Dr Augustin Betz (Neunkirchen, Germany) The Betz Institute

Member

Posts: 221

Joined: May 2014

Posted on May 22, 2014, 8:58 pm

#41

Quote from: Augustin on April 09, 2014, 08:28:16 AM
Quote from: Augustin on April 09, 2014, 08:25:48 AMHello everybody,

I'm back again and I know that you waited a long time for my reply. But first of all I have to care for my patients. Above it took me a lot of time to answer and annotate all questions and thoughts.
I'm sorry to reply in this moment in German but I know also a lot of Germans are in the forum.
I will send the translation as soon as possible - I plan to do it before Easter days.
Here my reply in German concerning osteotomy:

Zur Technik der Osteotomie an Femur und Tibia:

Seit den Anfängen des Ilisarov-Verfahrens wird die Osteotomie von außen durchgeführt. Hierzu sind verschiedene Techniken beschrieben, die sich teilweise Bohrern, teilweise speziellen Meißeln oder der Kombination aus beidem bedienen. Ebenso sind oszillierende Sägen im Einsatz, die - um es vorweg zu nehmen – meines Erachtens für Verlängerungsosteotomien keine Anwendung finden sollten, da die hochfrequente Bewegung zu Hitzeschäden an den Schnittflächen neigt, was wiederum die Heilung stört, ggf. Infekte begünstigt; darüber hinaus bedarf der Einsatz einer oszillierenden Säge des weitaus größeren chirurgischen Zugangs.
Um die knöcherne Heilung, die Osteoregeneration, besser zu verstehen, bedarf es Kenntnissen zur Ernährung des Knochens: in dem Bereich, in dem wir die Verlängerungsosteotomie durchführen müssen, wird der Knochen sowohl vom Endost, d. h. vom intramedullären Gefäßsystem als auch vom Periost, d.h. dem um den Knochen herum befindlichen Gefäßsystem ernährt.
Große Bedeutung wurde daher seit Beginn des Ilisarov-Verfahrens dem Erhalt des intramedullären Gefäßsystems zugesprochen, da bei der Durchtrennung von außen regelmäßig das periostale Ernährungssystem mehr oder weniger kompromittiert wird. Es hat sich jedoch gezeigt, dass durch die von Ilisarov selbst propagierte Corticotomie, d.h. der reinen Durchtrennung der zirkulären Hartsubstanz des Knochens nicht nur das periostale Gefäßsystem in Mitleidenschaft gezogen wird, sondern auch das endostale, auch bei noch so minutiöser Corticotomie-Technik. Arbeiten von Brutscher und Brunner am Forschungsinstitut der AO (Arbeitsgemeinschaft für Osteosynthese) in Davos haben darüber hinaus nachgewiesen, dass selbst bei Zerstörung beider Gefäßsysteme, sowohl des inneren als auch des äußeren, die knöcherne Heilung erfolgt, jedoch mit erheblicher zeitlicher Verzögerung. Daher muss es unser Bestreben sein, möglichst ein Gefäßsystem zu erhalten.
Wenn also die Indikation zur Anwendung eines Fixateur externe gegeben ist, so macht es Sinn, den Knochen über eine kleine Inzision von außen mit den oben beschriebenen Techniken schonend zu durchtrennen.

Besteht die Indikation zur Anwendung eines Verlängerungsnagels – hierzu gibt es Gott sei Dank im Indikationsbereich der kosmetischen Verlängerung kaum noch Diskussion (seit über zwei Jahrzehnten habe ich mittlerweile erfolgreich versucht, den Sinn der intramedullären Verfahren zu predigen) liegt es ebenfalls nahe, eine Osteotomietechnik zu wählen, die so gering als irgend möglich eine Schädigung der Knochenernährung hervorruft.
Die Anwendung der Marknagelverfahren zur Stabilisierung von Schaftfrakturen an Oberschenkel, Unterschenkel und Oberarm haben uns seit über 6 Jahrzehnten immer wieder gezeigt, wie wichtig es ist, die Frakturreposition und die Stabilisierung indirekt, d.h. ohne Berührung der Frakturregion – durchzuführen. Je weniger wir bei der Versorgung die Frakturregion freigelegt haben, um so besser war unser Heilungsergebnis bezüglich Zeit und Knochenneubildung.
Exakt gleich verhält es sich bei den Verlängerungsosteotomien, die letztlich künstlich herbeigeführte Frakturen darstellen. Je schonender wir die Osteotomie durchführen, umso besser wird unser Heilungsergebnis sein, d.h. wir werden in kürzerer Zeit eine weitaus bessere Knochenneubildung erzielen können. Dies hat gravierenden Einfluss auf die gesamte Nachbehandlungsphase.

