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[(w)heel(s)]

Regardless of how strange might it sound at first glance, I would ask you to take this idea seriously and contribute in discussion. This is an idea which I couldn't find on this (and the other) LL forum, so after a couple of years of being an occasional lurker, I created this account just to get to know your opinion.

Assumptions:
- Only one leg at a time.
- Patient will visit the hospital only to start and finish each leg's procedure and for regular checks.
- Try to coninue his normal life less affected between procedures.
- Adjustable shoes/lifts will be continuously used to avoid stature deformation due to difference in legs length.
- Lenghtening of the second leg will be started when the first one will be ready to take over its role of a primary performer of body movement.

Advantages:
- The most obvious and most important one: Patient will be able to continue his normal life (work, school, home, family, hobby, social group) not more affected than someone with a normal leg broken.
- All vital power is used to lenghten/build/heal only one leg. Better/faster recovery expected (?).
- Less visible, less obvious (for all of us who prefer to keep LL as a secret).

Disadvantages:
- Twice longer time until the whole procedure is ready.
- Two times more visits in hospital/operations.
- Possibly higher cost.

Pros seem to outgrow cons. Has anybody tried or considered this solution?

[Omagadai]

When I read what you say. Make me think differently from you in some matters.

[Android]

You described unilateral lengthening; this idea exists, and it's being practiced.

We have several diaries of patients who chose this method, namely Dr. Monegal patients as that's his preference. Key in Japan is doing this with Precice as well, and this was Key's preference as he wanted to minimize downtime for work.

There's no question that unilateral lengthening will cost more, it's not just a possibility. You're doubling the number of surgeries, physical therapy sessions, hospital stay, medication, etc.

If you live far away from the doctor, you'll also double the time away from home during the distraction phase as well, as many doctors will prohibit you from leaving the area during this phase.

If you can afford that, I would instead ask the potential patient to consider bilateral Precice Stryde. Since it's fully weight-bearing, having one good leg is not as vital anymore since the risk of nail breakage is eliminated. Once and done with faster overall recovery and less costly.

[MirinHeight]

unilateral LL is also very beneficial when it comes to pulmonary and fat embolism.

I am thinking of doing unilateral external tibias using TSF frame spaced 1 month apart when I have enough money for the surgery.

[Prodigy610]

unilateral LL is also very beneficial when it comes to pulmonary and fat embolism.

I am thinking of doing unilateral external tibias using TSF frame spaced 1 month apart when I have enough money for the surgery.

Which do you think is better for 6cm of tibial lengthening if you had the money to afford both. 6cm externail tibia unilateral or 6cm precise stride with paley? Also unilateral. Also does anyone know if Paley offers or would accept a patient that prefers unilateral LL. Im sure he wouldnt have a problem if the money is there lol

[MirinHeight]

Which do you think is better for 6cm of tibial lengthening if you had the money to afford both. 6cm externail tibia unilateral or 6cm precise stride with paley? Also unilateral. Also does anyone know if Paley offers or would accept a patient that prefers unilateral LL. Im sure he wouldnt have a problem if the money is there lol

i asked dr paley before and he said it will be 20-30k more for unilateral internal surgery.

The least invasive surgical technique is pure external because there is no reaming of the bone. Reaming of the bone causes the emboli from the bone canal to leak out into pulmonary circulation.

Femurs also are more risky when it comes to fat embolism than tibias, confirmed by Dr. Paley (prob. due to the fact that tibias have less yellow bone marrow)

Also keep in mind fat embolism syndrome can arise from soft tissue injury. Internal femurs result in more soft tissue injury and bruising due to the reaming as well.

[MirinHeight]

furthermore young children have very low chances of developing fat embolism syndrome post fractures and orthopedic surgeries because they only have red marrow. After you are 20 years old, most of all the marrow in your bone is yellow marrow (composed of fat).

There have been recent studies done that show that you can reduce the fat in your bone canal by keeping your body fat low, have a healthy diet to increase bone density, and run 2-3 miles/day.

