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[ItsMyLife]

I want to lengthen my femurs instead of tibae because my tibia are pretty long.

Would it be possible to lengthen both femurs at the same time??

Which russian doc does this?

[GeTs]

There may be a reason to why they don't do femurs at the same time

[TRS]

It depends on who is operating on you. I know some doctors don't like operating on both femurs at the same time due to higher chance of embolism and therefore separate to two surgeries. It is possible to do Ilizarov on both femurs and one of the doctors in the doctor list believes that LON on femurs are easier and less painful than LON on tibias. Maybe the surgery itself is easier on the thighs because the surgeon has to fixate only the femurs while the lower leg involves tibia and fibula fixation. But for the patient, it maybe more painful because of larger muscle mass. Femur lengthening is probably the most controversial because of the trade off between femur malalignment associated with internal method (can lead to arthritis in the future) and the loss of ROM (and maybe muscle damage) associated with external femurs. But one thing everyone may agree on is that internal method is more comfortable. But then I remember Disobedient (the member who did quadrilateral monorails) say that the monorails on her tibias were much more painful than the monorails on her femurs
You should contact the russian doctors in the doctor list and find out more about bilateral femurs.

[Greek-Semidget]

Fantastic topic,I mean with monorails this is possible,but they say monorails are not stable after 5cm so you better of go for Tibias and don't care so much about proportions

[Taller]

I think concern for proportions is about more than wanting to look good. It's about wanting to look as normal and natural as possible at our post-LL height.

I too am very interested in learning more about the feasibility and safety of external femurs. Apparently you can still walk while wearing Iliarov femur lengthening devices.

I wouldn't recommend monorails because their pins are so thick that they leave massive, deep, and hideous-looking scars in most cases.

[GROWtalORdieTRYING1]

get monorails. and then get surgical scar removal.

that is the safest method to prevent contracture.

there is a big difference in research papers between cages and monorail in regards to outcome. (in terms of statistics).

[Cannibal]

Femur lengthening is probably the most controversial because of the trade off between femur malalignment associated with internal method (can lead to arthritis in the future) and the loss of ROM (and maybe muscle damage) associated with external femurs.

Why would internal femurs cause misalignment and not monorails?

[TRS]

Why would internal femurs cause misalignment and not monorails?

With internal femoral lengthening, the nail tends to lengthen along the anatomical axis of the femurs causing a lateral shift in the mechanical axis. The general rate is about 1mm per 1cm http://www.ncbi.nlm.nih.gov/pubmed/22933497.
The external fixators lengthens along the mechanical axis of the femurs and therefore does not shift the mechanical axis. So malalignment should not be an issue unless if the surgeon does it incorrectly. 

[Taller]

With internal femoral lengthening, the nail tends to lengthen along the anatomical axis of the femurs causing a lateral shift in the mechanical axis. The general rate is about 1mm per 1cm http://www.ncbi.nlm.nih.gov/pubmed/22933497.
The external fixators lengthens along the mechanical axis of the femurs and therefore does not shift the mechanical axis. So malalignment should not be an issue unless if the surgeon does it incorrectly.

Thank you very much for this valuable information. Do you know if Ilizarov fixator for femur lengthen along the mechanical axis like monorails or the anatomical axis like internal nails. Also, would lengthening along the mechanical axis mean slightly anatomically crooked femur bones?

[TRS]

Thank you very much for this valuable information. Do you know if Ilizarov fixator for femur lengthen along the mechanical axis like monorails or the anatomical axis like internal nails. Also, would lengthening along the mechanical axis mean slightly anatomically crooked femur bones?

