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[KiloKAHN]

Dr Jean-Marc Guichet has registered with LL Forum. If you have any questions for Dr Guichet about limb lengthening, this is the thread to ask.

Here is the link to his thread in the Doctor Directory: http://www.limblengtheningforum.com/index.php?topic=2400.0

[CCMidwest]

Hello KiloKahn,

My apologies if this has already been covered, but what steps does this forum take to confirm the identities of the doctors participating here?

[KiloKAHN]

Hello KiloKahn,

My apologies if this has already been covered, but what steps does this forum take to confirm the identities of the doctors participating here?

We contact their official e-mail with a formal invite. Dr Guichet replied that he has registered and has made a post: http://www.limblengtheningforum.com/index.php?topic=3314.msg50649#msg50649

[CCMidwest]

We contact their official e-mail with a formal invite. Dr Guichet replied that he has registered and has made a post: http://www.limblengtheningforum.com/index.php?topic=3314.msg50649#msg50649

Thanks Kilo

[Nightwish]

Firstly, thank you Dr Guichet for registering to this forum. You are certainly a Dr that myself, and I'm sure others, will be very interested to hear from.

I noticed from reading your website that part of the initial preoperative tests you have a dental consultation. As someone who has an irrational fear of dentists (yet quite willingly would break bones!), what is the reason for this?

Other doctors have suggested that the muscular strength of leg muscles is not important as this can lead to resistance when lengthening. From what I understand this is contrary to your view. Is this a view you hold within respect to your nail, or is it for any lengthening method? If for the later, would you mind expanding on your reasons?

In regards to your Hyper Fast-Track recovery approach, how much do you credit this to the pre-operative fitness levels of your patients, and how much do you attribute to weight bearing and physiotherapy post surgery? In your view, if another method was used that was not fully weight-bearing - e.g. fitbone or precise - would having a unilateral procedure see a better recovery as a level of mobility and movement would be retained.

[ouroboros]

I noticed from reading your website that part of the initial preoperative tests you have a dental consultation. As someone who has an irrational fear of dentists (yet quite willingly would break bones!), what is the reason for this?

I was also very curious about this dental consultation.....how does it relate to LL?
Thanks.

[hyong]

The question i wish to ask is how much in total?

i know the set rate for operation is 65000 euros and 50 000 pounds but what are the estimate in total
if we require housing and food ?
i reckon somewhere between 75000 euros range? +/- ?

[LLCaptain]

I was also very curious about this dental consultation.....how does it relate to LL?
Thanks.

When I had surgery for my femurs (with another doc), the anesthesiologist also asked me if any teeth were loose. Not sure if they're looking for the same issues but here's what I found online:

When you are being intubated, the teeth are very close and there is always a possibility of a tooth being chipped or damaged, particularly if a tooth is capped or loose. By giving any details of loose or capped teeth, the anesthesiologist can make extra sure to prevent damaged teeth. Sometimes, if a tooth is really loose, it is wise just to take it out before your surgery.

[maximize]

The reason for the dentist is almost certainly because there is a theoretical small risk of bacteremia (spread of bacteria through the blood) from uncontrolled periodontal gum disease, which increases the risk of orthopedic surgery site infections post-operatively. Good dental care before surgery decreases the risk of prosthesis/bone infection, and it's good for everyone anyway, so it is a small potential benefit, and no risk requirement to implement. Even if it prevents just one case of osteomyelitis it will have been worth it.


Dr. Guichet, I have an enormous amount of respect for your nail design and surgical outcomes. I am wondering:

1) What you think of the Reverse Planning Method as described by Dr. Baumgart in 2009 for correcting and maintaining ideal axis during lengthening?

2) What steps specifically do you take during your surgeries to maintain good control over the axis of lengthening and the exact angulation/orientation of the proximal distal bone fragments after osteotomy but before fixation of the nail?

Thanks.

[Dr Guichet]

For dental consultation, it is related to risk of infection (bacteriemia).