[MirinHeight]

keeping the cost and risks in mind, i would prefer to do unilateral external tibias surgery spread 1 month apart. but i would not go over 5 cm. I advise to not exceed 5 cm on tibias.

If you have the money, and you want more than 5 cm... unilateral internal femurs should be generally safe if your surgeon is very good and knows how to diagnose and quickly treat complications IF they arise. Fat embolism syndrome would be rare in unilateral LL cases. Also, my assumption/theory is it will also be less severe if it does arise than in bilateral internal femur cases

[..]

keeping the cost and risks in mind, i would prefer to do unilateral external tibias surgery spread 1 month apart. but i would not go over 5 cm. I advise to not exceed 5 cm on tibias.

If you have the money, and you want more than 5 cm... unilateral internal femurs should be generally safe if your surgeon is very good and knows how to diagnose and quickly treat complications IF they arise. Fat embolism syndrome would be rare in unilateral LL cases. Also, my assumption/theory is it will also be less severe if it does arise than in bilateral internal femur cases

MirinHeight, I am curious about your opinion on athletic recovery. How much do you expect to regain after 5cm tibia and 11cm both segments?

[(w)heel(s)]

You described unilateral lengthening (...) We have several diaries of patients

Thanks for the keyword, following some links for your all convenience:
Milko, Auron, crimsontide, yagen, U only live once, Four Inch, Antonio, aboali1022

There's no question that unilateral lengthening will cost more, it's not just a possibility.

For sure unilateral lenghtening will cost more, comparing to bilateral done in the same clinic. But unilateral with e.g. Dr. Solomin might cost less than bilateral with e.g. Dr. Paley. There are many options to consider, I would rather first decide on the method and then select the doctor.

You're doubling the number of surgeries, physical therapy sessions, hospital stay (...)  you'll also double the time away from home during distraction phase

Agree, but at this expense I can continue relatively normal life because of having only one leg affected. By relatively normal life I understand:
- Being able to move across the city (bus, tram, stairs) unsupported;
- Do the shopping, tidy house, take a shower (with crucial areas water-protected);
- Sail, gym, scooter, ping-pong, bow, canoe, golf, etc.;
- Drive an auto-shift car,
- Join parties, meetings, concerts;
- Go to the pub and complain to strangers about my leg broken after unlucky ski accident

If you can afford that, I would instead ask the potential patient to consider bilateral Precice Stryde. Since it's fully weight-bearing, having one good leg is not as vital anymore since the risk of nail breakage is eliminated. Once and done with faster overall recovery and less costly.

Please do not feel offended by what I will write right now, please also consider that I am not a specialist, definitely without any medical background, sharing just my personal opinion. I would also appreciate your criticism.

So...
I can't understand why internal nails are so widely preferred on this forum. Two most serious complications: fat embolism and knee damage (e.g. after inserting/removal surgeries) seem to be far more frequent in internal techniques.

Personally, under no circumstances will I let anybody touch any of my healthy joints with a scalpel.

These are ones of the most precious parts of my body, directly determining the quality of my life, and I will not compromise their safety for any shor-time benefit. Long bones are different, they can undergo much deformation/damage until it will start noticeably affecting my life. Therefore I will consider only external systems, even though the procedure is longer and less convenient.

Am I wrong in this approach?

[myloginacc]

It's a discussion to be had, wheels.

The most severe - I believe (also not a doctor) - form of complication more typical of external methods also isn't discussed much here. Osteomyelitis. I also don't have a quote at hand for it being more prevalent in external methods, but I do recall reading that.

I believe it is hard to treat if not caught early.

Here's an overview from pediatric external fixator cases. Full paper. Great for learning about pin-site care, but it also delves into osteomyelitis.

From prevention of pin-tract infection to treatment of osteomyelitis during paediatric external fixation.

