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[NailedLegs]

What's better, internal methods such as the PRECICE nail ( https://www.nuvasive.com/procedures/limb-lengthening/precice-system/ aka an intramedullary nail), or external methods such as Modular Rail System ( https://smith-nephew.com/en-us/health-care-professionals/products/orthopaedics/modular-rail aka LON) , or Taylor Spatial Frames ( https://en.wikipedia.org/wiki/Taylor_Spatial_Frame aka external frames)

Well we have a study for it!

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8706718/

n=35, but with 39 procedures


-"Besides the long period of time in the frame, the most frequent adverse effects of external fixators include pin-site infections; implant loosening and frame destabilization; and problems with regeneration, such as premature consolidation, non-union or malunion, limited range of motion (ROM), and joint stiffness "
Is this not stuff we've talked about before? But something I hadn't considered was implant loosening and frame destabilization. Ouch! Does anybody here want to give themselves a non-union or a malunion? Probably not. Limited ROM and joint stiffness makes sense, since those frames are bulky.

-"Using intramedullary growing nails avoids some of these issues, but other serious complications, such as deep infections and the breakage of locking screws and the nail itself, may appear more frequently"
But hold on! Look at the studies(there are 4) this point is referencing! They are using LATN, or the problem has already been fixed, or it simply doesn't apply to us!

Study 1: "We lengthened 9 tibial segments over a nail to reduce the time in the external fixator in 5 patients with constitutional shortness."
See, it's LATN. Which means it does not apply to the PRECICE nail, a fully internal method.

Study 2: "26 PRECICE nails in 24 patients. 2 nails initially failed to function. Premature consolidation in 1 patient was resolved with a re-osteotomy, classified as a non-implant-associated obstacle. 2 nails broke during the consolidation phase, in 1 case due to a fatigue failure along the welding seam. The other nail broke at the connection between the lengthening unit and the extension rod when the patient fell accidentally."
4 nails had problems, none of which were infections. Additionally, this was the first iteration of the PRECICE nail! PRECICE 2.2 resolved all of these problems! Like I mentioned previously, the PRECICE 2.2 nail is the most up to date! It no longer has welding seams, which the first one had. Similarly, "The strength of the PRECICE 2 is up to 4 times stronger than PRECICE 1"! "Furthermore, the driveshaft connection strength has been increased 3 times more than PRECICE 1, which will reduce the risk of nail mechanism failure when a patient produces too much bone, which can result in premature consolidation, which arrests the lengthening process. In short, the PRECICE 2 permits greater lengthening with a stronger nail, a stronger drive shaft..."(Source: https://paleyinstitute.org/centers-of-excellence/stature-lengthening/the-precice/#/) ! The point is, these problems have already been resolved.

Study 3: "34 posttraumatic limb lengthening patients (femoral: 30, tibial: 4) were included from January 2010 until April 2019."
These are trauma patients, not cosmetic or LLD patients. This study is using the Fitbone, not PRECICE.
"Conclusion: Limb lengthening with a motorized lengthening nail for posttraumatic LLD is a relatively safe and reliable procedure."
So what's the deal?
"Compared with idiopathic LLD, posttraumatic patients are more likely to sustain complications when undergoing lengthening surgery due to pre-existing complicating factors, e.g., scare tissue, joint stiffness, dormant infection, skin issues, etc. "
Nobody on this forum is a trauma patient. As confirmed by this study, trauma patients are more likely to sustain complications, duh, but we are not trauma patients! Because we are specifically cosmetic patients, why do we care if this does not effect us?
We are cosmetic patients, so why are we so worried about hematomas that trauma patients get? Are lengthening delays something specific to an internal nail? NO. It's a bigger problem with external fixators, as mentioned in the original study. Sepsis? Again, we are not trauma patients with a dormant infection! Screw migration? Once again, our bones were not shattered in a car accident like many of these trauma patients! Where else in the literature is a screw migration this common!? And are we going to pretend that only internal nails use locking screws?

Study 4: "The Precice intramedullary limb-lengthening system has demonstrated significant benefits over external fixation lengthening methods, leading to a paradigm shift in limb lengthening."
So why is this study pertinent if it repeats what many others have said--Internal nails are better than external fixation?
"Hip and knee ROM was maintained and/or improved following commencement of femoral lengthening in 44 patients (60%) of antegrade nails and 13 patients (38%) of retrograde nails."
So hip and knee ROM either got better, or stayed the same, in over half of the 92 patients? That's pretty good, but does anyone refute the idea that some joint or muscle stiffness is to be expected when lengthening? Is that not why we do PT and stretch? So what's the concern here?
"Minor implant complications included locking bolt migration and in one patient deformity of the nail, but no implant failed to lengthen and there were no deep infections. Three patients had delayed union, five patients required surgical intervention for joint contracture. "
Key word: Minor. No implant failed to lengthen, and there were no deep infections? What's the problem? Now I'm not going to downplay 3 delayed unions and 5 joint contractures, that's a risk with all LL, but why are we acting like LON or external frames are any better? Why are we acting like it's unique to the PRECICE nail? It's not.
I'm going to leave the following quote from the study here:
"This study confirms excellent results in femoral lengthening with antegrade and retrograde Precice nails."

So we can say that the original problem of "deep infections and the breakage of locking screws and the nail itself, may appear more frequently" does not or no longer applies to us, except in the most exceptionally rare of cases. But again I ask, is this specific no internal nails? NO! All surgeries have risk involved, but some methods are safer than others, like using the PRECICE nail over external fixators.

-"The adverse effects of the therapy were observed and analyzed. The highest total rate of problems was noted in the TSF and MRS groups."
So NOT the IMN/PRECICE group.

-"At the pin sites of those in these groups, superficial infections were observed in five patients (29%) and two patients (18%), respectively."
Superficial, yes, but that shouldn't be ignored. Still, it gets even worse...

-"Moreover, one patient in the TSF group (6%) expressed painful heterotopic intramuscular ossifications in the pin site places."
Who would've thought having wires strewn through your leg like some patchwork quilt would hurt...

-"We found obstacles after the application of each method, including delayed consolidation in the IMN group (one patient; 9%), frame destabilization (two patients; 18%) and pre-consolidation (one patient; 9%) in the MRS group, and bone bending (two patients; 12%) in the TSF group."
Again, I'm not going to deny that there's risks involved. There are ALWAYS risks with ANY surgery. But I'll take having a delayed consolidation over bone bending any day! Delayed consolidation is just that, needing more time for the callus to form. But pre-consolidation will require another osteotomy in order to correct and allow lengthening. Which are you choosing?

-"Serious complications were fracture post frame removal (one patient; 9%; Figure 2) and malunion union (one patient; 9%) in the MRS group, two fractures post TSF removal (12%), and hardware failure—broken IMN and regenerate—in one patient (9%; Figure 3)"
Now you may read the "hardware failure" with the broken IMN and regenerate and think, "Well, the PRECICE/Internal nails must be far more dangerous!" Well, read further...
-"The patient did not follow the recommendations and went on a hike in mountains and started full weight bearing before the regenerate consolidation"
What the F?? Are we going to blame the nail, or the patients stupidity!?
Clearly, the PRECICE nail is far superior to the other two methods!

So all in all we have...
   IMN (n = 11)
Problems            None   

Obstacles            1 (9%)—delayed consolidation

Complications    1 (9%)—hardware failure (broken nail and regenerate fracture)
One instance of delayed consolidation, NOT non-union, but just a DELAYED consolidation. I'm not saying that is good, but that is entirely different than a malunion! And a hardware failure which was the fault of the PATIENT, not nail.

