Dr Alex Monegal (Barcelona, Spain) Clinica Diagonal

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Dear Kilokahn

I have been introduced to all sort of lengthening devices.  What made me decide for Fitbone Are several reasons.

1. Experience. Fitbone started in the 80's and more than 2300 procedures have been performed using the system. We Are Currently using 4th generation of implants.

2. Reliabilty of the system. There Are no failure of the implants. Electronic control gives the Patient an accurate control of the distance lengthened. You can see some issues from the group of Munster (Germany) in the following article http://informahealthcare.com/doi/full/10.3109/17453674.2014.913955

3. Triple correction. Whereas other implants Are just intramedullary devices, Fitbone is not exactly that. Implant is positioned in the bone according to a very exact pre-planning so you can achieve correction in length, torsion and allignment.

4. Instrument set. Special reamers and sleeves, allow to perform all kind of technical approach. Including suprapatellar for tibiae or parapatellar for retrograde femurs which prevents patellar tendon spreading and future anterior knee pain.

5. Management and handling. Control set unit is a small device and very easy to use. Magnetic system of the Precice nail is quite big, not as precise as the electric of the Fitbone, and more difficult to use.

6. Fitbone system has Also devices for limb reconstruction such as bone transport nails, lengthening prostheses or stum lengthening devices. This means that all users have the possibility to be trained in all kind of limb reconstruction procedures.

7. CEO. Stands for Centers of excellence. WITTENSTEIN selects and carefully trains the users, and choses clinics following a hight Standard and Medical equipment and quality. We do have users meetings every year sonWe can discuss cases, share experiences and improve our knowledge and techniques.

Kind regards

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Thanks alot for ur information, Dr.Monegal.

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Dear Dr. Monegal,
I have posted this question in another thread earlier but no one seemed to be able to give a decent answer to this.

From what I've read so far it's advised to stay as close to the 0,8\1 tiba\femur ratio as possible. What if you already have an almost perfect ratio (in my case, 390-460mm) and there is not enough space in either segment to get 7cm's.
Would it be adviseable to get the lengthening done in both segments but therefore in smaller amounts? 4\3,2cm's for instance.
Is there a benefit for the atheltic recovery if the biomechanical axes keep their initial ratio?
Many thanks in advance to your answer,
Cheers!

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Dear Alittletooshort

When lengthening there is always a modification of the mechanical axis due to lengthening.
It is very important to allign the limb and to predict How the axis of the limb will end-up at the end of lengthening. For that reason, and because the liver arm of the lengthened bone will be increased I think It is better to get the limb close to an ideal mechanical axis as much as possible.
I have seen plenty of deformities (tibia valga/femur varus) when lengthening with ex-fix or X shape limbs when doing antegrade internals on femurs. Tibia is not an issue most times. It is much more important to have an alligned leg rather than the lengthening itself.

On the other hand It is ideal to lengthen all 4 segments to keep the initial ratio. In some cases We can see a hypometry of femur or tibia and This leaves us the chance to lengthen only 1 segment and stay in a biomechanical safe ratio. In your case maybe 5 cm on tibiae + what you can get from limb allignment migth be good. But i would not recommend to go beyond that (in case you only consider to perform 1 segment only).
I always perform preop simulation of each case on x-rays and clinical pictures to figure out the best solution on each case.

Kind Regards

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Dear Dr Monegal,

- I think you've said previously that it is only possible to also perform alignment of the femur through Fitbone if it is entered through the knee. If the Fitbone nail is entered through the hip then it's very difficult to also do alignment in addition to lengthening. Is this correct?

- You've also said that there are techniques to avoid the patella tendon when doing the knee approach. But I'm curious about other parts of the knee also, like the contact surfaces between the femur and the tibia, the patellar surface and the lateral and medial condyles. When drilling through the knee, are these contact surfaces afected? Do they heal afterwards? Doesn't this bring problems in the future?

- If I do one full leg (tibia + femur simultaneously) through Fitbone, could I reach 10cm? When would I be able to come back and do the second leg? Would it be possible to also do aligment? Can this one full leg approach be done in one operation only and insert both Fitbone nails through the knee?

- When doing Fitbone in the tibias, how do you maintain the aligment and position of the smaller bone, the fibula? Are they also fixed to the tibia?

Thank you in advance for your answers and your participation in this forum.

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Thank you very much for your detailed and helpful answer!

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Dear Dingo

Yes It is correct. To perform correction in limb allignment It is much easier when doing retrograde nail. Antegrade is an option but It is not always possible due to femur curve and Also because of the femoral shape. I have seen some antegrade cases using other implants that end up with X shape legs due to lengthening along the mechanical axis which might cause This malalignment.

Lateral and medial condyles remain intact as the entry point is at the femoral notch which does not support any load. The reaming is performed theough special tubular sleeves so there is NO contact neither with femur/tibia and/or patella. Reaming is not an issue. I always try to avoid patellar tendon to prevent damage to It. I can go either parapatellar for femur or suprapatellar for tibia.

It can be performed simultaneous tibia/femur lengthening on the same leg and yes you can reach 10 cm. It is adviceable to addjust the lengthening pace and focus on PT and muscle stretching. When Doing This kind of procedures I do perform some soft tissue release (tenitomies) to reduce soft tissue stress. We Also perform limb allignment correction.

We do fix the fíbula to tibia distally with a screw. Some like Baumgart advice to fix Also proximal fíbula with a cannulated screw when lengthening goes beyond 4 cm in tibia

Kind regards

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Dr. Monegal these kinds of accusations are commonplace on most internet forums, I have also yet to see a thread with more than 10 pages that didn't have some sort of argument in it. Pay it no mind, surely you're a bigger man than to let some anonymous user keep you and your potential patients apart?

Anyway, I had a question: if the biomechanical angle changes due to femoral lengthening, could that cause back problems in the future?

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Thanks Uppland

Now talking about serious things, limb allignment can affect the distribution of the load at the main joints of the lower limbs. So This migth cause problems at hip, knee and ankle joints rather than in spine. One of the reasons It migth cause back pain could be the way It can affect the walking motion or even the slight LLD the malalignment migth cause.
Lower back pain is more usual when there is a significant limb length discrepancy which might alterate the body balance. It can appear Also due to tense or short Harmstring muscles after lengthening.

Regards.

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Thank you doctor. I know there's hardly any way for me to repay the favour you're doing us serious forum members from my laptop hundreds of miles away but if there is something just ask.

Also, is there any way to treat the back pain should it occur?

Finally, if you bear with me, would you say 7CM femoral lengthening is a reasonable goal for a person who is 179CM tall, I know this very much depends but if you had a spontaneous opinion?