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[Franz]

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!!

Accurate surgery will prevent deformities, but this is one ofthe potential complications of cll.
I do not use forteo.
I have no experience with Albizzia so cannot really comment.
Yes this is possible to replace precice with titanium if bent. Something like trigen nail from Smith and Nephew.
The 75 pounds would probably not be for the thin nails. The recommendation is not to exceed 75 pounds per nail until some bone consolidation takes place.
Lengthening at home is only really possible for our South African patients. The follow ups are essential in preventing complications and continuinh physio.

[Arche]

Dear Dr. B.,

I remember that you previously mentioned a patient doing external femurs using the LRS Monorail? I was wondering if you would recommend such a device for lengthening if the patient were to commit to 5 cm. Were the patient scars extremely visible? How much did that patient pay? Thanks, I'm just curious because we have a patient here from India who is doing quad external lengthening.

Thanks,

Arche (almost typed my real name haha)

[Franz]

Exfix for femurs is really not ideal. Scarring and knee stiffness are big risks. The cost would be cheaper - around 32k, but i really would then prefer for you to get LON tibia.

The patient in question had scarring and stiffness

[Cooper]

Dear Dr. Birkholtz,
Will you be OK if patient wants to lengthen humerus? How much it will be with precise and and non-precise? I am not thinking about doing it but want keep that as an option. My wingspan is short. I might transform way out of proportion when I do both femur and tibia which is my current plan.

Thank you!

[theuprising]

Dr B I was wondering if a patient could get precise femurs done, then after lengthening
get the femur nail removed and have their tibia's lengthened in the same op?
Thanks

[Franz]

Dr B I was wondering if a patient could get precise femurs done, then after lengthening
get the femur nail removed and have their tibia's lengthened in the same op?
Thanks

That is possible, provided the knees have returned to normal and the bone healing is sufficient.

[Franz]

Dear Dr. Birkholtz,
Will you be OK if patient wants to lengthen humerus? How much it will be with precise and and non-precise? I am not thinking about doing it but want keep that as an option. My wingspan is short. I might transform way out of proportion when I do both femur and tibia which is my current plan.

Thank you!

Humeral lengthening for pure cosmetic reasons is really not recommended. If you keep your femoral and tibial lengthenings within safe limits, it will not be necessary to adjust humerus.

[KiloKAHN]

Are monorail fixators on tibias just as feasible as the classic ilizarov fixators for external only of 5.5 cm? I run a small business and one of my concerns is that the bulky ilizarov frames may be too much of an office distraction.  For that reason I was considering LATN so I could consolidate once the frames are off without people knowing what exactly I did, but the risk of permanent knee pain does worry me and I'm thinking of suk it up and working near employees with frames on. I think monorails would be less "in your face", and perhaps more comfortable for extended wear, but then again I've got quite a bulky wrestler type of build and I don't want to risk my tibias snapping or something.

[Franz]

Are monorail fixators on tibias just as feasible as the classic ilizarov fixators for external only of 5.5 cm? I run a small business and one of my concerns is that the bulky ilizarov frames may be too much of an office distraction.  For that reason I was considering LATN so I could consolidate once the frames are off without people knowing what exactly I did, but the risk of permanent knee pain does worry me and I'm thinking of suk it up and working near employees with frames on. I think monorails would be less "in your face", and perhaps more comfortable for extended wear, but then again I've got quite a bulky wrestler type of build and I don't want to risk my tibias snapping or something.

LRS(monorail) fixators are strong and we fully weightbear on them. They have not snapped yet. The issue with LRS is the risk of malalignment.
An option to consider might be LATP (lengthening and then plating), where the exfix is converted to a locking plate internally after distraction. Cost would be similar to LON. This eliminates the risk of anterior knee pain.
Any infix(nail or plate) following exfix has a risk of infection.

[Franz]

Hey Dr.Birkholtz,

Just wondering if Precice 2 has any mechanical/functional advantage over Precice other than giving longer length?

Precice was modular and when it failed it usually did it at the joint between the modular sections. In precice 2 this has been adressed, making the nail much stronger. Eventually omce they run out of stock on precice, i think they will convert to only having precice 2.

[KiloKAHN]

LRS(monorail) fixators are strong and we fully weightbear on them. They have not snapped yet. The issue with LRS is the risk of malalignment.
An option to consider might be LATP (lengthening and then plating), where the exfix is converted to a locking plate internally after distraction. Cost would be similar to LON. This eliminates the risk of anterior knee pain.
Any infix(nail or plate) following exfix has a risk of infection.

