Dr Franz Birkholtz (Pretoria, South Africa)

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Morning Dr Franz

I have a question.. I did quadrilateral Limb Lengthening with monorail fixator, " it is  external only , no nail inside"
and right now I'm in the distraction phase, my callus is good according to my dr , but I want to speed up the consolidation time
so do you think if  I take  stem cell injection right now "in the distraction phase" will give me good result in term of  achieving  full consolidation in short time

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Dr. Franz, would you give us your opinion of which is better in terms of long-term complication rates: internal femurs or LON on tibias (assuming we lengthen 5-6 cm in each case)?

And what typically is the reason for non-union in LL patients? Could you look at a patient's X-Ray or do some tests to find out if he will have a non-union if he did LL?

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Quote from: Kilokahn on December 06, 2013, 12:48:40 AMWhen I sent an inquiry to another orthopedic surgeon about the use of PRECICE I was sent a word file talking about the advancements in cosmetic lengthening. Within it there was a section that addressed fibular complications.

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Fibular complications: With tibial lengthening the fibula has to be lengthened too. The implantable lengthening device only lengthens and fixes the tibia. The fibula has to be fixed to the tibia so that it lengthens together with it. If the fibula is not fixed or not fixed adequately it will not lengthen as much as the tibia and will lead to severe consequences including subluxation and arthritis of the ankle and flexion contracture of the knee. The method of fixation is critical. Many surgeons only fix the lower end of the fibula to the tibia. This can lead the fibula to prematurely consolidate and to pull down and dislocate from the tibia at its upper end. It is important to fix the fibula at both ends. With external fixation the fibula can be fixed with the wires of an external fixator. With implantable lengthening the fibula must be fixed with screws to the tibia; one screw at the upper end and one at the lower end. The angle, level, position, diameter, and type of screw are all important. E.g. a common mistake is to put the screw in horizontally between the two bones. This is not strong enough to prevent the fibula from pulling away from the tibia at the ankle. This is very subtle and even a few millimeters of difference in length of the fibula at the ankle lead to short term and/or long term consequences for the patient.
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I've seen many x-rays from other surgeons where the fibula is cut but it's not fixed to the tibia. There was an ongoing debate on that other site a while ago about how important fibula fixation really is. What is your opinion on the importance of the method of fixation of the fibula?

I am not sure who sent you this info, but it sure sounds like dr Paley! :-). I agree that the fibula should be managed appropriately during lower limb lenghening. Not everyone fixes both proximally and distally, and they get away with it, but again an experienced surgeon will address this appropriately.

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Quote from: Disobedient on December 06, 2013, 06:13:03 AMMorning Dr Franz

I have a question.. I did quadrilateral Limb Lengthening with monorail fixator, " it is  external only , no nail inside"
and right now I'm in the distraction phase, my callus is good according to my dr , but I want to speed up the consolidation time
so do you think if  I take  stem cell injection right now "in the distraction phase" will give me good result in term of  achieving  full consolidation in short time

If your callus (regenerate) is forming well, I would not bother with stem cells. We promote early weight bearing and non smoking to promote healing. (Even on monolaterals!)

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Quote from: short_and_depressed on December 06, 2013, 06:14:56 AMDr. Franz, would you give us your opinion of which is better in terms of long-term complication rates: internal femurs or LON on tibias (assuming we lengthen 5-6 cm in each case)?

And what typically is the reason for non-union in LL patients? Could you look at a patient's X-Ray or do some tests to find out if he will have a non-union if he did LL?


They are both pretty similar. LON tibias have a higher chance of ballerina foot and knee flexion contracture, but I allow early weight bearing.
Femoral nail lengthening has lower infection risk and lower risk of contractures but cannot start weight bearing early.
I wish we could predict who will get nonunions. We simply dont know. Good general health, not smoking and a surgeon comfortable with growing new bone are your best tools.

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Dr Franz,

I've read several diaries of lower limbs lengthening and in only in a very small minority did the two parts of the broken fibula bone end up aligned after consolidation. I find this very scary.

I looked up the Truelok after I read one of your posts about it and the images on the Orthofix website show that only one wire is passed through the fibula bone at the lower end.

Is it possible to maintain the fibula bones with their original alignment? Or is it pretty much left to luck?

If one does internal tibiae, is this goal of maintaining the original alignment of the fibula bones out of the question?

Thanks in advance.

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Quote from: Franz on December 06, 2013, 12:43:45 PMIf your callus (regenerate) is forming well, I would not bother with stem cells. We promote early weight bearing and non smoking to promote healing. (Even on monolaterals!)

the things is that I'm not allowed to stand.. so that's why I was thinking of the stem cell

thanks for replay Dr I really appreciate it

Also I have other question you mentioned earlier "During these weeks I teach the surgeons limb lengthening and reconstruction techniques. This includes surgeons from the US, UK, Sweden, UAE etc etc."

and since I'll be back home in the summer & in case if I'll  have any complication or so on I guess it is better to go with LL Dr who trained under you, so could you provide for me his name and his clinic details

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Quote from: Franz on December 06, 2013, 12:17:47 AMThanks for your questions. Lets get to them first. Small distances are safer, but end up being very expensive per cm! If youre really only looking for 3 each segment, one could shorten the times between top and bottom, but not before consolidation and full knee movement.

You may not like what I will tell you next, but as a doctor I have to.
Please think carefully about CLL. I do not think you are a candidate. The reason I say this is in your first paragraph where you state CLL will not be life changing. If it is not life changing, the potential risks are too high. In addition you are already at more than the target height most CLL patients dream of. Make up those 2-3 inches in personality and you will be much happier than with a CLL which may compromise your function for life...

My apologies if my response makes you angry! 

No, I'm not mad, I really aprecciate your honest answer.

I just have a final question:
You said you think I'm not a candidate but would you still perform this surgery on me, if I really wanted it?

Best regards,

ThePlague

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Dear Mr. Birkholtz,

Thank you so much for your participation on this forum! I was wondering if you would allow a patient to lengthen his femur one at a time? I understand that the Precise is not weight bearing, so to me it would make sense to do one femur and then the next using the Precise method. For a 5 CM gain I am sure it will take an entire year to complete, but would it perhaps enable a patient to work a desk job?

I was also wondering if you will use any other method of internal leg lengthening for femurs? I am considering pursuing this surgery with you primarily because of your active participation on this board.

Thank you,

Arche 

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I've got a question that I have been googling and havent been able to get a solid answer for.

My height is 155cm with an armspan of 158cm. If I were to follow Dr Franz's advice (which is to lengthen 5 (or 6?) cm in each part as a maximum), then I would be 165/167 cm with a 158cm armspan.


Would this be painfully obvious? Obviously not Apo level of obvious, but still very obvious?