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[Ascending]

Hello and happy new year to you all,

I thought I would provide some feedback about Dr. Ian Bacarese-Hamilton as not much is known about him - please note surgeons in the UK prefer to be called Mr. even though they are of qualified doctors.  I use the term Dr here for the sake of people outside of the UK reading this forum.

I had LL surgery of the femurs using the Stryde nail in Europe last year in April by a different surgeon who we shall refer to as Dr E.  Unfortunately there were problems with the nail not distracting and Dr E did not seem to understand the cause.  I also felt his relationship with Nuvasive was somewhat dysfunctional.

I therefore approached Dr Bacarese-Hamilton for a second opinion.  He was very professional and concerned.  He immediately contacted Nuvasive engineers and also Dr Paley and discussed my case and xrays.  Within a few days he had organised Nuvasive consultants to visit me at my home and they helped in part to make the ERC more effective - the osteotomy on my right leg had been performed unusually high making use of the ERC more difficult.

He also correctly identified the cause of the problem in distraction - it turned out I was prematurely consolidating and he provided advice on how to deal with the problem.  Whilst Dr E was reluctant and defensive at first - he did eventually cooperate with Dr Bacarese-Hamilton.  Dr Bacarese-Hamilton also booked me some excellent ll trained physiotherapists at the Princess Grace hospital in London and I cannot thank them enough for their help.  I was so impressed by Dr Bacarese-Hamilton that I asked him to continue monitoring via xrays and providing advice until the lengthening and consolidation is complete.

Dr Bacarese-Hamilton follows Dr Paley's taller methodology and I think he is an excellent surgeon for anyone considering LL surgery in Europe.  He is clearly well connected and I can't recommend him enough.

I may write more details about my journey at some point but for now I can state that my lengthening is complete and I am walking about quite well unassisted.  To his credit Dr E did complete the process though it took a total of 4 surgeries and replacement of both femur nails to get there.  Here are some key lessons learned:

• Go for the best Dr you can afford and save up and wait if needed.  As I found to my cost you may end up paying much much more by trying to save money.
• The taller methodology used by Dr Paley and Dr Bacarese-Hamilton is really the state of the art. By methodology I mean a repeatable, systematic process for sucessfull leg lengthening, covering everything from surgery to lengthening and consolidation.
• If things go wrong do get a second opinion - it very likely will help your original surgeon and also help you to keep things in check.
• The Stryde nail is truly brilliant and with the right surgeon you should be able to lengthen safely.
• Physiotherapy during lengthening is key to quick and effective recovery - be wary of surgeons that don't insist on this essential part of LL.
• During lengthening watch your xrays like a hawk.  Make sure you have a copy of every xray and make distraction measurements independently to check that things are going according to plan.

Good luck!

[limewalk]

Very insightful post mate! Problems due to distraction mechanism is not something we hear about often.

I have these questions if I may:

- Why 4 surgeries? I would think nail replacement alone and re-osteotomy would have been sufficient and this could have been done in one extra surgery.
- Was the reason lengthening was not happening properly due to high level of osteotomy or due to pre-consolidation or both? If you had gone to Dr Ian sooner, (before pre-consolidation) could the lengthening have continued normally with more surgeries?
- Did Dr E do the remaining surgeries? I feel Dr Ian would have been a better option going by your testimonial.
- Were there Nuvasive reps present there during your first surgery?
- Do you know the volume of cases Dr Ian handles, especially CLL?

Congrats on achieving your goals despite the complications. It's well worth it 

[Ascending]

I have these questions if I may:

- Why 4 surgeries? I would think nail replacement alone and re-osteotomy would have been sufficient and this could have been done in one extra surgery.

That's 4 surgeries including the original one.  Initially the distraction problem appeared to be only affecting the left leg and the idea of premature consolidation was entertained.  The second surgery was Dr E's attempt to solve the problem by cutting just the edges of callous that was forming.  This did not work.  The theory was then that the nail must be faulty and so the third surgery was to replace the nail.  There was some discussion about replacing the right nail too.
However, the decision was made to replace the left nail first.  The nail was replaced without creating a new Osteotomy site.  This somehow worked but analysis of the removed left nail showed that it had in fact been fully functional.  Later the right leg was having the same distraction problem and so a fourth surgery was performed to replace the nail in the right leg.  This time advice from Dr Bacarese-Hamilton (whom I will henceforth refer to as Dr IBH) was followed and an osteotomy was created that was more distal than the original.  All surgeries were performed by Dr E.  After some initial resistance on the part of Nuvasive, they had agreed to provide the replacement left nail for free and after Dr IBH's involvement to also provide the right nail for free.

- Was the reason lengthening was not happening properly due to high level of osteotomy or due to pre-consolidation or both? If you had gone to Dr Ian sooner, (before pre-consolidation) could the lengthening have continued normally with more surgeries?