For muscle strengthening, it is important. Isokinetic muscle testing (Biodex, Cybex, et.) show alterations of the muscle during lengthening and slow recovery if you do not act preventively. Of course, not doing muscle testing prevents knowing the effect of a lengthening on a muscle... When you do not do, you do not know! During lengthening there is a loss of 60-80% of the initial strength. Of course, if before surgery you increase by 50%, you loose less and recover faster. It is easier to gain muscle force on a normal healthy muscle than on a healing muscle (when a sports professional has an injury on the muscle, no strengthening is authorized; during lengthening, muscle cells are dividing like during natural growth) and a trained muscle keeps memory of the training and recovers faster.

The second reason for muscle training is the adaptation of the muscle: if you train before surgery, the muscle divide and learn that stretching and training is good. Doing muscle biopsies shows a normal muscle formed during lengthening with no fibrotic tissue. When no training is applied, fibrotic muscle is formed, and studies with external fixates (Ilizarov) proved a certain % of fibrotic tissue formed. Overall, the logics is that when you train for anything in life (going on the top of the Himalayas, marathon, sports competitions, etc.), the results is better with less problems or complications. The training is not detrimental to the lengthening and my patients are here to prove it, and we are promoting fast recovery as you know (hyper-fast-track)

[Dr Guichet]

The hyper fast track is a logics. It relates to more than only the pre-op or post-op training. It relates to the optimization of care for the patient. It is multifactorial.
- The blood loss needs to be controlled. A large blood loss and hematoma prevents feeling well and being able to do sports. It decreases local oxygenation of the scar and healing tissues thus slows down healing and increases infectious risks. This has been published widely in medical journals. For a bilateral procedure, it can be of several hrs of hemoglobin, but we have regularly only 1 to 2 hrs of Hb loss. It requires a know-how, but it allows the patient to stand up in operating room and walk, like we did recently, and also to do bike within a few hours after anaesthesia awakening.
- Pain control is required to be able to move after a major orthopaedic surgery and to do muscle activities (walking, stairs, biking). We can secure this know-how too, and if your patients are doing it, first it is because it is possible, and second because they do not have sufficient pain to prevent it.
- Returning to full activity is necessary to drain the local surgery area, to prevent clotting, and to reactivate the muscles for a normal life, not the one of a ill person. I suppose it is what all patients want... Deluding the body is one of the most important thing in this matter: the body feels no pain, is in good shape and returns to full activity, thus dos not feel the heavy surgery.
- Of course there are further reasons why it is important to return to normal activities fast. 20 years ago, having a hip replacement required heavy pain and 2 to 3 weeks in hospital. Currently, the hospitalization in some clinics is only 2-3 days: is it a bad thing? Who would complain? In lengthening procedures and also in cosmetic procedures, a fast recovery is essential. We need however to consider that is cannot be instant full recovery of the full muscle force: during natural adolescent growth, 6 cm of gain is achieved in approx. 5 years (i.e. 60 months). during a lengthening, we obtain it in 6-8 weeks (30-40 times faster). If we train for sports competition, we need to train far more for a more demanding procedure like lengthening, mainly if we want to recover fast.

[Dr Guichet]

Yes, it depends on where you go (London, Milan) and services and standard you want (residence, hotel, etc.). 75000 Euros is generally what most patients plan for. Some patients plan for 100000 Euros, but is it not needed. Of course, security is necessary not to be short of money.

[Nightwish]

Detailed and informative replies. Thank you very much Dr Giuichet.

[goodlucktomylegs]

Yes, it depends on where you go (London, Milan) and services and standard you want (residence, hotel, etc.). 75000 Euros is generally what most patients plan for. Some patients plan for 100000 Euros, but is it not needed. Of course, security is necessary not to be short of money.

Which city have your most profrofessional team and Which city do you suggest among these two cities?
Please anser me.Please

[jaymorgan712]

Dear Dr.guichet: What is your opinion of doing 6 centimetres in the tibia? So many surgeons say that is the max you go in the tibia. What are your thoughts on it? Thanks. Jay

[hyong]

Yes, it depends on where you go (London, Milan) and services and standard you want (residence, hotel, etc.). 75000 Euros is generally what most patients plan for. Some patients plan for 100000 Euros, but is it not needed. Of course, security is necessary not to be short of money.

Dr Guichet,

Thank you for the information and detailed response,
may i ask how long in the foreseeable future would you see yourself practicing ?
I know this is a  strange question , however, there are people like me that needs to save for a couple of years before being able to afford time off and the surgery......