Lassen Sie mich daher noch mal zurückkommen auf die beiden Ernährungssysteme, sowohl von außen als auch von innen: bei Einbringung jeglicher Marknägel zerstören wir vorübergehend das intramedulläre Gefäßsystem. In der Folge erholt sich dieses Gefäßsystem wieder, braucht jedoch wertvolle Zeit. Daher muss es in unserem Bestreben sein, soweit irgend möglich das äußere, das sogenannte periostale Gefäßsystem zu erhalten. Hieraus resultiert, dass wir möglichst das periostale System nicht von außen berühren. Was ist also naheliegender, als die Osteotomie über den Kanal durchzuführen, der später für die Einbringung des Marknagels genutzt wird. Hierzu verwenden wir verschiedene Ausführungen der Innensäge. Diese Säge wird vor Einbringung des Marknagels in die Markhöhle eingebracht und durchtrennt sukzessive exakt die Anteile des Cortex (der zirkulären Knochenhartsubstanz) und zwar nur soweit, als es erforderlich ist, durch leichten Druck von außen gegen die Gliedmaße die Fraktur zu komplettieren. D.h. wir berühren in der Regel nicht das Periost. Dies gelingt uns in nahezu 100% der Fälle in schonendster Weise mit einer speziellen von Hand betriebenen Säge die uns jegliche Hitzeentwicklung und damit Störung der Knochenheilung verhindert. Auch haben wir in unserem Repertoire druckluftbetriebene und elektrisch betriebenen Innensägen, jedoch machen wir davon nur selten Gebrauch, da sie wie jede andere oszillierende Säge zur Hitzeentwicklung und damit zur Verbrennung im Bereich der Osteotomieflächen führen können. Lediglich im Bereich der vorderen Schienbeinkante machen wir gelegentlich von diesen oszillierenden Sägen Gebrauch: im Gegensatz zum Oberschenkel, wo die Markhöhle zentral angeordnet ist und die Corticalis annähernd ähnliche dcken zirkulär aufweist, liegt die Markhöhle im dreiecksförmigen Unterschenkelknochen exzentrisch auf der Dorsalseite. Dadurch ergibt sich auf der Ventralseite im Bereich der vorderen Schienbeinkante ein erheblich größerer Corticalisdurchmesser, der aufgrund der größeren Eindringtiefe gelegentlich vorteilhaft mit einer meiner speziellen oszillierenden Sägen komplettiert wird.
Ich weiß, dass die Innensägen nicht beliebt sind, weil sie vom Operateur besonderes Geschick und technisches Einfühlungsvermögen verlangen. Ich hoffe jedoch, dass meine Ausführungen zur Anatomie und Physiologie der Knochenernährung Ihnen zweifelsfrei den Sinn der Durchtrennung des Knochens von Innen in Verbindung mit einem Verlängerungsnagelverfahren zeigen konnten.

Now the last part of the translation: please feel free to contact me if you have any questions.

Cheers
Nader Maai

Now somethingabout the osteotomy of the femur and tibia.

