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[Franz]

Dear Patient,

In light of the fact that responsible, cost effective and ethical limb lengthening in the world is getting rarer, I have reconsidered my stance on CLL.

I offer CLL in highly selective cases for either femoral, tibial or both. My technique of choice for CLL is internal lengthening nails. We have access to both the Precice and Fitbone products.

These services are provided in Stellenbosch, South Africa at the Mediclinic Winelands Orthopaedic Hospital. We are part of the Institute of Orthopaedics and Rheumatology, a Specialist Institute based at the Hospital. There is a great rehabilitation facility available and the expectation is that the patient will have the benefit of my multi-disciplinary team during their stay.

Stellenbosch is a University town in the Western Cape Province of South Africa - a really beautiful and safe place.

Contact details:
www.birkholtz.health
dr.fbirkholtz@ior.health

I will monitor the thread and answer reasonable questions, but will limit my time on the forum.

Best,

Franz Birkholtz
Orthopaedic Limb Lengthening and Reconstruction Surgeon

[KiloKAHN]

Good to see your return, Dr Birkholtz. Glad you're well.

For those that weren't here a few years back, one of our former mods named TRS had internal femur lengthening with Dr Birkholtz and reported a good result.

[c]

你是缺钱了吧...不过你技术应该会不错

[Franz]

Hehe

I am so glad for Apple's translation service. :-)

No, I don't really need the money. I am keeping myself quite busy with reconstructions. Performed 6 big limb reconstruction cases as well as a bilateral CLL fitbone lengthening in the last 10 days (in addition to other surgeries), so am actually too busy for my own good. My reasons for restarting is exactly as I stated in my original post...

With regards to my skills, I am not the best person to judge my own skills. My patients would be in a better position to do so, I guess. :-)

[Highest]

Hi Dr Franz has nuvasive been in contact with you about when Stryde or its replacement will be on the market again?

[Franz]

Hi Dr Franz has nuvasive been in contact with you about when Stryde or its replacement will be on the market again?

We are in discussion with them. It is unclear what the timelines would be. It has not cleared all our regulatory hurdles either. So wait and see for now...

We have negotiated a really good deal with Fitbone though and, as you know, they are weight-bearing, so gives us a good alternative at the same price-point.

[Achieverr]

We are in discussion with them. It is unclear what the timelines would be. It has not cleared all our regulatory hurdles either. So wait and see for now...

We have negotiated a really good deal with Fitbone though and, as you know, they are weight-bearing, so gives us a good alternative at the same price-point.

Hi Dr Franz,

by saying weight bearing nails ? so can they accommodate the same limitations as other mechanical nails ?
what is the possibility of doing the surgery , staying copule of weeks and then flying back home with such nails ?
and from your experience , any case studies or data base as It is first time me hearing about them
Thanks,

[randy]

What are the weight bearing specifications of Fitbone?

[Franz]

Fitbone is a motorized lengthening nail developed in Germany and in use since 1997.
Prof R Baumgart is the inventor.
Thousands of these nails have been implanted.
They were originally only available for limited use and were distributed by Wittenstein-Intens.
Recently Orthofix have acquired the rights to manufacture and distribute the device. It has become more widely available.
Quoted weight limitation is 100kg.

https://www.orthofix.com/ifus/fitbone/

Please note: this is for information only. I have no financial interest in the nail or the relevant companies.

[Highest]

Fitbone is a motorized lengthening nail developed in Germany and in use since 1997.
Prof R Baumgart is the inventor.
Thousands of these nails have been implanted.
They were originally only available for limited use and were distributed by Wittenstein-Intens.
Recently Orthofix have acquired the rights to manufacture and distribute the device. It has become more widely available.
Quoted weight limitation is 100kg.

https://www.orthofix.com/ifus/fitbone/

Please note: this is for information only. I have no financial interest in the nail or the relevant companies.

Am I understanding that this is a full weight bearing nail? As in no Walker or crutches required? Stryde nail was 115 kg post operative weight bearing and this is damn close. How is this not major news?

[Achieverr]

Am I understanding that this is a full weight bearing nail? As in no Walker or crutches required? Stryde nail was 115 kg post operative weight bearing and this is damn close. How is this not major news?

