Dear participants.
I do not perform simultaneous femur and tibia as an elective treatment. I think that there has been some misunderstanding orround this debate. The only thing I say is I prefer to go for femur/tibia ain one leg and then proceed with the other one for 2 basic reasons:
1- Performing the reaming of both femurs is high risk of fat embolism syndrome. this was discussed at last Fitbone user meeting and Profeesor Baumgart said there have been cases in the past where patient died due to this unlikely event.
It s not a matter of being conservative, it s a matter of safety.
2- Having a healthy leg during lengthenning allows patients to preserve more mobility and autonomy during lengthening and consolidation phases. Fitbone device does not allow full weight-bearing, in case patient performs bilateral femur or tibiae, they should remain in a wheel chair with straight legs during the procedure.
One thing you guys must be aware of is that bone lenthenning was originally indicated in cases of limb length discrepancies. You must be aware of that some of the LL specialists don't even want to talk about Cosmetic procedures.
In most cases of congenital massive LLD ther is a femur/tibia combined deffect. In the early days of LL specialists were treating such defficiencies performing simultaneous femur/tibia using externals (not even performing LON). You can check it http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2328726/
My ideal of cosmetic is to perform 4 segments in 4 different procedures to stay safe, functional and proportioned. But of course there are 2 variables I cannot control: TIME and MONEY
Simultaneous femur and tibia is just an option which is valid and can be performed.
So just stop messing arround a stupid question like that because I don t think this is the Point of this forum.
Dr Alex Monegal (Barcelona, Spain) Clinica Diagonal
Hey Dr Monegal, what about the likelihood of knee pain when doing internal tibias?
What are your thoughts on that? Can it be avoided? Or is there no way around it?
Hi shorty
It can be avoided performing a suprapatellar approach for the insertion of the nail.
Like this you avoid to split patellar tendon and we can prevent knee pain.
This is very usefull specialy in thhose patients with patella baja.
Please i am not saying you avoid 100% knee pain because there is always stress in soft tissues while lenghtening. It s then when muscular stretching becomes relevant, but this approach is in my opinion a great way not to harm the tendon (main cause of recurrent knee pain when performing this procedures).
I wish that helps
I want to thank Dr Mongeal for his candor and those who participated to the thread. 
Dear Tom
Once again thank you for your words
I do not perform simultaneous femur and tibia as an elective treatment. I think that there has been some misunderstanding orround this debate. The only thing I say is I prefer to go for femur/tibia ain one leg rather than proceed with the bilateral for 2 basic reasons:
1- Performing the reaming of both femurs is high risk of fat embolism syndrome. this was discussed at last Fitbone user meeting and Profeesor Baumgart said there have been cases in the past where patient died due to this unlikely event.
It s not a matter of being conservative, it s a matter of safety.
2- Having a healthy leg during lengthenning allows patients to preserve more mobility and autonomy during lengthening and consolidation phases. Fitbone device does not allow full weight-bearing, in case patient performs bilateral femur or tibiae, they should remain in a wheel chair with straight legs during the procedure.
One thing you guys must be aware of is that bone lenthenning was originally indicated in cases of limb length discrepancies. You must be aware of that some of the LL specialists don't even want to talk about Cosmetic procedures.
In most cases of congenital massive LLD ther is a femur/tibia combined deffect. In the early days of LL specialists were treating such defficiencies performing simultaneous femur/tibia using externals (not even performing LON). You can check it http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2328726/
My ideal of cosmetic is to perform 4 segments in 4 different procedures to stay safe, functional and proportioned. But of course there are 2 variables I cannot control: TIME and MONEY
Simultaneous femur and tibia is just an option whisch is valid and can be performed.
Regarding your questions, please find the answers as follows:
1) Why are you prepared to do one leg surgery as opposed to bilateral surgery? .
Performing bilateral is high risk of fat embolism yndrome. We can do bilateral performing 1st one leg and the second one 3 weeks later...but as I told you patient will remain on a weelchair during lengthening and consolidation periods.
2) How long do you have to wait after distraction ends (consolidation phase) until you are strong enough to walk on the new leg so you can return to lengthen the other leg?
One of the reasons of performing first one leg is that keeping one leg fully functional, allows patients to walk on crutches from day 2 after surgery. Patients walk partially weight bearing (20 kg) on the operated leg from day 2.
Once lengthening is completed patients increase load 10 kg per week until they are able to fully weight-bear.
3) Where do you make the cuts on the femur and tibia?
It depends on each case. Fitbone technique can be done antegrade or retrograde in femur. So the osteotomy is 1,5 cm below lesser trochanter when doing antegrade/9-10 cm above knee joint for retrograde.
When performing tibia, osteotomy is approximately 7-8 cm below knee joint.
To prevent patelar tendon split, I recommend antegrade femur and suprapatellar approach for tibia.
SOmetimes this is not possible or adviceable. One of the particularities of the Reverse planning Method is that with the Fitbone technique we can also corrert malalignment. This is only possible in femur performing retrograde procedure.
A lot of concern has been the 'range of motion' because of the strain on the soft tissue surrounding the knee as the leg lengthens .Tell us your thoughts on the soft tissue issue with 1 leg surgery.