        MRS (n = 11)
Problems            2 (18%)—pinsite/superficial infection

Obstacles           2 (18%)—frame Destabilization
                        1(9%)—pre-consolidation

Complications      1 (9%)—malunion
                        1 (9%)—fracture post removal
And people argue that LON/Modular Rail System is safe?

        TSF (n = 17)
Problems            5 (29%)—pin site/superficial infection
                        1 (6%)—heterotopic intramuscular ossifications in pin places

Obstacles           2 (12%)—bone bending

Complications      2 (12%)—fracture post removal
I prefer to not have my bone bend or fracture my newly formed bone right after frame removal. Pin site infections don't sound pleasant either, and painful intramuscular ossifications sound...terrifying. Do you agree?



-"Similarly, Black et al., who analyzed the results of femoral lengthening in skeletally mature children with congenital diseases, indicated a decreased “Category-I” complication rate (pin-track infection and mild joint contractures, which require minimal intervention) in the motorized nail group in comparison to the circular frame group"
tldr, internal nails are better than external frames.

-"who combined a monoliteral external fixator with intramedullary nail splinting and compared it with the Ilizarov method"..."Using this combined technique, the other authors confirmed its usefulness in the lengthening of the femur and tibia, although the rate of deep infections remains high, from 2.4% to 15%"
LON = 2.4% to 15% of deep infections. No thanks!

-"In our material, superficial pin-site infections were noted in seven cases of external fixators (25%), while deep infections were not observed. The main advantage of TSF over monolateral external fixators is the possibility to correct axial deformations simultaneously with bone distraction. This computer-assisted method is a valuable tool for bone distraction with the correction of complex deformities.
So maybe TSF is better than LON if you have a axial deformation? But who cares, we are cosmetic patients!

-"Fracture of the regenerate remains a significant complication of bone lengthening. Four events of fractures occurred: two in the TSF group, one in the MRS group, and one in the IMN group with concomitant nail fracture."
Again, the IMN fracture was due to the PATIENT not following the Doctor's instructions, not the nails fault!

-"The evident disadvantages of an external fixator are the presence of a frame, which hinders daily activity and exercise with the need for everyday pin-site cleaning, and a second surgical procedure for hardware removal. In the case of IMN, removal is not obligatory. Additionally, some doubts concern the possibility of magnetic resonance imaging (MRI) subsequently to IMN application. Despite this, it has not been tested for compatibility in the MRI environment and did not receive approval from the Federal Drug Agency (FDA); several studies have tested the safety from this aspect. Gomez et al. did not find negative effects, such as heating, elongation, and migration forces, acting upon this implant in 1.5T and 3T fields [40]. Nevertheless, they concluded that 3T protocols should be avoided in patients who are still undergoing lengthening or if lengthening is planned in the future. "
Make of this what you will. Maybe you don't *need* to get the IMN removed, but you probably *should*. I definitely will. There have been anecdotal reports of patients feeling much better after rod removal, for a few reasons. 1) The bone has a certain degree of 'bounce' and 'elasticity' to it, which a nail interrupts. The nail also adds excess weight, making your legs feel heavier. Additionally, the nail causes a stress point at where it's locked, which *could* increase the possibility of fracturing it from other physical activities. Nothing definitive here, but most Doctors are going to recommend you remove the nails, so you probably should.

-"Firstly, the small size of the examined groups is evident. We decided to only include patients with congenital etiology of the femur length deficiency. Post-infected and post-traumatic cases and patients with malignancies were excluded due to adverse influence on the femur lengthening process and the potentially higher frequency of complications."
Which again I have to state, we are cosmetic patients, not trauma patients. So this limitation does not apply to us.

-"The second limitation is the retrospective nature of this study and the lack of randomization. However, the compared implants were only available during a certain period (MRS and IMN). The design of the study with the selection of patients who could be treated with all implemented methods assessed in this research can correspond to the randomization."
This limitation is hardly a limitation, and doesn't change the outcome anyways. IMN over external fixators.

Conclusion:

-"In conclusion, our study indicates IMN as the most valuable method of treatment for femoral length discrepancy without axial deformity. The strongest advantages were noted in the lowest rate of adverse effects (especially problems and obstacles) and faster regenerate organization with a return to full weight bearing, but a potentially more invasive procedure of hardware removal. We believe that IMNs and TSFs are currently the best options for simple femur bone lengthening in adolescents with congenital disorders. However, there is a need to confirm our findings in a larger group of patients with the randomization protocol. "
Do we have axial deformity? NO, we are cosmetic patients. Is hardware removal a factor with LON? YES. Are external fixation, such as LON and External Frames, associated with fracturing the new bone regenerate? YES. Are we adolescents with congenital disorders/axial deformity? NO.

Let's post this quote from the abstract again:

"This study indicates that IMN is a more valuable method of treatment for femoral length discrepancy without axial deformity than MRS and TSF in complication rate and indexes of lengthening and consolidation."

Case settled! The Intra-Medullary Nail/PRECICE is superior to the Modular Rail System/LON and to the Taylor Spatial Frames/external frames.

[NailedLegs]

Too much conjecture and bro-science on this forum. Hopefully this thread will put all the nonsense to rest with actual facts and logic.

[KiloKAHN]

Sure internals are better, but external still has a lot of benefits. Superficial infections are annoying but not a huge deal. Bone bending will only happen after external fixation if the doctor is a moron and removes it too early or doesn't have the will power to not cave to patient pressure about removing the frame early.

[Medium Drink Of Water]

Wow a whole 39 cases of non-controlled anecdotal data. I'm finally convinced that reaming your bone marrow is the best option now.

[NailedLegs]

Sure internals are better, but external still has a lot of benefits. Superficial infections are annoying but not a huge deal. Bone bending will only happen after external fixation if the doctor is a moron and removes it too early or doesn't have the will power to not cave to patient pressure about removing the frame early.

What are the benefits of externals?

Price? Sure, I can't argue against that. Weight bearing? Eh, maybe. There are full weight bearing nails on the market like the BetzBone. Nuvasive is launching a new weight bearing nail/STRYDE replacement by the end of the year. As soon as that happens, then what benefit is left? External frames on tibias to avoid splitting the patella? Now your Tibia:Femur ratio is off, a significant predictor in knee and hip arthritis.

Superficial infections and bone bending are not the only complications with external methods. LON has a 2.4% to 15% chance of deep infections. Malunion, serious infections, frame destabilization, and pre-considation shouldn't be hand-waved. Granted, a pre consolidation isn't the worst thing in the world, but it would suck having to do an additional surgery for another osteotomy. Price goes up, anesthesia isn't good for you, and more trauma to the local area = more scarring. Nothing about fracturing your brand new bone regenerate is good.

I guess you could argue "Well if your Doctor just would've done this...", but then we get trapped in a circular argument that'll go nowhere. Plus, how do you know what that Doctor did or didn't do? Are you assuming that in all cases of bone bending and fractures, it was due to the Doctor being pressured by the patient? That is a massive assertion without any evidence.

Wow a whole 39 cases of non-controlled anecdotal data. I'm finally convinced that reaming your bone marrow is the best option now.

I assume you are joking, but for anybody else reading, the peer reviewed study was published in the Journal of Clinical Medicine. This was not anecdotal data. While the study did not have a control group, it was a retrospective study ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4093311/ See here for more). The original study did a good job in their inclusion criteria, starting with n=186.

(1) femoral length deficiency caused by congenital diseases without any axial deformities and (2), independently of the finally applied treatment, the technical possibility of use of each of the analyzed methods. Exclusion criteria were established as <10 and >18 years old and no technical possibility to apply any of the tested methods in the retrospective assessment, e.g., a too-narrow medullary canal for nail implantation, axial deformity of the femur bone before the treatment, acquired femoral length deficiency due to malignancy, infection, and/or fracture.

