I'm still researching this before I reply properly, but I preface first by saying that Dr. Giotikas himself did tell me during my consultation that external tibias were technically the safest methods. Dr. Solomon in Russia also told me via email that external methods were the safest option for limb lengthening.
Also, we haven't talked any about the relative risks of pulmonary/fat embolism with each method, which is obviously a determining factor when trying to quantify the safety of one method versus another. It's important obviously crucial to consider the seriousness of an infection versus other things that can go wrong. As has been pointed out, life threatening infections are extremely uncommon -- maybe they're more uncommon than the risk of death from embolism? We'd have to crunch the numbers. I mean, those that have died have died due to complications with internal methods.
I should also be cautious about putting too much weight on this study the arthritis study that keeps being banded around (https://pubmed.ncbi.nlm.nih.gov/26398436/). When I've checked, I don't have access to the full paper with my University login, and I highly doubt anyone else has read the full paper to be able to really analyse what the results mean. For example, we don't even know what method was used for the lengthening -- what if it was LON? In which case, the arthritis may be attributed to having the patella split, and isn't so relevant to the fully external methods.
It's also not like this paper is the only one to investigate the arthritis issue. Here's a paper which suppose risk of arthritis with femoral lengthening: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8231406/ .
I appreciate your reply to this thread, finally some logic and reasoning! And a new study to look at.
>we haven't talked any about the relative risks of pulmonary/fat embolism with each method, which is obviously a determining factor when trying to quantify the safety of one method versus another
This is what I'm curious about. How do Dr. Giotikas and Dr. Solomon quantify "safety"? Are they doing it by embolisms, are they doing it by arthritis, or they doing it by non-unions, are they doing it by infections, or something ambiguous like "post operative patient satisfaction"? Are they following up years later on those same subjects to confirm their hypothesis? I appreciate you mentioning this, as it opens up more questions to be asked.
>As has been pointed out, life threatening infections are extremely uncommon -- maybe they're more uncommon than the risk of death from embolism? We'd have to crunch the numbers. I mean, those that have died have died due to complications with internal methods.
This is something I'm curious about too. Specifically,
What is the rate(%) of embolisms of external methods compared to internal methods? External methods are much riskier than internals when it comes to infections...but embolisms are a whole different thing.
>For example, we don't even know what method was used for the lengthening -- what if it was LON? In which case, the arthritis may be attributed to having the patella split, and isn't so relevant to the fully external methods.
That's true. But how do you explain the hip arthritis? I could understand the potential for knee arthritis because the patella is being split, but what about the hip?
Here's some interesting things I found in the study you brought up. Some keypoints:
-The sample size is only 10, versus 1152 in the other study
-The sample size of 10 are discrepancy patients
-They used the Orthofix monolateral fixator, aka LON.
-Preoperative long standing radiographs were not available; however, according to the medical journals 1 patient had pre-existing malalignment described as moderate knee varus, which was not operatively addressed.We know that leg length discrepancy(LLD) causes a multitude of issues, such as scoliosis, and ankle, knee, and hip problems. What if these problems existed prior? We don't know because there were no pre-op radiographs. And at least 1 of the 10 already had a malalignment that wasn't addressed.
Here's something massively important:
-6 of 10 patients had low, 2 moderate, and 2 had high physical activity level at follow-up.-5 of 10 patients had impaired physical function (LSI < 85%) of the lengthened compared with the unlengthened limb on the single, cross-over, and timed hop test, and 6 of 10 on the triple hop test.We all know how important physical therapy and working out your lengthened limbs are for post-surgical success with limb lengthening! So 6 out of 10 patients had a low activity level, and 6 out of 10 patients had some level of impaired physical function! The only problem is, the study doesn't mention if it's those same patients, but I would be willing to bet that almost all of them are, if not every single of of them.
-Our results indicate that femoral lengthening may impair physical function in general, and/or physical function of the lengthened limb, and possibly lead to signs of radiographic OA in adjacent joints in the long term.But how can the study be so sure, when they don't even have pre-op radiographs? As I mentioned previously, LLD can cause these problems, and these are all LLD patients, not cosmetic.
-The patients were more sedentary and had higher BMI than the reference material, which on one hand could be a consequence of the lengthening procedure. On the other hand, we cannot rule out that the sedentary lifestyle could be random and have led to the reduced physical function without association with the lengthening procedure.So basically, the study can't say one way or the other, but we know factually that the patients were sedentary and had a high BMI. I know this is terrible to say, but how many patients do we know of anecdotally via interviews with Cyborg4Life or on this forum that did their PT, exercised, stayed active, and are doing well for themselves? And how many patients do we know of that didn't take their PT seriously, and wound up with complications? I know that I shouldn't mention anecdotes when we are discussing peer reviewed studies, but I just want to throw that thought out there for consideration.