(PMID:27848193 PMCID:PMC5145837)

Pin-tract infection (PTI) is the most commonly expected problem, or even an almost inevitable complication, when using external fixation. Left untreated, PTI will progress unavoidably, lead to mechanical pin loosening, and ultimately cause instability of the external fixator pin–bone construct. Thus, PTI remains a clinical challenge, specifically in cases of limb lengthening or deformity correction. Standardised pin site protocols which encompass an understanding of external fixator biomechanics and meticulous surgical technique during pin and wire insertion, postoperative pin site care and pin removal could limit the incidence of major infections and treatment failures. Here we discuss concepts regarding the epidemiology, physiopathology and microbiology of PTI in paediatric populations, as well as the clinical presentations, diagnosis, classification and treatment of these infections.

Some further reading that incorporates DO in the text, from 1996.
https://europepmc.org/abstract/MED/8948280
(Subscription required for the full text.)

[Great321]

interesting!

so the chance for PTI is higher with hybrid fixator (like pili's) than ring fixator (tsf) ?

[Android]

Ah, I thought you were considering unilateral internals. Which is why I recommended Stryde instead, because then the prices would be somewhat similar and justifiable.

I'm doing external tibias and femurs with doctors Solomin and Kulesh as we speak (diary link in signature), so I'm not entirely biased. That being said, I still place Precice Stryde at the pinnacle of limb lengthening methods for now.

But hey, if you've got the money and time, go for it! No question unilateral will be more comfortable. I'm just the type to think if I'm going to suffer, I'll suffer all the way to get it over with, but I know not everyone is like me.

I also quit my job to do this, so my priorities and requirements are different. But believe me, this journey itself is a full-time job itself, so do anticipate a drop in productivity either way.

[..]

Ah, I thought you were considering unilateral internals. Which is why I recommended Stryde instead, because then the prices would be somewhat similar and justifiable.

I'm doing external tibias and femurs with doctors Solomin and Kulesh as we speak (diary link in signature), so I'm not entirely biased. That being said, I still place Precice Stryde at the pinnacle of limb lengthening methods for now.

But hey, if you've got the money and time, go for it! No question unilateral will be more comfortable. I'm just the type to think if I'm going to suffer, I'll suffer all the way to get it over with, but I know not everyone is like me.

I also quit my job to do this, so my priorities and requirements are different. But believe me, this journey itself is a full-time job itself, so do anticipate a drop in productivity either way.

It's not just the suffering. What about life and death? Doing bilateral or worse quadrilateral means you have more chances to die.

[myloginacc]

It's not just the suffering. What about life and death? Doing bilateral or worse quadrilateral means you have more chances to die.

That all should be true, at least on a logical level. The problem is time.

The less pin-sites you have to care of, the more manageable they and their infections are (or should be). The point about your body not having to divide its resources, so it can heal one leg more efficiently might be true, too (we did discover different caloric intakes per bone break). The less bones you have to ream, the less emboli should get released into your bloodstream. Though, I'm pretty certain they still do get released just from fractures and osteotomies/corticotomies.

[myloginacc]

That all should be true, at least on a logical level. The problem is time.

The less pin-sites you have to care of, the more manageable they and their infections are (or should be). The point about your body not having to divide its resources, so it can heal one leg more efficiently might be true, too (we did discover different caloric intakes per bone break). The less bones you have to ream, the less emboli should get released into your bloodstream. Though, I'm pretty certain they still do get released just from fractures and osteotomies/corticotomies.

I was also thinking about my pin-site point in this post here. It certainly would be more manageable in terms of pin-site infections (half the pins/wires, half the locations for possible infection)... for that one leg.

However, I wonder if it'd really be better for the body to go for another huge dose of antibiotics when you finally get to the other leg? (If the interval between the surgeries was big... because you wanted to keep working, or something to that effect.)

There may be bacteria more common to the LL process (as one of the paper above indicates), and if some were hidden inside the other leg's bone, they could have, maybe, developed resistance to the antibiotics. That could become a huge problem when the external fixator on the final leg would allow them into other parts of the body. This is all layman theorizing by my part, though. It could be complete nonsense.

I'd say it's worth asking about, at least.

A question for a serious doctor, at least among those interested in unilateral lengthening followed by another lengthening in the more distant future.