Fitbone is a motorized lengthening nail developed in Germany and in use since 1997.
Prof R Baumgart is the inventor.
Thousands of these nails have been implanted.
They were originally only available for limited use and were distributed by Wittenstein-Intens.
Recently Orthofix have acquired the rights to manufacture and distribute the device. It has become more widely available.
Quoted weight limitation is 100kg.

https://www.orthofix.com/ifus/fitbone/

Please note: this is for information only. I have no financial interest in the nail or the relevant companies.

Hi Dr Franz,

It is quite confusing actually, as they are mentioning two type of nails I guess based on the patient weight (which is like you said 100 kg) but at the same time in their catalogue mentioned and I quote the follwoing :
"During the active phase and the initial healing phase, the weightbearing capacity of the intramedullary lengthening nail is limited to
partial weight-bearing of 20 kg"
Here is the catalogue :
https://www.orthofix.com/wp-content/uploads/2020/03/Clinician-Guide_FITBONE-TAA_USA-en_Version-012.pdf

Maybe it is them being extra cautious in case any accidental weight bearing and accidental nail breakage so they won't be hold accountable.
appreciate if I can get your thoughts on that

[randy]

Yes, I had spoken to a doctor in Europe who said the company officially does not recommend weight bearing.

If I may add, Fitbone is usually put in retrograde in the femurs which is not great for the knees.

[Franz]

I guess weight bearing is a relative concept. I still let the patient use crutches, but we allow as much weight as the pain will allow.

[Franz]

There is the guideline that the company gives.
Then there is the guideline that the doctor gives.
Then there is what the patient actually does.

Often these three are not aligned. Having said that, these nails do allow more weight than the original Precice nails and, with the Stryde not currently available to my patients, these nails give a good alternative option.

Fitbone nails are often implanted retrograde for alignment reasons, but can be implanted antegrade as well. The same is true for Precice: they can be inserted either antegrade or retrograde.

[Highest]

There is the guideline that the company gives.
Then there is the guideline that the doctor gives.
Then there is what the patient actually does.

Often these three are not aligned. Having said that, these nails do allow more weight than the original Precice nails and, with the Stryde not currently available to my patients, these nails give a good alternative option.

Fitbone nails are often implanted retrograde for alignment reasons, but can be implanted antegrade as well. The same is true for Precice: they can be inserted either antegrade or retrograde.

Do surgeons need special training or permission to use fitbone? Given the amount of patients putting off the surgery until Stryde returns it seems odd more surgeons aren't using this fitbone nail if they can weight bear as tolerated using it.

Why can't surgeons get antegrade insertion to give as good an alignment as retrograde? From what I've read the main issue with retrograde is splitting the patellar tendon which can cause ongoing knee pain.

[Franz]

Due to the anatomy of the femur it is not really possible to lengthen along the mechanical axis using an antegrade technique.

Fitbone does need surgeons to be trained.

[Franz]

Just for clarification:

Fitbone allows more weight bearing than the original Precice.

Caution is advised during distraction.

Stryde of course allows unrestricted weight bearing.

It is important to consider that due to pain considerations, full weight bearing during distraction may be difficult anyway.

[Thehighest]

We need more ethical doctors like you, very good you are doing this again to prevent the disasters we have seen

[Highest]

Where do your patients typically stay during distraction?

[Achieverr]

any fears with osteolysis as I understand that Fitbone is stainless steel , won't have a similar problem like the stryde ?

[randy]

Hey Dr Franz, I have some follow up questions

1. Is it true that doctors who use Fitbone for cosmetic femur LL tend to insert nails retrograde but doctors who use Precice tend to insert nails antegrade? Almost all cases of cosmetic femur LL I have seen on the internet of Precice involve antegrade insertion but those of Fitbone involve retrograde insertion. Is there any correlation here? Even the marketing illustrations we see from the companies have this pattern.
2. How do we make a trade off between high chances of permanent knee pain through retrograde insertion and alignment issues with antegrade insertion?
3. Can Fitbone be left in the body for long? Since there is no rare Earth magnet in it, is it as serious a matter to leave it in the body for a very long time?
4. How many Fitbone nails have been inserted worldwide? With Precice the number stands at around 13.000 so it would be interesting to compare. Understandably, Fitbone has only recently entered the global market so this number would probably not imply much.
5. How does Fitbone's reliability compare with that of Precice? I am talking about device failures leading to inability to distract.
6. Roughly speaking, can you estimate how many times is Fitbone stronger than Precice in terms of weight bearing? Since each nail comes in 3 sizes, please compare the respective sizes if possible.