[Dr Guichet]

I still have approximately 20 years of remaining work.... I began very early in life in this field when I was a student. I designed the Albizzia in my early orthopaedic residency. I hope, in the remaining time, to develop further the field of lengthening and to allow patients to have an easy procedure and a very fast uneventful recovery! Making access to the ultimate Dream of patients means creating new routes which do not currently exist, and with support of patients, it is a wonderful goal.

[Dr Guichet]

The max. gain is not the problem. The calf is fare less flexible than the quadriceps and thus the risk is tip toeing for several months.

Tibia has far less vascular supply than femur, and as a result, the bone blood flow is far less thus resulting in a far smaller healing capacity. In fractures of femur, we rarely have non healing due to no bone formation. In tibial fracture, it is common, because of the vascular problem and also of the smaller quantity of bone progenitor cells. If bone healing can be secured for a 6 cm gain in femurs in 3 months, in tibias it can be ...2 years and bone grafting!

The resulting problem is bone grafting, which is almost never needed in femoral lengthening, but may be required in tibial lengthening.

The second problem of tibias is that the bone is smaller than femur and the diameter of the nail to use is generally smaller resulting in a weaker construct. So, a longer healing time and a nail less resistant mechanically... this is not optimal.

The third element is the healing time of each patient. Some patients heal fast (wide bone heavy muscular caucasian type patients) and some heal slowly (e.g. small diameter brittle bones in some asiatic type patients). Healing time is never known in anticipation, unless there was a previous fracture.

All these reasons orient the choice in an honest way toward performing first femoral lengthening, and when the healing is secured (and when we know the bone is healing fast), we can propose a tibial lengthening in a secondary time. Of course in unilateral non cosmetic tibial shortening, this does not apply.

Tibias has been preferred for a long time by surgeons using external fixators because the pins/wires are very short on the medial skinny side of tibias with respect to longer ones for the lateral aspect of the thigh, through all muscles. The stability (nor motion) is not good in femurs using external fixators and thus there were all reasons to orient the choice toward tibias rather than femur. But times have changed with IM nails as they have the same stability in femurs and tibias.

An additional element for choosing femur versus tibia: Generally females prefer to lengthen femurs (6-8 cm) first as when they wear high heals, the knee is at a reasonable level, while lengthening 8 cm tibias and using 12-15 cm high heels looks awkward...

Cosmetically, there is no real issue, as proportions for attraction is in no way related to anthropometric proportions. The best and more attractive top models are completely disproportionned... When one see images of patients with femoral lengthening, no one prefers the patient/femurs before lengthening... and I always show a patient with a 18 cm isolated femoral lengthening: everyone thinks he has been proportionally lengthening both femurs and tibias, or 6 cm on femurs! Illusion is a surprising thing.

I designed and used the first tibial nail in 1993 and since then I improved the overall technique for tibias like for femurs, but still  tibial bone is not providing results patients ideally dream of.

[Revenge]

Is there any difference between femur or tibia using lon method.And do you have safe limit for tibia

[Quincy]

Dr. Guichet,

So glad you have joined the forum.

There has been much discussion on the forum about the issue of athletic recovery.  Many doctors, including yourself, claim that 100% athletic recovery is a realistic goal.  I recall reading somewhere you even saying that you have had patients win sports championships after surgery. 

However, the overwhelming consensus on the forum, from people who have actually had the surgery, is that 100% recovery is impossible.  Again, we're talking about ATHLETIC recovery here, not just basic functioning.  Most often cited are losses in speed, agility, and explosiveness — and this includes patients of yours, as well. 

I am ready to get the surgery and you are far-and-away my top choice for a doctor, but I, along many others here, am hung up on the concerns about athletic recovery.  If we could see proven cases of patients who had recovered fully, it would make the decision easy for us.  I understand that many of your patients are concerned about protecting their anonymity, but of all the hundreds of patients you've operated on, I'm sure there are at least a few who would be willing to give verifiable testimonials about their recoveries.  They need not share their names.