Why do we care about trauma patients!? Why do we care about congenital patients!? We are cosmetic patients! We are looking at otherwise healthy bone, that just so happens to have a discrepancy. While it would've been nice to have tibia patients included so that we could have a larger sample size, it is not the end of the world.

[Maison]

There is a paper on cosmetic limb lengthening that you can read here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342054/

The total number of patients was 795.
It shows that the longest average lengthening was achieved with LATN technique (7.6 cm (3.5 to 12.0)), while the shortest was with ILN (5.6 cm (1.7 to 8.0)).
Moreover, the ILN group had the fewest problems, obstacles, and complications per patient.

This means that the ILN has the lowest risk of complications, but if you want to lengthen your leg more than 8 cm, you would need external fixation.

[Medium Drink Of Water]

What are the benefits of externals?  External frames on tibias to avoid splitting the patella? Now your Tibia:Femur ratio is off, a significant predictor in knee and hip arthritis.

That ratio is determined by the amount lengthened, not by the device used.

Superficial infections and bone bending are not the only complications with external methods.

I never had a single infection in five months.  And neither did the other patient there who promoted leaving the pinsites alone.  An infection is determined by bacteria, and the patient's environment and behavior determine whether they get into the wounds or not.  It's not random chance.

Bone bending can be fixed by making minor adjustments to external frames through the course of lengthening.  If bones are bent at the end it's because either the patient or doctor messed up.

LON has a 2.4% to 15% chance of deep infections. Malunion, serious infections, frame destabilization, and pre-considation shouldn't be hand-waved. Granted, a pre consolidation isn't the worst thing in the world, but it would suck having to do an additional surgery for another osteotomy. Price goes up, anesthesia isn't good for you, and more trauma to the local area = more scarring. Nothing about fracturing your brand new bone regenerate is good.

Premature consolidation is determined by bone growth, which is determined by genes and nutrition.  How is that the frame's fault?

I guess you could argue "Well if your Doctor just would've done this...", but then we get trapped in a circular argument that'll go nowhere. Plus, how do you know what that Doctor did or didn't do? Are you assuming that in all cases of bone bending and fractures, it was due to the Doctor being pressured by the patient? That is a massive assertion without any evidence.

The combination of what you and your doctor do is mostly going to determine the outcome.  It's not something to be dismissed.  How much of an impact did the devices even have on the outcomes in this study anyway?  Correlation is not causation, and LL issues aren't due to random chance.  Distilling things down to numbers can often obscure the truth rather than reveal it.

the peer reviewed study was published in the Journal of Clinical Medicine. This was not anecdotal data. While the study did not have a control group, it was a retrospective study ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4093311/ See here for more). The original study did a good job in their inclusion criteria, starting with n=186.

Yeah, not technically anecdotatl data, but not much better really.  No control means there's no claim of cause and effect.  The researchers have no idea what caused the problems and are not claiming to, which is the standard for scientific journals like this.

The sample size is tiny, and many problems happend to either one or two patients.  One case of delayed consolidation in the whole study, and it happened to an internal patient, which is 9% of them in the study.  Zero for external patients.  This does not mean internals result in delayed consolidation 9% of the time and that there's zero risk of it for external patients.  Generalizing anything from this study is not justified.

And LON means Lengthening Over Nails, an approach to LL which involves placing a fixed internal nail into the intermedullary canal during the same surgery as the breaking of the bone and installation of an external device.  LON does not mean monorails.  You can do LON with TSF, Ilizarov, or monorails, or a rope tied to your foot with a donkey pulling on it.

[Medium Drink Of Water]

This means that the ILN has the lowest risk of complications, but if you want to lengthen your leg more than 8 cm, you would need external fixation.

No, it does not mean that.

"A little learning is a dangerous thing."
-Alexander Pope, 1709

[NailedLegs]

That ratio is determined by the amount lengthened, not by the device used.

Yes, but I was specifically talking about doing external frames on tibias only, which has been suggested on this forum. If you only do your tibias, you will skew your T:F ratio which is a significant predictor in hip and knee arthritis. ( https://pubmed.ncbi.nlm.nih.gov/26398436/ )

I never had a single infection in five months.  And neither did the other patient there who promoted leaving the pinsites alone.  An infection is determined by bacteria, and the patient's environment and behavior determine whether they get into the wounds or not.  It's not random chance.

So your argument is "Well I didnt get an infection, so its not a real risk"? Just because YOU didn't get an infection, does not mean OTHERS will not. That's why we use statistics so we can understand the RATE that a problem may occur at.

That is a bath faith argument. For someone that claimed the studies used anecdotes, why are you using anecdotes?

Bone bending can be fixed by making minor adjustments to external frames through the course of lengthening.  If bones are bent at the end it's because either the patient or doctor messed up.

"Bone bending and fracture: Decisions made about the timing for frame removal are based upon a number of factors, including x-ray appearances/ability to weight bear comfortably and time spent in frame. However, unfortunately, bones can still sometimes bend or fracture when the fixator is removed requiring further treatment and sometimes, further surgery."
( Source: https://foi.avon.nhs.uk/Download.aspx?did=26388&f=All%20About%20Frames-1.pdf Warning, the PDF automatically downloads for some reason! Do not click if you don't want to download it.)
The keyword is "HOWEVER". So while some of the risk can be mitigated, according to the NHS not all risk can be mitigated. Regardless, the fact remains that mistakes CAN happen with ANY surgery. This is something you must consider. Where in the literature do we see IMN nails causing fractures at the same rate of externals, besides patients not following their Doctor's instructions?

Premature consolidation is determined by bone growth, which is determined by genes and nutrition.  How is that the frame's fault?

I agree to a certain extent, but why did you ignore everything else? Why did you cherry pick premature consolidation(Which one could argue is worse than a delayed consolidation because you have to get another surgery to correct it.) and ignore serious infections? I already stated that a premature consolidation isn't the worst thing in the world.

The combination of what you and your doctor do is mostly going to determine the outcome.  It's not something to be dismissed.  How much of an impact did the devices even have on the outcomes in this study anyway?  Correlation is not causation, and LL issues aren't due to random chance.  Distilling things down to numbers can often obscure the truth rather than reveal it.

So what evidence do you have to support the contrary? NONE. That's the point of this thread. You have no evidence to support your claims, and I'm revealing the lies and falsities spewed on this forum. This is about harm reduction. This is about giving people all of the information so that they can determine for themselves what the best course of action is. At the end of the day, it's up to you to determine what method you use to lengthen. At least do it being completely informed. It's called informed consent.

Yeah, not technically anecdotatl data, but not much better really.  No control means there's no claim of cause and effect.  The researchers have no idea what caused the problems and are not claiming to, which is the standard for scientific journals like this.

So you admit that you lied or were being intentionally misleading in your original statement? I'm glad we are making progress then.

Ilizarov or TrueLok vs IMN(Fitbone) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7535106/

"A decreased number of complications was noted with use of a motorized intramedullary nail compared with circular external fixation in pediatric patients undergoing femoral lengthening for congenital femoral deficiency. "
Discrepancy patients, NOT trauma patients.

Orthofix Limb Reconstruction System vs IMN(PRECICE) https://www.reachyourheight.com/wp-content/uploads/2018/03/2017-Herzenberg-Lengthening_With_Monolateral_External_Fixation.JPO_.pdf



Here we can see a table of all the problems, obstacles, and complications that occurred. If you don't know, that is defined as "Difficulties that occur during limb lengthening were subclassified into problems, obstacles, and complications. Problems represented difficulties that required no operative intervention to resolve, while obstacles represented difficulties that required an operative intervention. All intraoperative injuries were considered true complications, and all problems during limb lengthening that were not resolved before the end of treatment were considered true complications."

