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[..]

It's a question that's been bothering me lately. Everyone here likes to point out that external tibia is the safest and least invasive form of LL. BUT the best LL doctor in the world doesn't even do that.

So what would be a safer move to do overall between internal femur with Paley and external tibia with other respectable doctor and good with the method, says Giotikas/Parihar/Catagni?

Safer = less likely to die, lose a leg, get other serious complications, better athletic recovery.

I'm beginning to question the advantages of being in Paley's hands. He's got some FE cases where other mediocre doctors haven't.

[RaaX]

He's got some FE cases

What does FE mean and elaborate his cases please.

[..]

What does FE mean and elaborate his cases please.

Fat embolism. Out of 250 cases. 4 patients got it. 1 almost died.

[Body Builder]

Safer are always externals only in terms of very serious complications, so external tibias are safer than internal femurs.

[myloginacc]

What does FE mean and elaborate his cases please.

The waters were pretty muddy in Paley's Rambam presentation. I personally didn't get a clear picture if it were 4 cases of FES, but it was almost certainly that. Fat emboli being released into other parts of the body after broken bones is too common of an occurrence. The four cases must have been Fat Embolism Syndromes.

https://en.wikipedia.org/wiki/Fat_embolism

A fat embolism (which via major trauma may progress to fat embolism syndrome) is a type of embolism in which the embolus consists of fatty material. They are often caused by physical trauma such as fracture of soft tissue trauma, and burns. Fat embolism syndrome is distinct from the presence of fat emboli, symptoms usually occur 1–3 days after a traumatic injury and are predominantly pulmonary (shortness of breath, hypoxemia), neurological (agitation, delirium, or coma), dermatological (petechial rash), and haematological (anaemia, low platelets). The syndrome manifests more frequently in closed fractures of the pelvis or long bones.

Clinical manifestation of fat embolism syndrome (FES) can start from 12 hours to 3 days after diagnosis of the underlying clinical disease. The three most characteristic features are: respiratory distress, neurological features, and skin petechiae. Respiratory distress (present in 75% of the cases) can vary from mild distress which requires supplemental oxygen to severe distress which requires mechanical ventilation. For neurologic features, those who have FES may become lethargic, restless, with a drop in glasgow coma scale (GCS) due to cerebral oedema rather than cerebral ischaemia. Therefore, neurological signs are not lateralised to one side of the body. In the severe form of cerebral odema, a person may become unresponsive. Petechiae rash usually happens in 50% of the patients. Such skin manifestation is temporary and can disappear within one day. The fat embolism syndrome can be divided into three types:

• Sublinical FES - It manifests as reduced partial pressure of oxygen (PaO2) on arterial blood gas (ABG) with deranged blood parameters (reduced haemoglobin or thrombocytopenia) associated with fever, pain, discomfort, tachypnoea, tachycardia. However, there is no respiratory distress. However, it is often confused with post-operative symptoms of fever, pain, and discomfort.
  
  
  • Subacute FES (non-fulminant FES) - The three characteristic features of fat embolism are present: respiratory distress, neurological signs, and skin petechiae. Petechiae are seen on the chest, axilla, shoulder, and mouth. Occulsion of dermal capillaries by the fat emboli resulted in petechial rash. Petechiae rash occurs in 50 to 60% of the cases. Neurologic signs such as confusion, stupor, and coma maybe present. These are usually temporary and does not happen on one side of the body. Respiratory distress can be mild and tend to improve on the third day. Retinal changes similar to Purtscher's retinopathy may also be present. Retinal changes happens in 50% of the patients with FES. These are the cotton wool exudates and small haemorrhages along the retinal vessels and macula.
    
    
    • Fuminant FES - This type of FES is much rarer than the above two types. It usually happens within the first few hours of the injury. The three characteristics of FES existed in the most severe form. Cause of death is usually due to acute right heart failure.
    
    

    Orthopaedic injuries especially fractures of the long bones are the most common cause of fat embolism syndrome (FES). The rates of fat embolism in long bone fractures varies from 1% to 30%. The mortality rate of fat-embolism syndrome is approximately 10–20%. However, fat globules have been detected in 67% of those with orthopaedic trauma and can reach as high as 95% if the blood is sampled near the fracture site. As the early operative fixation of long bone fractures become a common practice, the incidence of FES has been reduced to 0.9% to 11%
    
    Prevention
    
    For those treated conservatively with immobilisation of long bone fractures, the incidence of FES is 22%. Early operative fixation of long bone fractures can reduce the incidence of FES especially with the usage of internal fixation devices. Patients undergoing urgent fixation of long bone fractures has a rate of 7% of acute respiratory distress syndrome (ARDS) when compared to those undergoing fixation after 24 hours (39% with ARDS). However, movement of the fracture ends of the long bones during the operative fixation can cause transient increase of fat emboli in the blood circulation. Cytokines are persistently elevated if the long bone fractures is treated conservatively using immobilisation. The cytokine levels would return to normal after operative fixation. Although ream nailing increases pressure in the medullary cavity of the long bones, it does not increase the rates of FES. Other methods such as drilling of holes in the bony cortex, lavaging bone marrow prior to fixation, and the use of tourniquets to prevent embolisation have not been shown to reduce the rates of FES.
    