Thank you.

[Franz]

Where do your patients typically stay during distraction?

Our 'standard' quote includes a ten day period in the hospital and then an additional 14 days in the rehab facility with meals and physio included.

Beyond that, the patient can stay on in rehab unit, or alternative accommodation options are available.

[Franz]

any fears with osteolysis as I understand that Fitbone is stainless steel , won't have a similar problem like the stryde ?

Nothing that I am aware of.

[Franz]

Hey Dr Franz, I have some follow up questions

1. Is it true that doctors who use Fitbone for cosmetic femur LL tend to insert nails retrograde but doctors who use Precice tend to insert nails antegrade? Almost all cases of cosmetic femur LL I have seen on the internet of Precice involve antegrade insertion but those of Fitbone involve retrograde insertion. Is there any correlation here? Even the marketing illustrations we see from the companies have this pattern.
2. How do we make a trade off between high chances of permanent knee pain through retrograde insertion and alignment issues with antegrade insertion?
3. Can Fitbone be left in the body for long? Since there is no rare Earth magnet in it, is it as serious a matter to leave it in the body for a very long time?
4. How many Fitbone nails have been inserted worldwide? With Precice the number stands at around 13.000 so it would be interesting to compare. Understandably, Fitbone has only recently entered the global market so this number would probably not imply much.
5. How does Fitbone's reliability compare with that of Precice? I am talking about device failures leading to inability to distract.
6. Roughly speaking, can you estimate how many times is Fitbone stronger than Precice in terms of weight bearing? Since each nail comes in 3 sizes, please compare the respective sizes if possible.

Thank you.

Important disclaimer: I have no financial interest in Fitbone and am not promoting the nail as such. I also use the Precice 2 quite extensively in my practice. With this in mind, I will limit my responses to the questions above in the context of my position:

1) Yes. Traditionally surgeons had to be trained by Prof Baumgart to use the nail and his reverse planning method described for retrograde insertion. There are some of us who, based on the patient's anatomy choose to proceed with antegrade nailing, similar to Precice.

2) Your surgeon would be the best person to guide you.

3) It has an electric motor inside, as well as moving parts, so should ideally be removed.

4) I am not sure of the exact number, but thousands since 1997.

5) I do not know to be honest. Prominent limb lengthening surgeons would not be using the nail if it was prone to failure.

6) Hehe. Don't really have time to run comparisons. These are not necessarily the best comparisons, as it is immaterial how strong a nail is if the patient's pain stops them from mobilizing. Even with the so-called 'non-weight bearing' nails, it is possible with judicious physio and clever tricks to get people mobile on walking frames instead of wheelchairs only.

[Thehighest]

Do You still use LON method ir external fixators ir now only puré internal?

[Franz]

Generally femoral lengthening with nails is by far the most comfortable and practical in terms of time frames etc.

I am however very comfortable with exfix (hexapod based), LON, LATP techniques, as these are used regularly in my non-CLL practice.

As with any medical procedure, a specific plan needs to be created for each patient, as a cookie-cutter approach is usually not appropriate for everyone.

[-]

Generally femoral lengthening with nails is by far the most comfortable and practical in terms of time frames etc.

But is it the safest, Doc? It seems to have the highest mortality and serious complication rates.

[Franz]

But is it the safest, Doc? It seems to have the highest mortality and serious complication rates.

Safety is the most important issue with cosmetic limb lengthening.
Complications with surgery vary by technique, but also by patient and surgeon.
Fat embolism syndrome after nailing is certainly higher than with external fixators.
Joint contracture rates are higher with external fixators.
Deep vein thrombosis and pulmonary embolism rates should be similar between techniques.
Pin track infection is relatively common with exfix but non-existent with nails. Deep infection rates are low with both.
And so on and so on.

Choice of technique should be discussed with your EXPERIENCED limb reconstruction surgeon and should be individualised as such.
Hope this helps.

[4limbed]

I’ve recently had a consultation with Dr. Birkholtz. My surgery is scheduled to be on May 4th 2023.
Precise on Femur.

[1team]

Does Dr Birkholtz do retrograde or Antegrade femurs? I read on his old thread where he said that passing 6cm Antegrade will increase joint pressure and risk of osteopetrosis later in life.

But obviously doing retrograde can fk with your knees.

[Vogel]

Good luck! Awesome to hear that someone is doing this with Dr. Franz

Are you going to create a diary for your LL journey?