In essence, the further down you go (Problem -> Obstacle -> Complication) the worse it is. Looking at true complications, we can see that frame/rod failure, fracture postremoval, and shortening post removal are problems with LON, but not IMN. Similarly, subluxation and delayed/malunion is a problem with IMN, but not LON. Why? Read below.

"Subluxation is always a risk in CFD patients who undergo lengthening procedures. With the external fixator, this is mitigated by spanning the knee with a hinged external fixator construct. With the IM lengthening nails, we rely on dynamic splinting in full ex-tension."

I have not read about a cosmetic Limb Lengthening patient getting a hinged external fixator construct in addition to their lengthening fixator. Does that mean they are at the same risk level of subluxation? That's up to you to research and determine, I can't say.



"In summary, we feel that the IM lengthening nail represents a significant advance in technology for CFD lengthening. The increased potential for knee subluxation must be guarded against by strict bracing protocols, and in cases of preoperative radiographic instability, pro-phylactic knee ligament reconstruction."

If Medium Drink Of Water can make the argument of "If bones are bent at the end it's because either the patient or doctor messed up.", then can't I make the same argument that subluxation is because the Doctor or Patient messed up?

"The first stage of knee subluxation is the development of a knee contracture; vigilant splinting is crucial"

So it's the Doctor's or Patient's fault in not monitoring for a contracture, which could prevent knee subluxation by splinting? See how this works both ways? Does that mean we can ignore subluxation like Medium Drink of Water ignores bone bending and fractures?

I understand questioning a retrospective study. Did you look at the other paper I replied to you with? ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4093311/ ) But again I ask, what evidence do you have that shows the contrary? What evidence do you have that shows external fixators are better than intramedullary nails? And if you have that evidence, how are they better?

The sample size is tiny, and many problems happend to either one or two patients.  One case of delayed consolidation in the whole study, and it happened to an internal patient, which is 9% of them in the study.  Zero for external patients.  This does not mean internals result in delayed consolidation 9% of the time and that there's zero risk of it for external patients.  Generalizing anything from this study is not justified.

That's true, which is why it's important to maintain an open mind to new information. So again I ask, what evidence do you have that shows the contrary? What evidence do you have that shows external methods are superior to internal methods? I am not here proclaiming that internal methods have no faults or problems--they do. All surgeries carry some form of risk, but the purpose is to determine what's the safest. What method of limb lengthening will likely result in the best outcome? That is the question.

And LON means Lengthening Over Nails, an approach to LL which involves placing a fixed internal nail into the intermedullary canal during the same surgery as the breaking of the bone and installation of an external device.  LON does not mean monorails.  You can do LON with TSF, Ilizarov, or monorails, or a rope tied to your foot with a donkey pulling on it.

That is correct.

Dr. Paley created the modern day LON method.



https://pubmed.ncbi.nlm.nih.gov/9378732/

So the creator of the modern day LON method states that the LON is outdated, and that the PRECICE nail is the most advanced in the world. Should we give any credibility to the Doctor that created the modern LON method? Should we say he's wrong, and that we should continue to use LON?


Notice how I've done my best to provide studies for my claims. You have not. I want to be proven wrong, because that's how we can learn. Why are we believing anecdotes and assumptions over studies and logic? I understand your hesitancy towards retrospective studies, so why haven't you provided anything that shows the contrary? I'm willing to take any kind of study you can provide--but you can't.


I want to make my final point clear. If you disagree, tell me why. This sums up my entire argument:

We are cosmetic patients wanting to increase our height. The most effective and safest way to do so is not with external fixators. Intramedullary nails, such as PRECICE 2.2, come with risks. No surgery is 100% safe. All prospective patients should understand what they are about to put their body through, all the pros and the cons.

[NailedLegs]

No, it does not mean that.

"A little learning is a dangerous thing."
-Alexander Pope, 1709

According to that study...

Implantable lengthening nail had a mean complication rate of 0.02, which is lower than the four other methods. (0.2, 0.2, 0.1, 0.6)

Implantable lengthening nail had a mean obstacle rate of 0.23, which is lower than the other four methods. (1.5, 0.6, 0.7, 1.5)

Implantable lengthening nail had a mean problem rate of 0.16, which was lower than the other four methods. (0.7, 0.6, 1.1, 0.5)

It included a total of 11 studies, with a sample size of 795.

According to the study, an Implantable lengthening nail is safer than a Classic Ilizarov frame, hybrid advanced ring fixator, lengthening over nail, and lengthening and then nail.

What do you disagree with?

There is a paper on cosmetic limb lengthening that you can read here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342054/

The total number of patients was 795.
It shows that the longest average lengthening was achieved with LATN technique (7.6 cm (3.5 to 12.0)), while the shortest was with ILN (5.6 cm (1.7 to 8.0)).
Moreover, the ILN group had the fewest problems, obstacles, and complications per patient.

This means that the ILN has the lowest risk of complications, but if you want to lengthen your leg more than 8 cm, you would need external fixation.

Thank you for posting this study.

[GrowGrow123]

I want to make my final point clear. If you disagree, tell me why. This sums up my entire argument:

We are cosmetic patients wanting to increase our height. The most effective and safest way to do so is not with external fixators. Intramedullary nails, such as PRECICE 2.2, come with risks. No surgery is 100% safe. All prospective patients should understand what they are about to put their body through, all the pros and the cons.

You're doing God's work with all the facts! It baffles me that there are people on this forum who legitimately believe external methods are better than internal methods or that tibia's are safer than femurs despite the litany of evidence to the contrary.

I think some people are just looking for any justification for why they are opting for a riskier method instead of just being honest with themselves that price is the only reason. Nothing wrong with choosing a certain method because it's the only financially feasible option, but people should definitely be aware of the risks and not go in with eyes blind.

[Medium Drink Of Water]

What's the coefficient of determination? Is one even provided? I'm using statistics too here; knowledge of the science of statistics to be precise. Studies with sigma 3 confidence frequently get debunked, and this one can't even hold a candle to that. This is only a small step up from anecdotal stories.

I've personally met more than 39 LL patients. The reason I'm using anecdotes is because they're what I have. I'm offering them up as a way of illustrating an important point to consider: patient and doctor behavior matter A LOT. That idiot patient you mentioned in the OP is a perfect example. The method isn't to blame for what he did. What other stupid stuff happened that the study's authors didn't know about? I personally witnessed a lot of ridiculous patient behavior, and that was IN THE HOSPITAL. I have lots of anecdotal observations of recklessness and malfeasance which is why I don't trust the numbers.

Where in the literature do we see IMN nails causing fractures at the same rate of externals, besides patients not following their Doctor's instructions?

The literature is inadequate to use as a tool for making a judgment about that. A broken leg after LL (in cases in which the LL was even a factor) is due to insufficient regenerate. Does the literature tell us why the quality of internal patients' regenerate is so much better than that of external patients'? No; it doesn't even make the claim that there is a difference. That's you taking the ball and running out of the stadium and past the city limits with it. The study only covers three instances of fractures with no information about what caused them. Did the doctors take the devices off before there was enough regenerate? Did the patients do something stupid?

but why did you ignore everything else?

I didn't have anything else add about them specifically that wasn't covered by the other stuff I was saying in general.

That is correct.

Dr. Paley created the modern day LON method.

Sorry, I thought you were conflating monorail and LON. You have three instances of specific devices and methods separated by slashes here:

Intra-Medullary Nail/PRECICE is superior to the Modular Rail System/LON and to the Taylor Spatial Frames/external frames.

hence my incorrect assumption.