Ilizarov fixator does lengthen along the mechanical axis. But whether lengthening along the mechanical axis leads to anatomical crooked femur bones, this is actually a very good question! I will get Dr.B's opinion on this and whether it affects the physiology of the leg

[Overdozer]

It's possible, but you don't want to do that. Especially without LON. Spending at least 6 months with two bulky frames, that limit your movement, with a knee range of motion of like 40 degrees at best, without being able to sit, or to sleep with comfort, or to wear clothes. Fun times, ehh

[Taller]

whether lengthening along the mechanical axis leads to anatomical crooked femur bones, this is actually a very good question! I will get Dr.B's opinion on this and whether it affects the physiology of the leg

Thank you very much for asking him! I look forward to reading about his response.

[GeTs]

It's possible, but you don't want to do that. Especially without LON. Spending at least 6 months with two bulky frames, that limit your movement, with a knee range of motion of like 40 degrees at best, without being able to sit, or to sleep with comfort, or to wear clothes. Fun times, ehh

it depends, if its better afterwards I'd do it

[Overdozer]

it depends, if its better afterwards I'd do it

Easier said than done. With rather big amounts of lengthening like 8cm+ you can get stuck with the fixators for more than an year. You'll fking run insane, I know I am!

[Taller]

Wouldn't LATN for the femurs reduce the amount of time in fixators significantly? Also, don't femurs consolidate significantly faster than tibiae?

[Overdozer]

Also, don't femurs consolidate significantly faster than tibiae?

No, they don't. LON and LATN are both options that will reduce time spent in exfix

[TRS]

I thought I'd post this interesting image and article, related to this topic, which was posted in my diary by Taller (very good find Taller )

I'm no doctor, so defer judgement until we know Dr. B's take on the matter, but my research seems to indicate that lengthening along the mechanical axis does indeed produce anatomically crooked and zig-zagged femurs, as shown in the image bellow:



Drawings showing lengthening along the anatomical compared with the mechanical axis. The left femur (right side of figure) is lengthened with an external fixator parallel to the mechanical axis of the lower extremity. Lengthening along the mechanical axis creates a slight zigzag in the femoral shaft but does not change the displacement of the axis. The right femur (left side of figure) is lengthened with an external fixator parallel to the anatomical axis. Lengthening along the anatomical axis displaces the knee medially and therefore displaces the mechanical axis laterally. The displacement theoretically should increase with more extensive lengthenings. MAD = mechanical axis displacement

The article from which I pulled this information is a very worthwhile read for anyone interested in limb lengthening, I must say:

http://jbjs.org/content/79/10/1464


Edit: Also, I think that the femur bone might remodel itself to be straight and not crooked within a few years of lengthening along the mechanical axis. Bone remodeling occurs all the time in the body, so I wouldn't be surprised if this were actually the case. It would be another interesting thing to ask Dr. Birkholtz if circumstances permit.

This does show that lengthening parallel to the mechanical axis creates anatomically crooked bones. The bone does remodel itself but I don't know whether it does completely straighten the zig zag over time. Now whether the zig zag remains, would it affect the physiology of the leg?

This has also got me thinking whether femur LON actually lengthens along the anatomical axis, since the nails are actually inserted during the initial surgery? If that is not the case and it lengthens along the mechanical axis then wouldn't the nail and the anatomically crooked bone interfere with each other and risk breaking the bone?

Another thing to consider is whether LATN would be possible after external femurs? Is it possible to properly insert the nail when the femurs are crooked especially in a CLL patient who don't want any sort of subsidence or callus disruption. I know doctors insert nails in completely shattered or crooked femurs in non-CLL patients but they are not concerned with losing height and only want to fix the deformity.

I did not put much thought into LON/external femurs since I had focused my attention into internal nailing. Interestingly, the lateral shift in the mechanical axis will correct my leg alignment.
But this is actually a very interesting topic and it is a good idea to discuss and elucidate the process and consequences of external/LON femurs. 

[GROWtalORdieTRYING1]

can someone ask their doctor this question. I want to hear from a professional.

[GROWtalORdieTRYING1]

it is possible that the pelvic attachment just re adjusts its resting position to adjust for the new gait.

after all people have all kinds of gaits. it is possible that both positions become slightly altered.

can someone ask their doctor how the body compensates for this change. and if this change affects the body in any way. or does the body just re adjusts gait.

