yr plus). Unfortunately it may be permanent.
Lets hope for the best!

[Sweden]

I have to admit that I'm very impressed and happy to see an LL-doctor answering out questions.

I did LL on my tibias, LON - 7cm, in India with Dr Sarin and I am currently now 11 months post first surgery.
I can't run or jump. Only walk. My ankles are very stiff, especially the right.

1) Do you think I will be able to sprint and go for a 1 hour jog again?

I exercise every day. Physical therapy, cycling, swimming, gym, Taekwondo and long power walks.

2) Have you seen patients recover so they can move very quick to the sides while running like American football/basketball players do to fool their opponents?

3) Is it a bad idea to split the patellar tendon again when I want to remove the IM-nails?

My doctor in Sweden says they don't remove IM-nails and it's no problem having them in your legs for the rest of your life.

4) What is your opinion about this? Remember, I am very active and would very much like to go back and compete in Taekwondo, a martial art.

Thank you for taking the time, very much appreciated!

/Sweden, now 180cm.

[Franz]

Dr. Birkholtz are you aware of any prolonged pain in the hips, knees etc. after internal femur lengthening (5-6.5cm)?

I would also like to clarify the numbers you gave for tibia lengthening. Are you saying 50% of patients will experience knee pain throughout their life using LON, LATN or internal nail for tibia lengthening?

Thank you for your contribution to this forum.

Thanks for the kind words. Hip and knee pain following femoral lengthening is less well defined and it is difficult to know what percentage have this.
The anterior knee pain rates quoted is unfortunately permanent.

[Franz]

I have to admit that I'm very impressed and happy to see an LL-doctor answering out questions.

I did LL on my tibias, LON - 7cm, in India with Dr Sarin and I am currently now 11 months post first surgery.
I can't run or jump. Only walk. My ankles are very stiff, especially the right.

1) Do you think I will be able to sprint and go for a 1 hour jog again? Very difficult to say. 7cm for tibias is a long distance which fundamentally changes the muscle function. In my practice recovery can occur up to 2 yrs after incident. Of course we deal more with trauma and nonunions, but it should be similar.

I exercise every day. Physical therapy, cycling, swimming, gym, Taekwondo and long power walks.

2) Have you seen patients recover so they can move very quick to the sides while running like American football/basketball players do to fool their opponents? Agility and proprioception are what you are talking about and this can form part of the recovery, but these are complex actions and may not recover fully.

3) Is it a bad idea to split the patellar tendon again when I want to remove the IM-nails?If they were split during insertion, it is better to go through the same approach for removal.

My doctor in Sweden says they don't remove IM-nails and it's no problem having them in your legs for the rest of your life.

4) What is your opinion about this? Remember, I am very active and would very much like to go back and compete in Taekwondo, a martial art. Generally the rods can stay in. The problem is that the locking screws are painful when making contact. Especially against a training bag, or when soemone blocks you. Fore these reasons it may be better to remove them.

Thank you for taking the time, very much appreciated!

/Sweden, now 180cm.

[JP]

Dear Dr. Franz Birkholtz,

Do you know if reaming of the bone will cause a fat embolism in the future years later from doing femurs with interal lengthening?
is this an issue only with internal femoral method?

rexdime:
"Even if a post LL patient doesn't get blood clots or thrombus or an embolism that can cause death, the more fat or bone marrow that is released from the operation, the higher chance that it will enter your blood stream.

You can look at 10 years later, this fat and bone marrow will still be in your blood stream and say it hasn't done any damage yet, and I don't think the body knows how to get rid of this from your blood stream either.

You will think that everything is perfectly fine, but I am guessing that your chance of having a heart attack or a stroke will be a lot higher than if you never had a broken bone before. I think you can say this is one of the Side effects of doing LL , but I doubt many doctors warn their patients before LL of this risk , I might be wrong since I never done it before.

I know this young lady who had a stroke about a year ago and she didn't know why, she had no high blood pressure and she was healthy, but today the left side of her body is paralyzed and needs to be on a wheel chair everywhere she goes"

thank you

[masche]

Dear Dr. Birkholtz,

Thank you so much for your time and effort!

Could you possibly explain the pros and cons of separating the femoral bone with an internal saw vs. using an osteotome?
Are you planning on using the Precice 8cm in the near future?

Best regards.

[handy]

Hello Dr. Birkholtz, just to add to what masche is asking you. Here is what Dr. Paley says about bone healing. Please give us your opinion and thank you again for posting on this forum and answering all these questions. 