So the creator of the modern day LON method states that the LON is outdated, and that the PRECICE nail is the most advanced in the world. Should we give any credibility to the Doctor that created the modern LON method? Should we say he's wrong, and that we should continue to use LON?

Paley of course has lots and lots of credibility and I agree with those statements.

But external-only is by far the least invasive method of LL and that should count for something, based on nothing more than conjecture from my own common sense. I'd rather have broken legs and some serious body jewelry for several months than have my legs cut wide open and my bone marrow reamed out by a giant nail, and then cut back open again to take the nail out, with the bone marrow never coming back. Especially after the entire process is long over with and the frames are gone but the marrow isn't.

Problems that occurred more frequently (or exclusively) with externals in this tiny study but could occur with internals shouldn't be attributed to externals in general based on such a weak correlation and with zero causal linkage established.

Infection of course is a bigger worry with externals. But I think these "odds" are not what they appear to be. Based on anecdotal observations and basic knowledge of microbiology I further conject that environment and behavior affect the risk of infection occuring and that if you have the time and can take care of yourself properly, externals are the best.

If you don't, but have plenty of money, internals is the second best choice.

LON is a last resort but it's all there is for some peope.

So what evidence do you have to support the contrary? NONE. That's the point of this thread. You have no evidence to support your claims, and I'm revealing the lies and falsities spewed on this forum.

I don't have evidence to support the contrary. But non-robust, non-experimental correlational studies aren't strong evidence and are barely a blip on the weak evidence radar. We're still in the "use your common sense to figure it out" phase in the process of achieving enlightenment about CLL, and this topic doesn't advance us out of it in any appreciable way. We need real experiments or at the very least massive amounts of correlational datapoints to start generalizing.

Making big, sweeping proclamations about what is better and why, and saying any divergenet proposition is a lie, based on this dearth of evidence is arguably misinformation too.

[Medium Drink Of Water]

What do you disagree with?

Thank you for posting this study.

The part about method affecting maximum length achievable.

[Maison]

Dr. Paley, the world's most famous cosmetic limb lengthening surgeon, already has only PRECICE on his surgical menu now.
https://limblengthening.org/lengthening-strategies/

In my opinion, PECICE is the best choice if your budget is sufficient, except for the following cases

(1) When you need to lengthen the limb by more than 8 cm in one segment.

(2) When there is a severe deformity before the surgery.

(3)  When the doctor's skill is poor and there is concern about postoperative bone deformity.
In the case of a poorly skilled doctor, knock-knees are likely to occur in the tibia.
With circle-type external fixation, even if bone deformity occurs during limb lengthening, it can be corrected by adjusting the external fixator.

[Body Builder]

The term best is a very subjective one.
I don't know what is considered as best for every single LLer, but the safest and cheapest way is objectively the external tibias.
Lon is the worst way imo because it combines both the cons of externals.and internals without being better than both the other methods in anything.

[Maison]

The classic Ilizarov procedure is not safer than PRECICE because of the risk of osteomyelitis due to exacerbation of pinsite infection.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342054/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342054/table/T3/?report=objectonly

There are only three cases of osteomyelitis in these statistics, all of which occurred with the classic Ilizarov procedure.

[Body Builder]

The classic Ilizarov procedure is not safer than PRECICE because of the risk of osteomyelitis due to exacerbation of pinsite infection.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342054/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342054/table/T3/?report=objectonly

There are only three cases of osteomyelitis in these statistics, all of which occurred with the classic Ilizarov procedure.

Don't write the same again and again. With ilizarovs it is way too rare to have osteomyelitis from pin site infections because you should left an infection for too many days untreated and with terrible pains and swelling to come in deep inside the skin and then inside the bone.
If someome does LL in India or Turkey or any other third world country that left you without any assistance after LL to rot with the first complication then yes it may happen. In ANY other case, when there is redness and a little.pain in the pin site the doctor will simply prescribe otan antibiotics for a few days and you have ZERO risk of a further complication like bone infection. Simple as that.

Even in the second link you  refered there was no case of osteomyelitis even with some Egyptian butchers that used ilizarov fixators.
So don't mention again and again the same things about some imaginary risks with external LL that doesn't exist, at least more than the internal one. And by far the most important risk of LL is embolism which is fatal in many cases and it is almost completely linked to internal methods, not externals.

[Maison]

Don't write the same again and again. With ilizarovs it is way too rare to have osteomyelitis from pin site infections because you should left an infection for too many days untreated and with terrible pains and swelling to come in deep inside the skin and then inside the bone.
If someome does LL in India or Turkey or any other third world country that left you without any assistance after LL to rot with the first complication then yes it may happen. In ANY other case, when there is redness and a little.pain in the pin site the doctor will simply prescribe otan antibiotics for a few days and you have ZERO risk of a further complication like bone infection. Simple as that.

Even in the second link you  refered there was no case of osteomyelitis even with some Egyptian butchers that used ilizarov fixators.
So don't mention again and again the same things about some imaginary risks with external LL that doesn't exist, at least more than the internal one. And by far the most important risk of LL is embolism which is fatal in many cases and it is almost completely linked to internal methods, not externals.

Yes, you are right, there is a risk of embolism with intramedullary nail surgery. Paley says fat emboli are about 5%.

However, as far as I can tell from this forum, most of the doctors who offer external techniques in cosmetic limb lengthening are surgeons from Turkey, India, and other less developed countries.

Thus, the dilemma is that when a patient chooses Ilizarov in favor of low price and embolism risk management, choosing a country that is too cheap will increase the risk of osteomyelitis.
Generally speaking, the risk of osteomyelitis is higher than the chance of dying from embolism. There have been several osteomyelitis patients on this forum, and I think most of them were external.

Furthermore, Rozbruch, one of the top physicians, also stated
Internal limb lengthening devices are associated with fewer complications than alternative methods of limb lengthening.　
https://journals.lww.com/jbjsoa/Fulltext/2020/12000/Motorized_Internal_Limb_Lengthening__MILL_.22.aspx

If the risk of embolism in nail insertion were significant, no physician in the world would perform internal procedures. In reality, however, the internal technique is still widely practiced. With "bent," surgeons can reduce the risk of fat embolization.

Which doctors in which countries do you think are reliable for the Ilizarov procedure, for example?　
I too believe that Ilizarov surgery by a good doctor is safe.

[YOUNGandSTRONG]

Albizzia nail

[Maison]

Sorry, bent is a misspelling, correct is vent.
A vent is a procedure in which several holes are made in the bone before reaming to create exits for the bone marrow fat.

[Medium Drink Of Water]

However, as far as I can tell from this forum, most of the doctors who offer external techniques in cosmetic limb lengthening are surgeons from Turkey, India, and other less developed countries.

Thus, the dilemma is that when a patient chooses Ilizarov in favor of low price and embolism risk management, choosing a country that is too cheap will increase the risk of osteomyelitis.

You can get externals in developed countries.  Aside from a few big ego docs with an agenda, you can get what you want if you ask for it.  I talked to two different (American) doctors about otoplasty (cosmetic ear surgery); a simple outpatient procedure that isn't very painful and doesn't take very long.  The first one said there was absolutely no way he'd do it under local anesthesia - I had to pay more than double his own fee for an OR and an anesthesiologist that I didn't need - his way or the highway.  I took the highway a couple of blocks west to a different doc who offered a choice.

Generally speaking, the risk of osteomyelitis is higher than the chance of dying from embolism. There have been several osteomyelitis patients on this forum, and I think most of them were external.

It's not a roulette wheel.  If you and your doctor conduct yourselves as you should thoughout the process you can beat these "odds" that appear in publish-or-perish studies.