With LATP is the main benefit over externals a somewhat reduced fixation time? The frames still have to stay on with the plate until the bones consolidate, right?

Also, I've read in a few sources that there is a higher risk of refracture with externals than with LON/LATN. Say I lengthened 5 cm and it took 10 months wearing the fixator before it was removed. Would this mean that even after fixator removal I wouldn't be able to bear significant weight until months afterward? I don't plan on doing barbell squats at the gym right after, but I'm wondering if I'd still have to be careful not to run or anything like that for a long while afterward so as to avoid refracturing the bone.

[Franz]

With LATP is the main benefit over externals a somewhat reduced fixation time? The frames still have to stay on with the plate until the bones consolidate, right?

Also, I've read in a few sources that there is a higher risk of refracture with externals than with LON/LATN. Say I lengthened 5 cm and it took 10 months wearing the fixator before it was removed. Would this mean that even after fixator removal I wouldn't be able to bear significant weight until months afterward? I don't plan on doing barbell squats at the gym right after, but I'm wondering if I'd still have to be careful not to run or anything like that for a long while afterward so as to avoid refracturing the bone.

LATP has the advantage of shorter frame times, as the plates serve the purpose of stability during consolidation.

We allow full weight bearing throughout exfix only treatment. The frames are removed when bone consolidation is complete. After removal the bone is strong, but we do suggest protected weight bearing for 6 weeks. The refracture rate quoted is really when the frames are removed too early before full regenerate consolidation. Once consolidated completely, the bone is stronger than before the surgery!

[shawty]

Long frame times do not necessarily equate to permanent muscle damage. We encourage early functional rehab including full weight bearing which promotes muscle function.
New bone (regenerates) are often wider than the original bone. This is a good thing. It means your surgeon knows what he's doing and you're creating good quality bone. Will have no effect on function.

Hi Dr. Franz,

On doing externals only, you bypass the need for an internal nail, correct?  Does this make it a less invasive process?  How is the healing time on this vs LON/LATN? Is is significantly longer?  I like the idea of using no nails through the knee. Are there issues of nonunion or the bone not growing straight for a smaller length gain such as 5cm. I apologize if you've already answered these questions within the forum, but I'm really interested in doing externals only for a 5cm gain. What was the price for this? Thanks!

[TRS]

Hey Dr.B!

Can you please clarify this question raised by thetallerman?

Hey guys since Femurs do not run straight up and down like the tibias as seen in this picture (attached) but in fact run at a slanted angle, if you were to lengthen for example, 5 cm in them, would the actual gain be 5 cm, or it would it be more or less? Can math whizzes help me out on this and also give the reason behind their answers. Thanks guys and looking forward to the responses. It's just I would hate to lengthen a certain amount and then when I measure myself post-lengthening I don't get the amount I thought I would.

[Franz]

Hi Dr. Franz,

On doing externals only, you bypass the need for an internal nail, correct?  Does this make it a less invasive process?  How is the healing time on this vs LON/LATN? Is is significantly longer?  I like the idea of using no nails through the knee. Are there issues of nonunion or the bone not growing straight for a smaller length gain such as 5cm. I apologize if you've already answered these questions within the forum, but I'm really interested in doing externals only for a 5cm gain. What was the price for this? Thanks!

Hi,
Externals only means there are no internal devices used. The consolidation time is the same, but the big difference is that exfixes are worn for the entire time. In adults this is around 6-9 months for 5 cm.
there is a small chance of subsidence and length loss, which can be compensated for by overlengthening by 5-10mm. Deformity is possible, but unlkely.
Cost is 30K USD for new frames and 25K for re-used ones.

[Franz]

Hey Dr.B!

Can you please clarify this question raised by thetallerman?

Great question,

Yes with exfixes we lengthen along the mechanical axis which should correspond pretty much to patient height. With femoral nails, we tend to lengthen along the anatomic axis, which might not correspond perfectly to height gain (it is oblique). It is well described too that patients end up with 5-10 mm less than expected. I would suggest going 1cm beyond target length and then backing the nail up by 5mm. This would ensure quick consolidation. 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.

[The View]

Thank you very much for taking your time to answer these questions Dr Birkholtz.