Since the beginning of the Ilisaraov method the bone was cut from outside. Therefore different technique are discribed, may it be by using drills or special chisels or a combination of both. Oscillating saws are also in use – (in my opinion they shouldn’t be used for a lengthening osteotomy since the oscillating movement produces a lot of heat which impairs the healing or in some cases it may increase the risk of an infection, and furthermore the use of an oscillating saw requires a much bigger surgical approach)
In order to understand the bone healing, the so called osteoregneration, basic knowledge about the bone’s supply are required: The area in which we have to do the lengthening- osteotomy the bone is supplied from both, the endosteum ( the intramedullary vascular system) and the periosteum (the vascular system surrounding the bone)
Since the beginning of the Ilisarov procedure a great importance was awarded to the intramedullary vascular system. Because due to the cutting from outside regularly the periosteal supply of the bone was more or less comprimised.
However it has been shown that by even using the technique Ilisarov himselp propagated (the corticotomy where only the compact bone is circularly cut) not only the the periosteal but also the endoosteal supply gets impaired. But still the researchers Brutscher and Brunner (working at institute of Davos and concerned with osteosynthesis) have proven that even when the bone’s both supply systems are damaged, a regeneration can occur, it just requires then more time. Thus our goal must be to obtain both vascular systems.
So if there is an indication for using an external fixateur, it makes sense to cut the bone gently from outside with one of the above mentioned techniques.
Is there now an indication for the use of an intramedullary nail one still should try his best to maintain both vascular supply systems and thus choose an ideal cutting technique. Thank god there is no more discussion about the use of an intramedullary nail for a cosmetic lengthing (For two decades I’ve been now successfully preching about the advantage and significance of an intramedullary system).
6 decades of fracture repair with an intramedullary nail in lower or upper leg and in the upper arm have shown that the best way to reposition a fractured bone and to stabilize it, is the indirect approach, which means without touching the fractured area. The less we work on the fractured area the better the healing and the osteoregeneration process is.
The same implies for the lengthening osteotomy, since the cutting can actually be seen the same as a fracture. The more careful we cut the bone, the better the healing process will be and the faster the boneregeneration starts and this of course has a huge effect on the post-treatment care.
That’s why I want to mention again both the internal and external supply systems of the bone: When introducing any intramedullary nail into the marrow hole we destroy the intramedullary vascular system. Of course the vascular system will recover after a certain time, but this is valueable time. Knowing this our highest priority must be to maintanin the external supply system as sufficient as possible. Thus we do not touch the periosteal supply system from outside. So obviously the only reasonable way to cut the bone is from inside using the same pathway one needs anyway to insert the intramedullary nail. Therefore we use different types of intramedullary saws. These saws are inserted into the intramedullary hole (which needs to be opend anyway to insert the nail) and cut the bone from inside. This saw cuts the compact bone from inside to a point where just small pressure from outside is enough to break the bone. This means the periosteum doesn’t get touched. In almost 100% of our cases we are successful with this gentle method of cutting the bone and since we are using a manual intramedullary saw we also prevent heat production which as stated above also impairs the bone regeneration. Of course we also have electrical or air pressurized saws but we use them only rarely since they also produce a lot of heat which causes burns in the osteotomy region and thus slows down the healings process. We only use the oscillating saw sometimes in lower leg surgeries for cutting the tibia. In contrary to the femur, where the marrow hole is in the center of the bone, in the tibia the marrow whole is located more dorsaly. The tibia is also triangularly shaped which makes is harder to cut the ventral part of the bone. Using an oscillating saw is then very beneficial.
I know that the intermedullary saw is not popular, since the surgon using it requires a lot of skill and technical ability.
But still I hope that my explanation showed you how reasonable the use of an internal saw is regarding the anatomy and physiology of the bone. Especially if you use an intreamedullary nail.

Edit Post

Quote from: Augustin on April 09, 2014, 08:28:16 AM
Quote from: Augustin on April 09, 2014, 08:25:48 AMHello everybody,

I'm back again and I know that you waited a long time for my reply. But first of all I have to care for my patients. Above it took me a lot of time to answer and annotate all questions and thoughts.
I'm sorry to reply in this moment in German but I know also a lot of Germans are in the forum.
I will send the translation as soon as possible - I plan to do it before Easter days.
Here my reply in German concerning osteotomy:

Zur Technik der Osteotomie an Femur und Tibia:

Seit den Anfängen des Ilisarov-Verfahrens wird die Osteotomie von außen durchgeführt. Hierzu sind verschiedene Techniken beschrieben, die sich teilweise Bohrern, teilweise speziellen Meißeln oder der Kombination aus beidem bedienen. Ebenso sind oszillierende Sägen im Einsatz, die - um es vorweg zu nehmen – meines Erachtens für Verlängerungsosteotomien keine Anwendung finden sollten, da die hochfrequente Bewegung zu Hitzeschäden an den Schnittflächen neigt, was wiederum die Heilung stört, ggf. Infekte begünstigt; darüber hinaus bedarf der Einsatz einer oszillierenden Säge des weitaus größeren chirurgischen Zugangs.
Um die knöcherne Heilung, die Osteoregeneration, besser zu verstehen, bedarf es Kenntnissen zur Ernährung des Knochens: in dem Bereich, in dem wir die Verlängerungsosteotomie durchführen müssen, wird der Knochen sowohl vom Endost, d. h. vom intramedullären Gefäßsystem als auch vom Periost, d.h. dem um den Knochen herum befindlichen Gefäßsystem ernährt.
Große Bedeutung wurde daher seit Beginn des Ilisarov-Verfahrens dem Erhalt des intramedullären Gefäßsystems zugesprochen, da bei der Durchtrennung von außen regelmäßig das periostale Ernährungssystem mehr oder weniger kompromittiert wird. Es hat sich jedoch gezeigt, dass durch die von Ilisarov selbst propagierte Corticotomie, d.h. der reinen Durchtrennung der zirkulären Hartsubstanz des Knochens nicht nur das periostale Gefäßsystem in Mitleidenschaft gezogen wird, sondern auch das endostale, auch bei noch so minutiöser Corticotomie-Technik. Arbeiten von Brutscher und Brunner am Forschungsinstitut der AO (Arbeitsgemeinschaft für Osteosynthese) in Davos haben darüber hinaus nachgewiesen, dass selbst bei Zerstörung beider Gefäßsysteme, sowohl des inneren als auch des äußeren, die knöcherne Heilung erfolgt, jedoch mit erheblicher zeitlicher Verzögerung. Daher muss es unser Bestreben sein, möglichst ein Gefäßsystem zu erhalten.
Wenn also die Indikation zur Anwendung eines Fixateur externe gegeben ist, so macht es Sinn, den Knochen über eine kleine Inzision von außen mit den oben beschriebenen Techniken schonend zu durchtrennen.

Besteht die Indikation zur Anwendung eines Verlängerungsnagels – hierzu gibt es Gott sei Dank im Indikationsbereich der kosmetischen Verlängerung kaum noch Diskussion (seit über zwei Jahrzehnten habe ich mittlerweile erfolgreich versucht, den Sinn der intramedullären Verfahren zu predigen) liegt es ebenfalls nahe, eine Osteotomietechnik zu wählen, die so gering als irgend möglich eine Schädigung der Knochenernährung hervorruft.
Die Anwendung der Marknagelverfahren zur Stabilisierung von Schaftfrakturen an Oberschenkel, Unterschenkel und Oberarm haben uns seit über 6 Jahrzehnten immer wieder gezeigt, wie wichtig es ist, die Frakturreposition und die Stabilisierung indirekt, d.h. ohne Berührung der Frakturregion – durchzuführen. Je weniger wir bei der Versorgung die Frakturregion freigelegt haben, um so besser war unser Heilungsergebnis bezüglich Zeit und Knochenneubildung.
Exakt gleich verhält es sich bei den Verlängerungsosteotomien, die letztlich künstlich herbeigeführte Frakturen darstellen. Je schonender wir die Osteotomie durchführen, umso besser wird unser Heilungsergebnis sein, d.h. wir werden in kürzerer Zeit eine weitaus bessere Knochenneubildung erzielen können. Dies hat gravierenden Einfluss auf die gesamte Nachbehandlungsphase.