Furthermore, Rozbruch, one of the top physicians, also stated
Internal limb lengthening devices are associated with fewer complications than alternative methods of limb lengthening.　
https://journals.lww.com/jbjsoa/Fulltext/2020/12000/Motorized_Internal_Limb_Lengthening__MILL_.22.aspx

If he's talking about less severe complications, over which the patient and doctor have a lot of control, then that doesn't mean much.

If the risk of embolism in nail insertion were significant, no physician in the world would perform internal procedures. In reality, however, the internal technique is still widely practiced.

Actually, they would continue to do the surgery.  Plenty of riskier stuff than internal LL goes on every day.

With "vent," surgeons can reduce the risk of fat embolization.

Now you're on the right track.  Think about why the numbers for any complication are what they are, and think of ways you can improve your chances instead of following numbers blindly.  Doctors follow the numbers because that's what they have; they don't know what will happen with each patient and can't control patient behavior/genes/environment or their own natural skill.

[Maison]

You can get externals in developed countries.  Aside from a few big ego docs with an agenda, you can get what you want if you ask for it.  I talked to two different (American) doctors about otoplasty (cosmetic ear surgery); a simple outpatient procedure that isn't very painful and doesn't take very long.  The first one said there was absolutely no way he'd do it under local anesthesia - I had to pay more than double his own fee for an OR and an anesthesiologist that I didn't need - his way or the highway.  I took the highway a couple of blocks west to a different doc who offered a choice.

It's not a roulette wheel.  If you and your doctor conduct yourselves as you should thoughout the process you can beat these "odds" that appear in publish-or-perish studies.

If he's talking about less severe complications, over which the patient and doctor have a lot of control, then that doesn't mean much.

Actually, they would continue to do the surgery.  Plenty of riskier stuff than internal LL goes on every day.

Now you're on the right track.  Think about why the numbers for any complication are what they are, and think of ways you can improve your chances instead of following numbers blindly.  Doctors follow the numbers because that's what they have; they don't know what will happen with each patient and can't control patient behavior/genes/environment or their own natural skill.

Rozbruch compared LON and PRECICE, concluding that the overall costs are similar given that PRECICE requires fewer surgical procedures. In developed countries, the cost of hiring a skilled surgeon may exceed the cost of the device.
https://pubmed.ncbi.nlm.nih.gov/30278015/

Although the classic Ilizarov method requires fewer surgeries, it is widely recognized that patients need to use external fixators for an extended period, which significantly inconveniences their daily lives.

https://journals.lww.com/jbjsoa/Fulltext/2020/12000/Motorized_Internal_Limb_Lengthening__MILL_.22.aspx
The cases compared in this study are all from the US and the UK. However, osteomyelitis was still observed in external method.
This implies that even the most skilled surgeons in developed countries cannot entirely eliminate the risk of osteomyelitis associated with external procedures.

In my opinion, if budget is not a constraint, the internal method is preferable. However, if there are surgeons who can perform the external method of surgery generally safely and at a relatively reasonable cost, it would be beneficial to share that information.

You are the administrator here, and a neutral view is desired, but you appear to favor the external method.
With all due respect, I suspect that your own experience with external surgery may have influenced your opinion. It seems to me that you place more value on personal experience than on medical literature.

[NailedLegs]

You're doing God's work with all the facts! It baffles me that there are people on this forum who legitimately believe external methods are better than internal methods or that tibia's are safer than femurs despite the litany of evidence to the contrary.

I think some people are just looking for any justification for why they are opting for a riskier method instead of just being honest with themselves that price is the only reason. Nothing wrong with choosing a certain method because it's the only financially feasible option, but people should definitely be aware of the risks and not go in with eyes blind.

Thank you.

I agree with you about people trying to justify their decision. I understand the financial aspect...if you want to cheap out on this surgery, that is your choice. The problem is people publicly justifying their bad decisions, not necessarily lying to other people, but lying to themselves. I think a lot of them want to make themselves feel better...the issue is other people read/watch that and think "Oh, maybe I should do the same thing then?" and they wind up hurting themselves in the process, which could've been entirely avoided. I'm all about safety, but also harm reduction.

The part about method affecting maximum length achievable.

I agree, internals don't necessarily cap you out at 8cm...depends on what internal nail we're talking about. But PRECICE 2.2 has a max of 8cm, so maybe he was talking about that.

What's the coefficient of determination? Is one even provided? I'm using statistics too here; knowledge of the science of statistics to be precise. Studies with sigma 3 confidence frequently get debunked, and this one can't even hold a candle to that. This is only a small step up from anecdotal stories.

"Statistical analysis was performed with the use of STATISTICA 13 Software (Tibco Software Inc., Palo Alto, CA, USA). The Shapiro–Wilk test was performed to determine the normality of the data. Due to the small groups of patients and the lack of normal distribution, the Kruskal–Wallis ANOVA test and Mann–Whitney U test were used to calculate the statistical relationships between the demographical and clinical data. The χ2 test (2 × 3) was carried out to assess the differences in dichotomous variables. The significance level was adopted as p < 0.05."

I've personally met more than 39 LL patients. The reason I'm using anecdotes is because they're what I have. I'm offering them up as a way of illustrating an important point to consider: patient and doctor behavior matter A LOT. That idiot patient you mentioned in the OP is a perfect example. The method isn't to blame for what he did. What other stupid stuff happened that the study's authors didn't know about? I personally witnessed a lot of ridiculous patient behavior, and that was IN THE HOSPITAL. I have lots of anecdotal observations of recklessness and malfeasance which is why I don't trust the numbers.

Why do your 39 anecdotal stories carry more validity than Dr. Szymon Pietrzak, Dr. Tomasz Parol, Dr. Jarosław Czubak, and Dr. Dariusz Grzelecki at the Gruca Orthopedic and Trauma Teaching Hospital, and their study published in the Journal of Clinical Medicine?

I'm not going to 100% and completely disregard someones personal experiences. Isn't that what this forum is about with the patient diaries? Why after providing study after study, digging up more research the more I look, nothing is ever good enough to compare to your anecdotal experiences? What exactly do you need in order to admit, "External fixation is not the safest way to do cosmetic limb lengthening."? What criteria must be met before you change your mind?

What have you seen that makes you believe externals are safer and better than internals for cosmetic limb lengthening? What is your reasoning?

The literature is inadequate to use as a tool for making a judgment about that. A broken leg after LL (in cases in which the LL was even a factor) is due to insufficient regenerate. Does the literature tell us why the quality of internal patients' regenerate is so much better than that of external patients'? No; it doesn't even make the claim that there is a difference. That's you taking the ball and running out of the stadium and past the city limits with it. The study only covers three instances of fractures with no information about what caused them. Did the doctors take the devices off before there was enough regenerate? Did the patients do something stupid?

The sample size is small. Could it be more thorough? Yes. The more information we can collect, the better. But what's it going to take? What do you need in order to be satisfied?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342054/

What about the 795 patients? Granted, this study is hardly a study. They didn't even observe the patients themselves, all they did was look at other studies and pooled them together. But every single metric we're looking at points to externals being, on average, less safe. What metric are you using to determine that externals are better?

Sorry, I thought you were conflating monorail and LON. You have three instances of specific devices and methods separated by slashes here:

hence my incorrect assumption.

I should have been more specific and precise(lol). You are completely correct about monorails not necessarily meaning LON. Oftentimes that is how monorails and LON is done in regards to cosmetic limb lengthening. When you look at the Turkish clinics, that's what they often do. Is anyone aware of a Doctor in the United States doing cosmetic limb lengthening with monorails + LON, like what they're doing in Turkey? I don't know of a single one. What about in Europe? Turkey is the only place I'm aware of that does it, but maybe if you found some random Orthopedic surgeon somewhere in Romania he'd do it...