Actually in fairness to Dr E - there were a number of factors any one of which were likely to be insufficient to create the problem but when combined they guaranteed it.  The factors were:

• a decision by Dr E to start lengthening at 0.7mm a day instead of the usual 1mm a day.
• Faulty ERCs - each replacement meant time lost lengthening
• Dr E not recognizing the problem in time and adequately dealing with it
• Use of the older ERC model which has very poor diagnostic capability - the latest ERCs have smartsense technologies which can detect when they have engaged with the nail and whether the nail is distracting.
• I do seem to genuinely consolidate much faster than expected.  In fact after the fourth surgery there was no grace period before starting lengthening - I started lengthening the right leg the very next day after surgery.

- Did Dr E do the remaining surgeries? I feel Dr Ian would have been a better option going by your testimonial.

No Dr E did all the surgeries.  Dr IBH was only involved after the third surgery and yes I had the same thoughts at the time but whilst Nuvasive had agreed to provide a replacement right nail for free to Dr E, they had not extended that courtesy to Dr IBH.

- Were there Nuvasive reps present there during your first surgery?

No.  However, they were present at the third surgery when the left nail was being replaced.

- Do you know the volume of cases Dr Ian handles, especially CLL?

I don't know, but please free to contact him.

Congrats on achieving your goals despite the complications. It's well worth it 

Thanks!  It was a roller coaster of a ride but we got there in the end.  And yes it is worth it.

I should also say that Dr E is not a bad surgeon and certainly far away from the horror stories I have read on this forum.  I think he was perhaps a little too complacent in the beginning and then got stuck in the mantra of 'It's never happened to me before' instead of really trying to understand and deal with the problem.  Once Dr IBH was involved Dr E became much better again.

[limewalk]

Thanks for the answers mate. That was one roller coaster ride for sure 

I think Nuvasive should at the very least start providing new ERC devices to everyone. Patients have so much to lose and so much pain and trauma to endure. Not an area where they should be saving costs.

Did you happen to see any x-rays other patients at Dr E? Did they also have osteotomies in a higher location?

I'm really curious to know who Dr E is, but I understand you might want to keep it private. 

[Ascending]

Thanks for the answers mate. That was one roller coaster ride for sure 

I think Nuvasive should at the very least start providing new ERC devices to everyone. Patients have so much to lose and so much pain and trauma to endure. Not an area where they should be saving costs.

I think there are plans to upgrade the ERCs for Europe this year.  However, the extra features are useful only in the case when things go wrong in terms of distraction.  I think with the proper surgical and post operative technique the old ERC would be adequate.  The new ERC is a much better product though.

Did you happen to see any x-rays other patients at Dr E? Did they also have osteotomies in a higher location?

Yes I did and no they did not have the same very high osteotomy nor were they instructed to lengthen at the 0.7mm rate - they did not have distraction problems.  I suspect that the reason Dr E chose to do a high osteotomy in my case was because my femur was curved and he did not have a flexible drill to hand during the surgery and so he took whatever steps he could to continue the surgery.  I remember he told me after the surgery that it took 5 hours because he did not have a flexible drill for reaming which was needed because of femur curvature and so he had to go very slowly and carefully with the straight drill.  There is no reason why he couldn't have known about the curvature prior to surgery from pre-operation x-rays and for him to be prepared with the right tools or even just have a complete set of tools as contingency.  I suspect therefore that this was just poor planning.

The reason he chose to have me lengthen at 0.7mm was because he was concerned about my flexibility - this is what he told me after the surgery and when he suggested the 0.7mm lengthening rate.  Again I think he should have addressed that issue prior to surgery when other options could have been considered.  The most obvious being to postpone the operation until I have sufficient flexibility or alternatively use the strategy of the Taller method - do IT band releases during surgery and use daily physio after surgery to manage remaining soft tissue resistance to lengthening - by stretching quads, hamstrings etc.  In fact after Dr IBHs suggestion he did do an IT band release of my right leg during the 4rth surgery and combined with the physio organised by Dr IBH it did make lengthening much easier and even recovery after lengthening - my left leg is still playing catchup with my right leg even though lengthening was completed on the left leg more than a month before the right leg.

I really think Nuvasive should have an onboarding process for surgeons to use Stryde.  This should include a certification course and an exam covering patient pre-checks, the operational process and the post operational process.  At the end of the course the attending surgeons should be provided with template checklists they can use to help ensure they follow the process.  That way Nuvasive would set minimum standards for surgeons irrespective of where they are in the world.  Furthermore patients would be able to check that their surgeon is qualified to perform the LL surgery using Stryde. Stryde Limb Lengthening Practitioner ^TM.

Lastly before your first consultation read one or both of the following guides depending on whether you are going to have lengthening of femurs, tibias or both:

sami-syed-r7op.squarespace.com/s/Antegrade-Femur-Operative-Technique.pdf
sami-syed-r7op.squarespace.com/s/Antegrade-Tibia-Operative-Technique.pdf