-On one hand, we cannot rule out that the difference between the limbs was already present before the lengthening procedure as we do not have preoperative measurements. Preexisting differences have previously been described by Krieg et al. (2018), who found that the shorter limb was weaker than the longer both before and 2 years after femoral lengthening. On the other hand, the patients in the study by Krieg et al. (2018) could have had etiologies associated with impaired physical function of the lengthened limb, a weakness accounted for by the strict inclusion criteria in our study. Thus, the fact that we found impaired physical function of the lengthened limb in addition to the significant difference between the limbs in 2 of 4 hop tests strengthens the assumption of reduced physical function associated with the lengthening procedure.Something commonly mentioned with limb lengthening, in general, is that you will never recover your peak performance potential. If you are an athlete, you should wait until after your stint/career is over before lengthening. How many times has that been mentioned on this forum? Is this something unique to a method/device, or is it just a fact of life that comes with all limb lengthening?
Again, the study can't say anything conclusively because they do not have pre-op radiographs or measurements, but it does assume a point.
-Our study adds to the literature suggesting that femoral lengthening might be associated with impaired physical function of the lengthened limb.-The association between femoral lengthening and radiographic OA has to our knowledge not previously been described in humans.-However, literature describing the long-term functional outcome and eventual late side effects such as osteoarthritis (OA) in adjacent joints is rare.My takeaway is that the results are rare and limited in scope. I think it would be difficult to say definitively, which the study cannot say, that femur lengthening is worse than tibia. Is there a study that is similar to this one, but lengthened tibias instead of femurs? Something we could cross reference?
-Our findings are in line with both animal research (Stanitski 1994) and assumptions in textbooks describing limb lengthening procedures (Herring 2008, Sneppen et al. 2014). However, we must acknowledge that the presence of radiographic OA in our sample could be random and explained as “natural history,” as all patients were in an age group at risk of developing OA (Sakellariou et al. 2017). In addition, we have to make reservations for the results in 1 of the patients with radiographic knee OA because of varus alignment outside the normal ranges in the lengthened limb at assessment, a known risk factor for development of knee OA (Brouwer et al. 2007). However, we believe that the absence of radiographic OA in unlengthened limbs despite the literature suggesting an association between LLD and hip OA in the longer limb (Gofton and Trueman 1971), in addition to the fact that 2 patients had varus alignment outside the normal ranges in the unlengthened limb at assessment, indicate a possible association between the lengthening procedure and development of radiographic OA in the long term.The animal research lengthens by 30%! Well over the 'safe limit' of 15% of the original bone length, 20% maximum! But anyways, a canine leg is quite a bit different than a human one. The study talks about the association between LLD and hip OA, which is very important to this discussion. Yet, they still can't say anything conclusively. But heres the big question.
What would tibia lengthening look like compared to femur lengthening? Do we have another study that we can cross reference that instead of lengthening femurs, lengthens tibias? If we only are looking at the femurs without the tibias to compare it to, how can we say anything conclusively? The study can't. We know limb lengthening, in general, will reduce your peak performance potential. It just comes with the territory. But which is best, femurs or tibias? Are we going to use a study of n=10 that admits it cannot say anything conclusively, or point to a study n=1152 that strongly predicts hip and knee arthritis if you're tibia:femur ratio is off? At least with the latter, we can get a more complete picture, versus the former which
does not compare tibia patient outcomes.
Here's
my takeaway:
This study is important and we should consider it, but it's
inconclusive and incomplete. It only looks at femurs and femurs only, whereas the other study considers tibias AND femurs, particularly the ratio between them. Any limb lengthening, may it be on your tibias or femurs, will likely reduce your peak performance potential. You must accept that you might be 99%(or less), but you may not ever be 100%. I'm ok with that because I am not a professional athlete, all I really care about is weight lifting. But how are you going to determine doing femurs over tibias? Most Doctors, from what I've seen and read, recommend femurs over tibias. Am I going to change my mind by a study n=10,
that itself admits it can't say anything conclusively? No. But I will keep my eyes and ears open to any new information. Maybe in a year, studies and Doctors start coming out proclaiming femurs to be dangerous over tibias, then I'll change my mind, but that's just not the case currently.
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