[GROWtalORdieTRYING1]

http://www.wheelessonline.com/ortho/anatomic_axis

^basic description

my understanding is that the method of lengthening will not change the result. all lengthening of femurs will cause the same change.

[Taller]

Those are very good questions, TheRisingShorty, and hopefully we'll know the answers soon. I'm glad that, in your case, internal lengthening was able to improve your joint alignment rather than worsen it. I take it that, as a result, you are able to responsibly lengthen more (assuming other significant complications do not arise) than most cosmetic Precise 2 patients, am I right?

If a LON nail can be interested so that the femur lengthens along the mechanical axis, then I wonder if the same can be done for an internal nail. If non-vertical weight bearing is what puts the most stress on precise nails, than having the nail along the mechanical (vertical) axis would be safer for weight bearing than inserting it along the slanted anatomical axis. My guess would nailing along the mechanical axis will have many risks for the hip joint, due to the nail insertion point. Otherwise nail insertion would have to be done through the knee, which is very dangerous.

It seems like LATN Ilizarov femurs would be ideal for lengthening along the mechanical axis and telhen recovering quickly. However, you do bring up a very good point in questioning whether an atomically crooked femur is as strong or mechanically sound as a naturally aligned one in real-life situations.

[Medium Drink Of Water]

This has also got me thinking whether femur LON actually lengthens along the anatomical axis, since the nails are actually inserted during the initial surgery? If that is not the case and it lengthens along the mechanical axis then wouldn't the nail and the anatomically crooked bone interfere with each other and risk breaking the bone?

Another thing to consider is whether LATN would be possible after external femurs? Is it possible to properly insert the nail when the femurs are crooked especially in a CLL patient who don't want any sort of subsidence or callus disruption. I know doctors insert nails in completely shattered or crooked femurs in non-CLL patients but they are not concerned with losing height and only want to fix the deformity.

The IM nail in LON mechanical axis lengthening would remain along the anatomical axis, but it would not prevent the bone from zig-zagging nor would it force the bone to lengthen along the anatomical axis.  In Beijing I saw patients having bowing and x-ing corrected despite using LON.  Lengthening along the mechanical axis will work as long as the medullary cavity is big enough to accommodate the nail, with a little bit of space left over.

[Overdozer]

The IM nail in LON mechanical axis lengthening would remain along the anatomical axis, but it would not prevent the bone from zig-zagging nor would it force the bone to lengthen along the anatomical axis.  In Beijing I saw patients having bowing and x-ing corrected despite using LON.  Lengthening along the mechanical axis will work as long as the medullary cavity is big enough to accommodate the nail, with a little bit of space left over.

That's true. Look at this guy (Agrios):

You can clearly see some curvation especially on his right leg, take a look how the rod is located in his medullary cavity around the broken piece of bone, it probably broke because of varus pressuring if that makes any sense (though varus will only make it worser for him, pushing his feet even more inside)

[TRS]

The IM nail in LON mechanical axis lengthening would remain along the anatomical axis, but it would not prevent the bone from zig-zagging nor would it force the bone to lengthen along the anatomical axis.  In Beijing I saw patients having bowing and x-ing corrected despite using LON.  Lengthening along the mechanical axis will work as long as the medullary cavity is big enough to accommodate the nail, with a little bit of space left over.

This makes sense. Thanks.

I'm glad that, in your case, internal lengthening was able to improve your joint alignment rather than worsen it. I take it that, as a result, you are able to responsibly lengthen more (assuming other significant complications do not arise) than most cosmetic Precise 2 patients, am I right?