I think that for a person who is ready to spend $80,000, it is reasonable to expect some assurances that a 100% athletic recovery is a realistic goal, beyond just the doctor's word.  I think some patient testimonials would meet this need.  An added benefit to you is that it would no doubt  save you countless hours of time responding to patient inquiries, as I'm sure the vast majority of them have to do with recovery.

Best,
Quincy

P.S.  By the way, I see that you do currently have testimonials on your site, and they're great.  However, I don't see any that speak specifically to ATHLETIC recovery.  If you had a few testimonials from patients who were high-level athletes prior to surgery and then were able to recover to the same performance level after the surgery, I think your website would be perfect.

[crimsontide]

I'd like to hear his thoughts on achilles lengthening, and if it's possible to recover from this surgery

[maximize]

Dr. Guichet, thank you for your detailed and thorough answers. I am still wondering if you can reply to my questions posted above.

Again, I am wondering:

1) What do you think of the Reverse Planning Method as described by Dr. Baumgart in 2009 for correcting and maintaining ideal axis during lengthening?

2) What do you think about the retrograde femoral approach that is suggested by this method for giving precise control over the post operative axis?

3) What steps specifically do you take during your surgeries to maintain good control over the axis of lengthening and the exact angulation/orientation of the proximal distal bone fragments?

Thanks again.

[Lgazer]

Welcome to the forum Dr Guichet. Your expertise is appreciated.

[ShortandStubborn]

Hi Dr. Guichet, I have a few questions:

First is regarding the pain; How bad is the pain generally? I understand it varies depending on the person, time of the day and stage of the procedure among other things but I've seen posts regarding pain varying from people claiming to pray to crucifix for strength to screaming to wake up the whole floor on their first clicks.

Secondly, what about drinking and smoking? I'm not talking about 2 packs a day but a cigarette or two a day and perhaps a drink or two once or twice a week during both lengthening and consolidation.

Lastly, would you recommend Arm lengthening to patients who can't go a single inch without lengthening their arms? If yes, then how and when? I mean, do you think it's a good idea for such patients to lengthen their arms first and go for LL once their arms are fully consolidated(with the nail still inside their arms - say 4 to 6 months post AL) to support their weight during LL?

Thanks.

[blahblah]

Dr. Guichet,

Thank you for being a participant in this forum, you are a great wealth of knowledge that will help us be more informed about this procedure. I do have 3 questions for you:

1.) What do you think about quad lengthening?

2.) What are you thoughts on two stage lengthening that other doctors perform. Example femur and tibia preformed on the same leg in a one surgery, and few months later on the opposite leg?

3.) Is it possible to do two stage quadrilateral lengthening, as mentioned above, if the total lengthened amount is less than 8 cm, and if so will recovery be much faster since each portion is lengthened less?

Thank you again for being a participant and a guide to all of us here.

[Average2Tall]

Dr. Guichet,

So glad you have joined the forum.

There has been much discussion on the forum about the issue of athletic recovery.  Many doctors, including yourself, claim that 100% athletic recovery is a realistic goal.  I recall reading somewhere you even saying that you have had patients win sports championships after surgery. 

However, the overwhelming consensus on the forum, from people who have actually had the surgery, is that 100% recovery is impossible.  Again, we're talking about ATHLETIC recovery here, not just basic functioning.  Most often cited are losses in speed, agility, and explosiveness — and this includes patients of yours, as well. 

I am ready to get the surgery and you are far-and-away my top choice for a doctor, but I, along many others here, am hung up on the concerns about athletic recovery.  If we could see proven cases of patients who had recovered fully, it would make the decision easy for us.  I understand that many of your patients are concerned about protecting their anonymity, but of all the hundreds of patients you've operated on, I'm sure there are at least a few who would be willing to give verifiable testimonials about their recoveries.  They need not share their names.

I think that for a person who is ready to spend $80,000, it is reasonable to expect some assurances that a 100% athletic recovery is a realistic goal, beyond just the doctor's word.  I think some patient testimonials would meet this need.  An added benefit to you is that it would no doubt  save you countless hours of time responding to patient inquiries, as I'm sure the vast majority of them have to do with recovery.