    Supportive treatment
    
    Once FES develops, the person should be admitted into intensive care unit (ICU), preferably with central venous pressure (CVP) monitoring. CVP monitoring would be helpful to guide the volume resuscitation. Supportive treatment is the only proven treatment method. supplemental oxygen can be given if a person has mild respiratory distress. However, if a person has severe respiratory distress, either continuous positive pressure ventilation (CPAP), or mechanical ventilation using positive end-expiratory pressure (PEEP) may be indicated. Fluid replacement is required to prevent shock. Volume resuscitation with human albumin is recommended because it can restore blood volume in the circulatory system while also binds to free fatty acids in order to reduce lung injuries. In severe cases, dobutamine should be used to support the right ventricular failure. Frequent Glasgow coma scale (GCS) charting is required access the neurological progression of a person with FES. A placement of intracranial pressure monitor may be helpful to direct the treatment of cerebral odema.
    
    
    Obviously, everyone wanting to undergo CLL should do some research on FES and Pulmonary Embolism, and ask their doctors questions about their own concerns, and how they handle these matters.
    
    These are merely snippets I took straight from the Wikipedia article.

[..]

Safer are always externals only in terms of very serious complications, so external tibias are safer than internal femurs.

So in which department would you say the internal is safer?

[fokid]

in many aspects like bone healing, muscle recovery, even nerve recovery (from what i have read).

[Body Builder]

So in which department would you say the internal is safer?

Bone and soft tissue healing, less chances of malunion and no pin site infections. However if you have an infection with internals it is far more dangerous than externals. But very unlikely to happen.

[..]

Bone and soft tissue healing, less chances of malunion and no pin site infections. However if you have an infection with internals it is far more dangerous than externals. But very unlikely to happen.

Less chances of malunion really? I thought the anatomic axis of the femur is more likely to causes malunion and secondly external fixator is capable of fixing it whereas internal nail isn't.

And when you said bone and soft tissue healing, do you mean it's simply faster with femur or with tibia, it will be permanently more crippled?

[Body Builder]

Less chances of malunion really? I thought the anatomic axis of the femur is more likely to causes malunion and secondly external fixator is capable of fixing it whereas internal nail isn't.

And when you said bone and soft tissue healing, do you mean it's simply faster with femur or with tibia, it will be permanently more crippled?

I meant non union, not malunion. My mistaktle. Femur heals better and faster than tibias thats why non union is harder.
Malunion with internals are harder too but with good hexapod frames malunions can be easily treated so there is no problem with that even in tibias.

Soft tissues is a big problem with tibias. Most people cant go more than 6-6.5 cm or they risk oversttetching of gastrocnemius-soleus which leads to permanent weakening. I dont even mention atl to fix equinus which is a madness.
On the other hand, on femurs most people can lengthen more than 6 cm without much problems as it band release is not significant and can fix most of problems that femur LL causes (duck ass mainly).

Anyway, if you want to lengthen up to 6cm, tibia LL with an hexapod and a good doctor is the way to go.
For more than that, Stryde on femurs is the best.

[..]

I meant non union, not malunion. My mistaktle. Femur heals better and faster than tibias thats why non union is harder.
Malunion with internals are harder too but with good hexapod frames malunions can be easily treated so there is no problem with that even in tibias.

Soft tissues is a big problem with tibias. Most people cant go more than 6-6.5 cm or they risk oversttetching of gastrocnemius-soleus which leads to permanent weakening. I dont even mention atl to fix equinus which is a madness.
On the other hand, on femurs most people can lengthen more than 6 cm without much problems as it band release is not significant and can fix most of problems that femur LL causes (duck ass mainly).

Anyway, if you want to lengthen up to 6cm, tibia LL with an hexapod and a good doctor is the way to go.
For more than that, Stryde on femurs is the best.

I think 6cm might be a little too much for tibs.

The problem with tibia lengthening is I believe it will lead to inferior stability and athleticsm compared to femur lengthening. But it's very confusing, long femurs simply don't look aesthetic, besides being much more expensive and more dangerous. And I'm not sure how the feeling of heavy thighs is gonna affect.

If I do tibs, I'm probably gonna settle for TSF.

[MirinHeight]

It's a question that's been bothering me lately. Everyone here likes to point out that external tibia is the safest and least invasive form of LL. BUT the best LL doctor in the world doesn't even do that.

So what would be a safer move to do overall between internal femur with Paley and external tibia with other respectable doctor and good with the method, says Giotikas/Parihar/Catagni?

Safer = less likely to die, lose a leg, get other serious complications, better athletic recovery.

I'm beginning to question the advantages of being in Paley's hands. He's got some FE cases where other mediocre doctors haven't.

messaged you back