To prevent this we can do different surgical gestures
1- is approach (antegrade femur/Suprapatellar Tibia)
2- Tenotomies (adductors/Fascia Latta/Harmstrings
3- Pace of lengthenning (Not 1 mm + 1 mm) I recomend 1,5 mm/day in total.
4) How much can someone lengthen one leg in this procedure?
Implants allow to lengthen 8 cm in femur and 6 in tibia. This is a massive lengthening for an adult (kids are different)
I think that an initial goal of 4-6 or 4,5-5,5 (Tibia/Femur) is good enought. It is important to follow up the soft tissue/the bone creation and the ankle/knee rehab and progress during the procedure.
If everything is fine, there is always a chance to add some extra mm.
I hope everything was helpfull. Sorry for the misunderstanding out there.
Do believe me that I care for my patients and I want the best for them. I don t want them to suffer or to be in trouble.
The day this happens I will stop performing cosmetic procedures.
I write in the forum to help people out there. I want to be in touch with you guys to improve my understanding and to share with you thoughts and experiences.
, I had patients in the past insisting to go for simultaneous femur and tibia nd they ended up lengthening just one segment, and 6 cm later...they were happy and did not go for the whole lot.
Have a pleasent evening
Dr Alex Monegal
Notes:
The Doctor sticks by his guns that doing the femur /tib one leg is viable but he wont do it for simple cosmetic procedures. His goal is to talk us into doing the 4 segments in 4 different surgeries. However, he does prefer the femur/tib combo on one leg to bilateral surgery .
He conclusively puts to rest any concerns regarding lengthening, soft tissue wear and range of motion regarding the 1 leg procedure. Its too bad he insists on 1 segment only. 
My goals do not allow for flying to Spain for 4 different surgeries so I am going to have to pass . 
Quote from: TomD on December 27, 2014, 05:44:56 PMYou raised a good point. Yes he did. He indicated that someone my age would have no issues someone in their 20s would have, save for the rate of recovery. In other words, what you guys can lengthen at age 25 is the same I can, but you will on your feet much faster
7 cm + 7 cm on a single leg will be a tremendous feat I must admit, but if your set on 14 cm, then no harm aiming for it, it's not like it's set in stone.
Quote from: galaxy1 on December 28, 2014, 03:20:49 PM7 cm + 7 cm on a single leg will be a tremendous feat I must admit, but if your set on 14 cm, then no harm aiming for it, it's not like it's set in stone.
Thank you for the encouragement Galaxy. I want to be stubborn but not stupid. Therefore I am prepared to go for 6cm each segment (12) and then is everything is fine go for the extra 1 cm each segment.
Who knows? I may end up only doing 5cm if my legs cant hack it. I would be disappointed if I only did 5 but could live with it.
Quote from: TomD on December 28, 2014, 03:19:01 PM
Notes:
The Doctor sticks by his guns that doing the femur /tib one leg is viable but he wont do it for simple cosmetic procedures. His goal is to talk us into doing the 4 segments in 4 different surgeries. However, he does prefer the femur/tib combo on one leg to bilateral surgery .
He conclusively puts to rest any concerns regarding lengthening, soft tissue wear and range of motion regarding the 1 leg procedure. Its too bad he insists on 1 segment only.
My goals do not allow for flying to Spain for 4 different surgeries so I am going to have to pass .
Correct - he states single leg tib & femur is best suited for LLD (limb length discrepancy) patients, their physiology can handle single leg tib & femur method.
QuoteI do not perform simultaneous femur and tibia as an elective treatment.
The Doctor sticks by his guns that doing the femur /tib one leg is viable but he wont do it for simple cosmetic procedures
I hope everyone can realize that dr monegals opinion and mine are the same in this regard...............
600 posts later.................
I have always said it is a valid procedure but not equal to traditional methods. in any case I guess those here will say I am wrong even when me and monegal express the same opinion.
thank you for clearing this up dr monegal. I wish you a good xmass.
Dear all
In the mail I sent to Tom I wrote:
My ideal of cosmetic is to perform 4 segments in 4 different procedures to stay safe, functional and proportioned. But of course there are 2 variables I cannot control: TIME and MONEY
Simultaneous femur and tibia is just an option which is valid and can be performed..
Every patient is particular. That s why I introduce the non-controled variables time and money.
Performing 4 procedures It always takes longer and It s more expensive particularly for patients coming from other countries. That s why I always try to agree with them their best option and the most suitable treatment for each one.
Quote from: Dr Monegal on December 28, 2014, 04:23:08 PMDear all
In the mail I sent to Tom I wrote:
My ideal of cosmetic is to perform 4 segments in 4 different procedures to stay safe, functional and proportioned. But of course there are 2 variables I cannot control: TIME and MONEY
Simultaneous femur and tibia is just an option which is valid and can be performed..
Every patient is particular. That s why I introduce the non-controled variables time and money.
Performing 4 procedures It always takes longer and It s more expensive particularly for patients coming from other countries. That s why I always try to agree with them their best option and the most suitable treatment for each one.
Hi Doctor. I sent you an updated email with questions regarding the different options. Many of us may not want to go to Spain for 4 surgeries. Especially someone like myself who lives in the United States.
None of us feel 1 surgery for all 4 segments is something we want to pursue. However, if we insist on 2 surgeries only, what would you suggest?
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