Paley of course has lots and lots of credibility and I agree with those statements.

But external-only is by far the least invasive method of LL and that should count for something, based on nothing more than conjecture from my own common sense. I'd rather have broken legs and some serious body jewelry for several months than have my legs cut wide open and my bone marrow reamed out by a giant nail, and then cut back open again to take the nail out, with the bone marrow never coming back. Especially after the entire process is long over with and the frames are gone but the marrow isn't.

That is incorrect. Unless you are a child.

( https://www.leukaemia.org.au/blood-cancer/understanding-your-blood/bone-marrow-and-blood-formation/ )

"Bone marrow is spongy tissue in the middle of certain bones. Most blood cells are made in your bone marrow. This process is called haemopoiesis.

In children, haemopoiesis takes place in the long bones, like the thighbone (femur). In adults, it’s mostly in the spine (vertebrae) and hips, ribs, skull and breastbone (sternum). You may have a bone marrow biopsy taken at the back of your hip (the iliac crest)."

Dr. Paley also talked about it but I can't find the source, but I do recall him mentioning that (paraphrasing) "the pelvis makes most of your blood supply, and your bone marrow will regenerate after the nail is removed". Since I can't find the source, take it for what you'd like. Regardless, has anyone heard of this being an issue? How many thousands of patients have had their femurs reamed, and where do we see complications resulting from that? I have not seen or heard anything in regards to that.

I have heard of fat embolisms being a risk, which is specifically why the bone marrow is reamed in order to prevent that.

How do we quantify "less invasive"? Tibias(tibia + fibula) require two bones to be cut, femurs only one.

Problems that occurred more frequently (or exclusively) with externals in this tiny study but could occur with internals shouldn't be attributed to externals in general based on such a weak correlation and with zero causal linkage established.

Infection of course is a bigger worry with externals. But I think these "odds" are not what they appear to be. Based on anecdotal observations and basic knowledge of microbiology I further conject that environment and behavior affect the risk of infection occuring and that if you have the time and can take care of yourself properly, externals are the best.

Why are externals the best?

If you don't, but have plenty of money, internals is the second best choice.

LON is a last resort but it's all there is for some peope.

I don't have evidence to support the contrary. But non-robust, non-experimental correlational studies aren't strong evidence and are barely a blip on the weak evidence radar. We're still in the "use your common sense to figure it out" phase in the process of achieving enlightenment about CLL, and this topic doesn't advance us out of it in any appreciable way. We need real experiments or at the very least massive amounts of correlational datapoints to start generalizing.

Making big, sweeping proclamations about what is better and why, and saying any divergenet proposition is a lie, based on this dearth of evidence is arguably misinformation too.

So why can you say the same, based entirely on your own personal experiences and without any evidence, that externals are the best? Why can you say externals are best but I can't say the opposite?

[GrowGrow123]

Dr. Paley also talked about it but I can't find the source, but I do recall him mentioning that (paraphrasing) "the pelvis makes most of your blood supply, and your bone marrow will regenerate after the nail is removed". Since I can't find the source, take it for what you'd like. Regardless, has anyone heard of this being an issue? How many thousands of patients have had their femurs reamed, and where do we see complications resulting from that? I have not seen or heard anything in regards to that.

According to Dr. M on his TikTok page, the marrow completely regenerates 2 weeks after rod removal and doesn’t pose a risk.

[NailedLegs]

The term best is a very subjective one.
I don't know what is considered as best for every single LLer, but the safest and cheapest way is objectively the external tibias.
Lon is the worst way imo because it combines both the cons of externals.and internals without being better than both the other methods in anything.

Why are external tibias the safest?

[Medium Drink Of Water]

Although the classic Ilizarov method requires fewer surgeries, it is widely recognized that patients need to use external fixators for an extended period, which significantly inconveniences their daily lives.

Yep, externals are for people who have a lot of time and an environment conducive to be wearing those frames.

The cases compared in this study are all from the US and the UK. However, osteomyelitis was still observed in external method.
This implies that even the most skilled surgeons in developed countries cannot entirely eliminate the risk of osteomyelitis associated with external procedures.

Of course the risk is higher.  There's no denying that when you have pins going in and out of your legs, something is more likely to get in there than with a device that's sealed inside.  I have not been arguing that there is no risk just because I didn't get one.  But I do contend that patient health and hygeine have a big impact on whether this happens or not and that aggregated numerical data aren't especially useful in determing the odds of an individual case.  Do you disagree with that?

In my opinion, if budget is not a constraint, the internal method is preferable.

You have your opinion and I respect that opinion.  I may have done all internals if I'd had the money in 2007.  My objection to the OP was the certainty and boldness of his claims based on what I thought was flimsy evidence.

You are the administrator here and a neutral view is desired

I am not the administrator here.  I was a regular poster in the beginning who was given very limited moderator powers to lend the credibility of an elder stateman to a new David forum competing with the old Goliath forum whose name is still auto-censored here as a relic of that battle, since none of the original LL Forum founders had even had LL at the time.  I didn't even ask to be a mod, it was suddenly added to my account one day.  The administrator is so neutral as to be almost completely hands-off.  He hasn't posted here in years and doesn't check the forum much, which is why we have such a big troll problem here.

With all due respect, I suspect that your own experience with external surgery may have influenced your opinion.

I was always advocating for pure externals even before I had LL.  The admin of the old forum was kind of annoyed by my posts, and I suspected the fact that he'd had LON was making him more defensive of the method than he should've been.

Was I making a virtue out of a necessity because I couldn't afford internals back then?  It's possible that that colored my opinion, but the low-invasiveness of externals compared to the shudder-inducing brutality of not one but two major surgeries for internals was always on my mind when I was weighing the pros and cons of everything.

It seems to me that you place more value on personal experience than on medical literature.

I do, for two reasons:

1. I know what I saw, and I know more about what I saw than just a few numbers on a page with no backstory about how they came to be.  If my anecdotal observations of fellow patients were quantified and distilled down to raw data, they would paint a different picture from the truth.

2. I know a bit about scientific literature.  The people who write it often have an incentive to publish it: it's how they maintain their prestige over their workhorse colleagues.  The publish-or-perish mentality is what it's called, and it's being increasingly criticized as more and more studies thought to be good are reviewed and discredited as garbage.  Most often this is because of small sample sizes and correlations assumed to be causative, two red flags being waved proudly in the OP.

[Maison]

Why are external tibias the safest?

And by far the most important risk of LL is embolism which is fatal in many cases and it is almost completely linked to internal methods, not externals.

He expressed concern about embolisms associated with internals.

Paley comments on fat emboli as follows
To date, we have never had a patient die of FES (fat embolism syndrome).
We have however had 2 patients require prolonged ICU treatment prior to discharge
In both these cases the patients had a history of vaping which they failed to disclose.

[Medium Drink Of Water]

I agree, internals don't necessarily cap you out at 8cm...depends on what internal nail we're talking about. But PRECICE 2.2 has a max of 8cm, so maybe he was talking about that.

Yeah maybe.  I thought he was looking at the range of the datapoints and assuming the highest one in the dataset was the maximum possible.

The significance level was adopted as p < 0.05."[/b]

It's the industry standard in an industry that ends up retracting a lot of its assertions.  Plenty of studies with that level of confidence have proven a lot of false stuff.

Why do your 39 anecdotal stories carry more validity than Dr. Szymon Pietrzak, Dr. Tomasz Parol, Dr. Jarosław Czubak, and Dr. Dariusz Grzelecki at the Gruca Orthopedic and Trauma Teaching Hospital, and their study published in the Journal of Clinical Medicine?