Lassen Sie mich daher noch mal zurückkommen auf die beiden Ernährungssysteme, sowohl von außen als auch von innen: bei Einbringung jeglicher Marknägel zerstören wir vorübergehend das intramedulläre Gefäßsystem. In der Folge erholt sich dieses Gefäßsystem wieder, braucht jedoch wertvolle Zeit. Daher muss es in unserem Bestreben sein, soweit irgend möglich das äußere, das sogenannte periostale Gefäßsystem zu erhalten. Hieraus resultiert, dass wir möglichst das periostale System nicht von außen berühren. Was ist also naheliegender, als die Osteotomie über den Kanal durchzuführen, der später für die Einbringung des Marknagels genutzt wird. Hierzu verwenden wir verschiedene Ausführungen der Innensäge. Diese Säge wird vor Einbringung des Marknagels in die Markhöhle eingebracht und durchtrennt sukzessive exakt die Anteile des Cortex (der zirkulären Knochenhartsubstanz) und zwar nur soweit, als es erforderlich ist, durch leichten Druck von außen gegen die Gliedmaße die Fraktur zu komplettieren. D.h. wir berühren in der Regel nicht das Periost. Dies gelingt uns in nahezu 100% der Fälle in schonendster Weise mit einer speziellen von Hand betriebenen Säge die uns jegliche Hitzeentwicklung und damit Störung der Knochenheilung verhindert. Auch haben wir in unserem Repertoire druckluftbetriebene und elektrisch betriebenen Innensägen, jedoch machen wir davon nur selten Gebrauch, da sie wie jede andere oszillierende Säge zur Hitzeentwicklung und damit zur Verbrennung im Bereich der Osteotomieflächen führen können. Lediglich im Bereich der vorderen Schienbeinkante machen wir gelegentlich von diesen oszillierenden Sägen Gebrauch: im Gegensatz zum Oberschenkel, wo die Markhöhle zentral angeordnet ist und die Corticalis annähernd ähnliche dcken zirkulär aufweist, liegt die Markhöhle im dreiecksförmigen Unterschenkelknochen exzentrisch auf der Dorsalseite. Dadurch ergibt sich auf der Ventralseite im Bereich der vorderen Schienbeinkante ein erheblich größerer Corticalisdurchmesser, der aufgrund der größeren Eindringtiefe gelegentlich vorteilhaft mit einer meiner speziellen oszillierenden Sägen komplettiert wird.
Ich weiß, dass die Innensägen nicht beliebt sind, weil sie vom Operateur besonderes Geschick und technisches Einfühlungsvermögen verlangen. Ich hoffe jedoch, dass meine Ausführungen zur Anatomie und Physiologie der Knochenernährung Ihnen zweifelsfrei den Sinn der Durchtrennung des Knochens von Innen in Verbindung mit einem Verlängerungsnagelverfahren zeigen konnten.

Now the last part of the translation: please feel free to contact me if you have any questions.

Cheers
Nader Maai

Now somethingabout the osteotomy of the femur and tibia.

Since the beginning of the Ilisaraov method the bone was cut from outside. Therefore different technique are discribed, may it be by using drills or special chisels or a combination of both. Oscillating saws are also in use – (in my opinion they shouldn’t be used for a lengthening osteotomy since the oscillating movement produces a lot of heat which impairs the healing or in some cases it may increase the risk of an infection, and furthermore the use of an oscillating saw requires a much bigger surgical approach)
In order to understand the bone healing, the so called osteoregneration, basic knowledge about the bone’s supply are required: The area in which we have to do the lengthening- osteotomy the bone is supplied from both, the endosteum ( the intramedullary vascular system) and the periosteum (the vascular system surrounding the bone)
Since the beginning of the Ilisarov procedure a great importance was awarded to the intramedullary vascular system. Because due to the cutting from outside regularly the periosteal supply of the bone was more or less comprimised.
However it has been shown that by even using the technique Ilisarov himselp propagated (the corticotomy where only the compact bone is circularly cut) not only the the periosteal but also the endoosteal supply gets impaired. But still the researchers Brutscher and Brunner (working at institute of Davos and concerned with osteosynthesis) have proven that even when the bone’s both supply systems are damaged, a regeneration can occur, it just requires then more time. Thus our goal must be to obtain both vascular systems.
So if there is an indication for using an external fixateur, it makes sense to cut the bone gently from outside with one of the above mentioned techniques.
Is there now an indication for the use of an intramedullary nail one still should try his best to maintain both vascular supply systems and thus choose an ideal cutting technique. Thank god there is no more discussion about the use of an intramedullary nail for a cosmetic lengthing (For two decades I’ve been now successfully preching about the advantage and significance of an intramedullary system).
6 decades of fracture repair with an intramedullary nail in lower or upper leg and in the upper arm have shown that the best way to reposition a fractured bone and to stabilize it, is the indirect approach, which means without touching the fractured area. The less we work on the fractured area the better the healing and the osteoregeneration process is.
The same implies for the lengthening osteotomy, since the cutting can actually be seen the same as a fracture. The more careful we cut the bone, the better the healing process will be and the faster the boneregeneration starts and this of course has a huge effect on the post-treatment care.
That’s why I want to mention again both the internal and external supply systems of the bone: When introducing any intramedullary nail into the marrow hole we destroy the intramedullary vascular system. Of course the vascular system will recover after a certain time, but this is valueable time. Knowing this our highest priority must be to maintanin the external supply system as sufficient as possible. Thus we do not touch the periosteal supply system from outside. So obviously the only reasonable way to cut the bone is from inside using the same pathway one needs anyway to insert the intramedullary nail. Therefore we use different types of intramedullary saws. These saws are inserted into the intramedullary hole (which needs to be opend anyway to insert the nail) and cut the bone from inside. This saw cuts the compact bone from inside to a point where just small pressure from outside is enough to break the bone. This means the periosteum doesn’t get touched. In almost 100% of our cases we are successful with this gentle method of cutting the bone and since we are using a manual intramedullary saw we also prevent heat production which as stated above also impairs the bone regeneration. Of course we also have electrical or air pressurized saws but we use them only rarely since they also produce a lot of heat which causes burns in the osteotomy region and thus slows down the healings process. We only use the oscillating saw sometimes in lower leg surgeries for cutting the tibia. In contrary to the femur, where the marrow hole is in the center of the bone, in the tibia the marrow whole is located more dorsaly. The tibia is also triangularly shaped which makes is harder to cut the ventral part of the bone. Using an oscillating saw is then very beneficial.
I know that the intermedullary saw is not popular, since the surgon using it requires a lot of skill and technical ability.
But still I hope that my explanation showed you how reasonable the use of an internal saw is regarding the anatomy and physiology of the bone. Especially if you use an intreamedullary nail.