"Delayed or failure of consolidation: Slow or failed bone healing can occur with any lengthening surgery. This complication can usually be prevented by making drill holes at the level of the planned osteotomy before reaming the bone. This is a technique I introduced in 1990. Stable fixation is also important so the choice of nail length and diameter are important as well as the level of the osteotomy. Even the type of osteotomy affects the rate of bone healing. Cutting the bone with multiple drill holes and an osteotome is the most minimal invasive way while using an intramedullary saw or performing an open osteotomy have higher failure rates."

[Franz]

Dear Dr. Franz Birkholtz,

Do you know if reaming of the bone will cause a fat embolism in the future years later from doing femurs with interal lengthening?
is this an issue only with internal femoral method?

rexdime:
"Even if a post LL patient doesn't get blood clots or thrombus or an embolism that can cause death, the more fat or bone marrow that is released from the operation, the higher chance that it will enter your blood stream.

You can look at 10 years later, this fat and bone marrow will still be in your blood stream and say it hasn't done any damage yet, and I don't think the body knows how to get rid of this from your blood stream either.

You will think that everything is perfectly fine, but I am guessing that your chance of having a heart attack or a stroke will be a lot higher than if you never had a broken bone before. I think you can say this is one of the Side effects of doing LL , but I doubt many doctors warn their patients before LL of this risk , I might be wrong since I never done it before.

I know this young lady who had a stroke about a year ago and she didn't know why, she had no high blood pressure and she was healthy, but today the left side of her body is paralyzed and needs to be on a wheel chair everywhere she goes"

thank you

Hi, strokes and heart attacks are multifactorial. Fat embolism syndrome is an acute condition related to fractures or surgery and does not manifest later.

[Franz]

Hello Dr. Birkholtz, just to add to what masche is asking you. Here is what Dr. Paley says about bone healing. Please give us your opinion and thank you again for posting on this forum and answering all these questions. 

"Delayed or failure of consolidation: Slow or failed bone healing can occur with any lengthening surgery. This complication can usually be prevented by making drill holes at the level of the planned osteotomy before reaming the bone. This is a technique I introduced in 1990. Stable fixation is also important so the choice of nail length and diameter are important as well as the level of the osteotomy. Even the type of osteotomy affects the rate of bone healing. Cutting the bone with multiple drill holes and an osteotome is the most minimal invasive way while using an intramedullary saw or performing an open osteotomy have higher failure rates."

Dear Masche and handy,

i agree completely with dr paley on this.

[Taller]

Dr. Birkholtz,

Thank you so much for participating on this forum. The diffierence you make in people's lives by providing quality advice, information, and warnings is invaluable and unfathomably appreciated.

I was wondering what your take is on cosmetic arm lengthening. As you know, some people who desire cosmetic LL are not so ideally proportioned for the surgery, but still would love to be taller. Arm length is sometimes a limiting factor, and some have researched cosmetic arm lengthening as a means to maintain a proportional appearance.

Recently, in a discussion, it was brought up by several sources that cosmetic forearm lengthening is not safe and sensible at this point in time. One reason being that the pronation and supination capabilities of the forearm would never recover. Is this true? If so, why would this capability not recover with sufficient physical therapy once the radius and ulna have completely consolidated?

Also, what is your take on cosmetic lengthening of the humerus?

I look forward to your responses.

[rickybobby]

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!!

[Franz]

Dr. Birkholtz,

Thank you so much for participating on this forum. The diffierence you make in people's lives by providing quality advice, information, and warnings is invaluable and unfathomably appreciated.

I was wondering what your take is on cosmetic arm lengthening. As you know, some people who desire cosmetic LL are not so ideally proportioned for the surgery, but still would love to be taller. Arm length is sometimes a limiting factor, and some have researched cosmetic arm lengthening as a means to maintain a proportional appearance.

Recently, in a discussion, it was brought up by several sources that cosmetic forearm lengthening is not safe and sensible at this point in time. One reason being that the pronation and supination capabilities of the forearm would never recover. Is this true? If so, why would this capability not recover with sufficient physical therapy once the radius and ulna have completely consolidated?

Also, what is your take on cosmetic lengthening of the humerus?

I look forward to your responses.

Stay away. The forearm has too many fine structures in it and permanent damage can occur and lead to loss of hand function. Not worth it for cosmetic reasons!
Pro and supination are dependent on the curved bones in the forearm. As we can ot lengthen around corners, lengthening will always permanently affect pro and supination.