What is your opinion on quadrilateral lengthening ? Is it safe if it is kept under 5 cm (I was think 5.5(femur) + 4.5(tibia)(absolute max)) and is done using safe "less strenuous" internal devices such as precise ? What are the disadvantages of lengthening quadrilateraly compared to doing one lengthening and returning 3-4 months into consolidation for the second.
Would the inability to push your self as hard in physio with 6 broken bones be an issue ?
Would combining recovery times increase total recovery time or reduce it ?
What would you recommend.

Thank you Doctor

[Franz]

Thank you very much for taking your time to answer these questions Dr Birkholtz.

What is your opinion on quadrilateral lengthening ? Is it safe if it is kept under 5 cm (I was think 5.5(femur) + 4.5(tibia)(absolute max)) and is done using safe "less strenuous" internal devices such as precise ? What are the disadvantages of lengthening quadrilateraly compared to doing one lengthening and returning 3-4 months into consolidation for the second.
Would the inability to push your self as hard in physio with 6 broken bones be an issue ?
Would combining recovery times increase total recovery time or reduce it ?
What would you recommend.

Thank you Doctor

Hi,

Quad lengthening is dangerous because it is a massive operation. You suddenly increase risk of fat embolism tremendously. Also this almost definitely means blood transfusion. It does not really save that much in cost, and might mean less total length achieved. I do not recommend it.

[Polycrates.]

Doctor,

A question for you to answer when you can. Do femur and tibia lengths of equal measurement ever occur naturally in a population? And if so, have you any idea what the rate of occurrence would be? All resources I've read state the femur as the longer of the two, without exception. Is there anything anatomically disadvantageous to having equal length bones or a tibia that is slightly longer than the femur (~1cm)?

[Franz]

Doctor,

A question for you to answer when you can. Do femur and tibia lengths of equal measurement ever occur naturally in a population? And if so, have you any idea what the rate of occurrence would be? All resources I've read state the femur as the longer of the two, without exception. Is there anything anatomically disadvantageous to having equal length bones or a tibia that is slightly longer than the femur (~1cm)?

Dear Poly,

You are absolutely right. The ratio is normally 0.8, ie tibia 80% of the length of the femur give or take.
There is probably a very good biomechanical reason for this. Having said this, I am not aware of any long-term negative effects if the tibias are longer than normal.

F

[KiloKAHN]

Hi Dr Birkholtz,

For prospective patients looking to lengthen tibias, do you think it's always the case that lengthening with a TSF is better than lengthening with the traditional Ilizarov frames?

[Franz]

Hi Dr Birkholtz,

For prospective patients looking to lengthen tibias, do you think it's always the case that lengthening with a TSF is better than lengthening with the traditional Ilizarov frames?

Very good question. The TSF or TLHex devices are hexapod circular external fixators. They allow very accurate threedimensional computer based corrections. This means that the likelihood of deformity is less. They are however quite expensive. A compromise would be to use TSF or TLHex rings, but with Ilizarov distaction components. This is cheaper and allows us the ability to slot in the hexapod struts to optimize the alignment should it be necessary. This is done in the office. Because we use the hexapod struts short term, there is the option to use second hand components for this phase. Of course anything that goes into the bone must be new!

[Taller]

Hello Dr. Birkholtz.

I hope you had a wonderful weekend. Also, I had a few questions about biomechanics involving LL and athletic recovery and was wondering if you'd be willing to answer them for me. I am a dedicated runner and accept that I will possibly lose some degree of athletic ability from this surgery. However, in order to create the best biomechanical ratio for speed and comfortable running, along with optimum heat desipitation, would you recommend the lengthening of the femurs or tibiae? I was hoping that improved bodily ratios could help me counterbalance the loss of muscle strength after LL. What do you think? Also, how much athletic recovery do you believe is possible after cosmetic LL for 4CM versus around 7CM on tibiae and how much for these same amounts on the femurs? Thank you so much for your time and help. They mean a tremendous deal to the members of this forum.

[Franz]

Hello Dr. Birkholtz.

I hope you had a wonderful weekend. Also, I had a few questions about biomechanics involving LL and athletic recovery and was wondering if you'd be willing to answer them for me. I am a dedicated runner and accept that I will possibly lose some degree of athletic ability from this surgery. However, in order to create the best biomechanical ratio for speed and comfortable running, along with optimum heat desipitation, would you recommend the lengthening of the femurs or tibiae? I was hoping that improved bodily ratios could help me counterbalance the loss of muscle strength after LL. What do you think? Also, how much athletic recovery do you believe is possible after cosmetic LL for 4CM versus around 7CM on tibiae and how much for these same amounts on the femurs? Thank you so much for your time and help. They mean a tremendous deal to the members of this forum.