Best,
Quincy

P.S.  By the way, I see that you do currently have testimonials on your site, and they're great.  However, I don't see any that speak specifically to ATHLETIC recovery.  If you had a few testimonials from patients who were high-level athletes prior to surgery and then were able to recover to the same performance level after the surgery, I think your website would be perfect.

Yes Guichet! Tell us about the athletic recovery. Can we get back to Alpine Climbs, Triathlons or soccer? To some of us that is equally important.

[chineseguy]

is it possible to ride a bike after this surgery?roller skating? skate board? is it possible to hike a mountain after this?

 i very love skating and i always walk mountain up

[juiceer]

What do you think about HGH or IGF-1 Administration post op for increased bone growth and reduced recovery time?

[Alu]

Dr. G

Thank you for your time and assistance. It's honestly amazing to have someone as revered and experienced in any form of LL join this community: if only to briefly answer questions about the procedure.

My one simple question(s):

What amount, in each segment, guarantees the best possible recovery? And to this end, what do you consider is realistic recovery in  undergoing LL?

[Dingo]

Dr Guichet, thanks for joining the forum and answering our questions.

What is your opinion on staged lengthening for people who can't take 3 months off from work?

By this I mean doing one femur first and then the other femur a few months later.

I know that you advise against it in your page but would it be even possible?

[lestrac]

The max. gain is not the problem. The calf is fare less flexible than the quadriceps and thus the risk is tip toeing for several months.

Tibia has far less vascular supply than femur, and as a result, the bone blood flow is far less thus resulting in a far smaller healing capacity. In fractures of femur, we rarely have non healing due to no bone formation. In tibial fracture, it is common, because of the vascular problem and also of the smaller quantity of bone progenitor cells. If bone healing can be secured for a 6 cm gain in femurs in 3 months, in tibias it can be ...2 years and bone grafting!

The resulting problem is bone grafting, which is almost never needed in femoral lengthening, but may be required in tibial lengthening.

The second problem of tibias is that the bone is smaller than femur and the diameter of the nail to use is generally smaller resulting in a weaker construct. So, a longer healing time and a nail less resistant mechanically... this is not optimal.

The third element is the healing time of each patient. Some patients heal fast (wide bone heavy muscular caucasian type patients) and some heal slowly (e.g. small diameter brittle bones in some asiatic type patients). Healing time is never known in anticipation, unless there was a previous fracture.

All these reasons orient the choice in an honest way toward performing first femoral lengthening, and when the healing is secured (and when we know the bone is healing fast), we can propose a tibial lengthening in a secondary time. Of course in unilateral non cosmetic tibial shortening, this does not apply.

Tibias has been preferred for a long time by surgeons using external fixators because the pins/wires are very short on the medial skinny side of tibias with respect to longer ones for the lateral aspect of the thigh, through all muscles. The stability (nor motion) is not good in femurs using external fixators and thus there were all reasons to orient the choice toward tibias rather than femur. But times have changed with IM nails as they have the same stability in femurs and tibias.

An additional element for choosing femur versus tibia: Generally females prefer to lengthen femurs (6-8 cm) first as when they wear high heals, the knee is at a reasonable level, while lengthening 8 cm tibias and using 12-15 cm high heels looks awkward...

Cosmetically, there is no real issue, as proportions for attraction is in no way related to anthropometric proportions. The best and more attractive top models are completely disproportionned... When one see images of patients with femoral lengthening, no one prefers the patient/femurs before lengthening... and I always show a patient with a 18 cm isolated femoral lengthening: everyone thinks he has been proportionally lengthening both femurs and tibias, or 6 cm on femurs! Illusion is a surprising thing.

I designed and used the first tibial nail in 1993 and since then I improved the overall technique for tibias like for femurs, but still  tibial bone is not providing results patients ideally dream of.

Salve Dottor Guichet, le pongo anche io una domanda: sappiamo che contemporaneamente all'allungamento osseo (femore e tibia oppure femore o tibia) si ottiene anche un allungamento dei muscoli e che maggiore è la massa muscolare presente nel nostro organismo e maggiore è la quantità di calorie che si bruciano quotidianamente; detto questo volevo sapere quindi: dopo l'allungamento c'è un maggior consumo giornaliero di calorie ovvero c'è un'accelerazione del metabolismo basale? Grazie