They don't.  No doctor will read my posts and change his mind.  Most doctors won't read them period.  They don't know who I am and they don't know what I saw.  Despite all my rage I am still just a rat in a cage.  But think for yourself and think about the degree to which your interests align with theirs.  They deal in odds while patients deal in individual circumstances.  Circumstances under your control can allow you to do better than the calculated odds, as may have happened in my case (or maybe not; sample size of 1 after all). 

I'm not going to 100% and completely disregard someones personal experiences. Isn't that what this forum is about with the patient diaries? Why after providing study after study, digging up more research the more I look, nothing is ever good enough to compare to your anecdotal experiences? What exactly do you need in order to admit, "External fixation is not the safest way to do cosmetic limb lengthening."? What criteria must be met before you change your mind?

What are the consequences of the trauma of shoving those nails in there and pulling them out again, long-term?  The answer to that question is what I want to hear.

I had LON with an Ilizarov fixator.  Not sure which doctors do that now but I'd imagine (almost) any that offer ring fixators will do the nail too.  I know one clinic in Russia, possibly the Ilizarov clinic, won't do the nailing.

That is incorrect. Unless you are a child.

The long bones of an adult contain yellow marrow.  It's not normally useful but the body has the ability to transform it into red marrow in some circumstances.  I don't know anything more than that, but I'm assuming that if the body would go to the trouble of doing that, it needs the red marrow for some reason.  If that happens, internal patients are left without the backup marrow.  Consequences?  Dunno.

How do we quantify "less invasive"? Tibias(tibia + fibula) require two bones to be cut, femurs only one.
Why are externals the best?

I'd say let's not quantify by counting the number of bones involved but by the amount of stuff that "invades" the body.  And you can do internal tibias so it's not like 1 vs 2 contributes to internal devices' superiority.

So why can you say the same, based entirely on your own personal experiences and without any evidence, that externals are the best? Why can you say externals are best but I can't say the opposite?

You can and did, but as long as there's room for doubt, claims like that are debatable.

[Maison]

Yep, externals are for people who have a lot of time and an environment conducive to be wearing those frames.

Of course the risk is higher.  There's no denying that when you have pins going in and out of your legs, something is more likely to get in there than with a device that's sealed inside.  I have not been arguing that there is no risk just because I didn't get one.  But I do contend that patient health and hygeine have a big impact on whether this happens or not and that aggregated numerical data aren't especially useful in determing the odds of an individual case.  Do you disagree with that?

You have your opinion and I respect that opinion.  I may have done all internals if I'd had the money in 2007.  My objection to the OP was the certainty and boldness of his claims based on what I thought was flimsy evidence.

I am not the administrator here.  I was a regular poster in the beginning who was given very limited moderator powers to lend the credibility of an elder stateman to a new David forum competing with the old Goliath forum whose name is still auto-censored here as a relic of that battle, since none of the original LL Forum founders had even had LL at the time.  I didn't even ask to be a mod, it was suddenly added to my account one day.  The administrator is so neutral as to be almost completely hands-off.  He hasn't posted here in years and doesn't check the forum much, which is why we have such a big troll problem here.

I was always advocating for pure externals even before I had LL.  The admin of the old forum was kind of annoyed by my posts, and I suspected the fact that he'd had LON was making him more defensive of the method than he should've been.

Was I making a virtue out of a necessity because I couldn't afford internals back then?  It's possible that that colored my opinion, but the low-invasiveness of externals compared to the shudder-inducing brutality of not one but two major surgeries for internals was always on my mind when I was weighing the pros and cons of everything.

I do, for two reasons:

1. I know what I saw, and I know more about what I saw than just a few numbers on a page with no backstory about how they came to be.  If my anecdotal observations of fellow patients were quantified and distilled down to raw data, they would paint a different picture from the truth.

2. I know a bit about scientific literature.  The people who write it often have an incentive to publish it: it's how they maintain their prestige over their workhorse colleagues.  The publish-or-perish mentality is what it's called, and it's being increasingly criticized as more and more studies thought to be good are reviewed and discredited as garbage.  Most often this is because of small sample sizes and correlations assumed to be causative, two red flags being waved proudly in the OP.

I must apologize for my previous misunderstanding, I was under the impression you were the administrator.
Now that I know you're not, I understand that you are free to express your personal opinions.

I've noticed that you generally mistrust medical papers. It's not entirely implausible that both Paley and Rozbruch, who perform cosmetic leg lengthening procedures, may be suppressing or omitting certain inconvenient aspects from their publications for profit.

However, I believe you might be overly concerned about the potential harm to the bone marrow from nail implants.
As GrowGrow123 has mentioned, bone marrow fully regenerates after the rod is removed.

According to Dr. M on his TikTok page, the marrow completely regenerates 2 weeks after rod removal and doesn’t pose a risk.

Moreover, the gold standard surgical technique for fractures in the diaphysis of the tibia or femur is the intramedullary nail, which often isn't removed after the fracture surgery.
If, as you suggest, the nails cause irreversible damage to the bone marrow and losing marrow in the lower extremity is detrimental to adults, then intramedullary nail surgery for fractures will likely be discontinued in the future.

Yeah maybe.  I thought he was looking at the range of the datapoints and assuming the highest one in the dataset was the maximum possible.

Since the mainstream internal method is PRECICE, I mentioned 8 cm, which is the limit of PRECICE. I apologize for not explaining that earlier.

[Body Builder]

Yes, you are right, there is a risk of embolism with intramedullary nail surgery. Paley says fat emboli are about 5%.

However, as far as I can tell from this forum, most of the doctors who offer external techniques in cosmetic limb lengthening are surgeons from Turkey, India, and other less developed countries.

Thus, the dilemma is that when a patient chooses Ilizarov in favor of low price and embolism risk management, choosing a country that is too cheap will increase the risk of osteomyelitis.
Generally speaking, the risk of osteomyelitis is higher than the chance of dying from embolism. There have been several osteomyelitis patients on this forum, and I think most of them were external.

Furthermore, Rozbruch, one of the top physicians, also stated
Internal limb lengthening devices are associated with fewer complications than alternative methods of limb lengthening.　
https://journals.lww.com/jbjsoa/Fulltext/2020/12000/Motorized_Internal_Limb_Lengthening__MILL_.22.aspx

If the risk of embolism in nail insertion were significant, no physician in the world would perform internal procedures. In reality, however, the internal technique is still widely practiced. With "bent," surgeons can reduce the risk of fat embolization.

Which doctors in which countries do you think are reliable for the Ilizarov procedure, for example?　
I too believe that Ilizarov surgery by a good doctor is safe.

The american doctors you mentioned get much more money and much easier by doing internals with precise than doing externals. Thats the main reason they advertise it that much and say all these bs about its superiority in safety compared to hexapods.
Internals were and will always be a more risky way of doing LL and should be the first option only if someone wants to do LL on femurs. On tibias there is no reason to do internals except you can't take it to have some bulky fixators for about a year which is something I respect and I can understand. But saying that reaming your bone and doing 2 major surgeries is safer compared to just have some screws on your bone which will be removed in about a year (much less if you lengthen 5cm) without even a new surgery is the most stupid thing ever.
And I start to believe that even Paley, who I thought was the most respectable LL doctor, had become a plain merchant who wants to promote precise (which he created and takes money from its rights) and write bs only to gain more money.

[Body Builder]

Why are external tibias the safest?

I have explained it a thousand of times on this forum.
Much less invasive method, almost zero risks for fat embolism which is the most fatal complication of LL and only one major surgery compared to two for internals (and 3 for latn especially).
Also the most stable method in terms of weight bearing and the best way to correct any malunions or problems you had even  before LL as this is the main use of hexpods, to correct bones.
It is plain obvious why externals on tibias are for sure the safest LL method. Only merchant doctors say otherwise.