Yup, Dr.B may allow me to go up to 7cm if I have no major complications. I was at a much higher risk of arthritis pre-op but my alignment will be perfect between 6-7cm and therefore he is willing to go up to 7 cm.
If I do reach 7cm on femurs then I'll reduce my tibia goal to 4-4.5cm. This would reduce my time in frames by 2-3 weeks

If a LON nail can be interested so that the femur lengthens along the mechanical axis, then I wonder if the same can be done for an internal nail. If non-vertical weight bearing is what puts the most stress on precise nails, than having the nail along the mechanical (vertical) axis would be safer for weight bearing than inserting it along the slanted anatomical axis. My guess would nailing along the mechanical axis will have many risks for the hip joint, due to the nail insertion point. Otherwise nail insertion would have to be done through the knee, which is very dangerous.

Unfortunately internal nails cannot lengthen along the mechanical axis because the nail must fit the IM cavity. Ideally, the surgeon would want to insert the largest diameter nail possible without over-reaming the bone and therefore allow more weight bearing. This would mean that the nail would have to lengthen along the anatomical axis. MDOW explained that the LON nail accommodates lengthening along the mechanical axis because of the nails smaller size and then locked in after the frames are removed. But the non-LON internal nails are locked in during the initial surgery and therefore must follow the anatomical route and it's impossible to lengthen along the mechanical axis.
With the internal nails, it's the vertical weight bearing (standing and walking) that puts the most stress on the nail while non-vertical (lying down) does not. This is why most internal nails are at risk of bending or breaking when walking.

It seems like LATN Ilizarov femurs would be ideal for lengthening along the mechanical axis and telhen recovering quickly.

Even though many doctors tend to discourage LATN, it's interesting that Dr. Rozbruch finds LATN to have faster bone growth and consolidation. I read in his book that reaming the regenerate and providing it with stem cells + growth factors stimulates faster bone formation. 

[ItsMyLife]

Is this the way to (estimate) femur length?

http://www.clockworkbikes.com/images/measurements/femur-length.gif

If I measure like this, then my femur is quite long after all

[ItsMyLife]

The moscow doctor (Bagirov) said that his apparatus is small, thus both femurs can be lengthened.

Dr Barinov (volgograd) says that lengthening both femurs will take 6 months and it is impossible to lengthen both femurs together. Each has to be done separately.

What's the risk of both-femur lengthening?

What's the advantage of having a long tibia compared to femur? (ie, a very high tibia-femur ratio), eg tibia 40 cm and femur is 42 cm, lets say.

[Overdozer]

Barinov is just being conservative, as it's not usual to lengthen both femurs at the same time with exfix - if they do lengthen it, it's usually either done for patients with one-leg shortening or cross-lateral for patients with dwarfism. Reason are mainly discomfort from just having the frames up your ass and also very bad knee ROM, which contributes to the discomfort even further.

There are no real advantages of having a long tibia, all I can say is that it looks quite unnatural and just bad.

[Taller]

Also, your strides WILL be shorter, biomechanically speaking, with long tibiae. With long femurs, your strides will be longer.

[GeTs]

Barinov is just being conservative, as it's not usual to lengthen both femurs at the same time with exfix - if they do lengthen it, it's usually either done for patients with one-leg shortening or cross-lateral for patients with dwarfism. Reason are mainly discomfort from just having the frames up your ass and also very bad knee ROM, which contributes to the discomfort even further.

There are no real advantages of having a long tibia, all I can say is that it looks quite unnatural and just bad.

you have to specify that only when the tibia is longer than the femur it looks bad

[Greek-Semidget]

you have to specify that only when the tibia is longer than the femur it looks bad

I agree...but really shorter tibias look bad too...I think adding up to 8cm to femurs looks good....not more...hope externals will be proved to be safe though :/

[123]

I think all of you here who are planning to do LL are very unrealistic about the procedure. Imagine having 2 frames on your whole femur (http://www.ilizarov.org.uk/images/mikea1.jpg) for AT LEAST 6 MONTHS. Just do external on tibia like everyone else, it's more comfortable and you can sleep, walk and sit better.

Just trying to help you guys, because external tibia lengthening is already hell, could not imagine external femur...