For optimal function the tibia to femur ratio should be around 0.8. Unfortunately every persons response to lengthening is different and matching predicted outcomes to patients accurately is almost impossible to do consistently. I think it is dangerous to expect CLL to improve athletic ability. If anything, it tends to diminish.

[theuprising]

Dr Birkholtz what is your opinion on lengthening individuals who have mild bow legs. Are you able to both lengthen and correct the bowing
or is it 2 separate operations?

[Franz]

Dr Birkholtz what is your opinion on lengthening individuals who have mild bow legs. Are you able to both lengthen and correct the bowing
or is it 2 separate operations?

Usually relatively mild deformities can be addressed with the lengthening surgery, especially during exfix techniques where we can use advanced computer based hexapod fixators like the TSF or TL-Hex. It can even be done with internal nails, using a small acute correction of deformity. This is not always possible with nails though.
Ilizarov/Hexapod based deformity correction with lengthening is what we do all the time for malunions in the practice. We do upwards of 150 circular fixators per year, placing us in the top bracket of surgeons as far as numbers are concerned.

[gettingtaller]

Both. Larger lengthenings have more complications both during lengthening and longer afterwards.
Hopefully you will be OK. Sounds like youre doing very well so far.

In lay mans terms, what kind of complications? Is there a risk my legs will fall off in the next few days? Appreciate the kind response, but would be grateful for specific examples.

[Franz]

In lay mans terms, what kind of complications? Is there a risk my legs will fall off in the next few days? Appreciate the kind response, but would be grateful for specific examples.

I think you will appreciate that complications are very difficult to predict and individualize and every person would be different. For this reason, it is impossible to put accurate percentages to the complications.
In general, longer distractions have higher complication rates. Potential complications related to longer distractions may include the following:
increased pain during and after distraction
increased muscle stiffness
increased joint contractures and stiffness
a shift in the mechanical axis of the limb, leading to malalignment
delayed union of a regenerate
nonunion of a regenerate
bending of a regenrate, resulting in malalignment
increased articular pressures
increase in long-term arthritic changes
decrease in function and sporting ability
higher infection rates (if using exfix)
higher potential for failure of instrumentation
longer recovery period

I hope this helps?

[Wannabegiant]

Lengthening and consolidation in externals takes 1.5 - 2 months per cm. this means 7.5 - 10 months in frames.
Comfortable running should be possible 6-9 months after frame removal, but is difficult to predict.

Interesting, about how long after frame removal are you allowed to jump? similar timeframe as running? (external only)
And what about working out the legs, doing leg press etc?

Also we have a diary here of a patient who did 9 cm in 10 months externals only, so with that in mind i assume it is possible but uncommon to heal faster than 1.5 - 2 months per cm. Since 9 cm in 10 months is ca 33 days per cm, ie slightly more than a month/cm

Thank you for all the info Dr. Franz

[Franz]

Interesting, about how long after frame removal are you allowed to jump? similar timeframe as running? (external only)
And what about working out the legs, doing leg press etc?

Also we have a diary here of a patient who did 9 cm in 10 months externals only, so with that in mind i assume it is possible but uncommon to heal faster than 1.5 - 2 months per cm. Since 9 cm in 10 months is ca 33 days per cm, ie slightly more than a month/cm

Thank you for all the info Dr. Franz

I allow full weight bearing from day one as much as the patient can tolerate. If you want to jump, you are welcome to (as long as it is not off a buiding! :-). Generally I would say that jumping comfortably would be similar to running.
Our fastest healers have been at just below 1 month per cm (28 days), but the average is around 1.3 - 1.5. Not to create false hope, we add another 0.5.

[KiloKAHN]

Hi Dr Birkholtz,

Is the loss of athletic ability after limb lengthening influenced more by the stretching of the soft tissues or more so the change in ratio between tibs/femurs? Or is it just the surgical trauma? I guess what I'm wondering is if a loss of athletic ability after one lengthening can be minimized by lengthening a second segment and getting the ratio between femurs/tibs closer to what they were originally. Or would a second lengthening just cause a further dip in athletic ability because of the additional surgical trauma?