Like (0)

C

Caribe

Member

Posts: 447

Joined: May 2014

Posted on May 23, 2014, 1:26 am

#42

Thank you Dr Betz for your time to explain us several important issues on LL operation and definitely the physiological principia makes sense. THis can help people realize why internal LL is safer and faster than external LL.
Iam wondering wether the corrosion problem on "the other nail" is referring to old albizzia, or also new Gnail would have also this disadvantage of not being corrosion-free.
Can anyone of the veteran members or ex LL patients remember a case of a problem due to corrosion on internal nail. Ive never read this complication mentioned before..

Best regards

Like (0)

M

MAN-OF-STEEL

Member

Posts: 216

Joined: Mar 2014

Posted on May 23, 2014, 5:14 am

#43

Many thanks for the excellent info and translating work!
It would be nice if this info is posted more prominently

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G

GP203

Member

Posts: 194

Joined: May 2014

Posted on May 28, 2014, 5:29 pm

#44

Quote from: Caribe on May 23, 2014, 01:26:41 AMThank you Dr Betz for your time to explain us several important issues on LL operation and definitely the physiological principia makes sense. THis can help people realize why internal LL is safer and faster than external LL.
Iam wondering wether the corrosion problem on "the other nail" is referring to old albizzia, or also new Gnail would have also this disadvantage of not being corrosion-free.
Can anyone of the veteran members or ex LL patients remember a case of a problem due to corrosion on internal nail. Ive never read this complication mentioned before..

Best regards

Dear Caribe
As stated above corrosion is an very big issue. All lengthening nails on the market which need a sealing can produce corrosion. Just to remind you what corrosion actually is: when the aggressiv body fluids get in contact with the internal parts of the nail they react with the internal parts and corrosion results which can produce an non bacertiel infection etc. Normally a type of surgical steal is used that is both easy to manufacture and as far as possible stable. The nail developer can not just take another material since different features are needed. The problem is this type of steal can produce corrosion. Of course there are other types which are corrosion free but these are very hard to manufacture and to modify and also very expensive. So far the Betzbone is the only nail which does not need any sealing because better material is used. Thus it does not produce corrosion.

Some may say the sealing used is very good but as soon as the telescopic mechanism starts automatically the sealing gets weakened and leaky.

I hope this answered your question

Nice regards

Nader Maai

Edit Post

Quote from: Caribe on May 23, 2014, 01:26:41 AMThank you Dr Betz for your time to explain us several important issues on LL operation and definitely the physiological principia makes sense. THis can help people realize why internal LL is safer and faster than external LL.
Iam wondering wether the corrosion problem on "the other nail" is referring to old albizzia, or also new Gnail would have also this disadvantage of not being corrosion-free.
Can anyone of the veteran members or ex LL patients remember a case of a problem due to corrosion on internal nail. Ive never read this complication mentioned before..

Best regards

Dear Caribe
As stated above corrosion is an very big issue. All lengthening nails on the market which need a sealing can produce corrosion. Just to remind you what corrosion actually is: when the aggressiv body fluids get in contact with the internal parts of the nail they react with the internal parts and corrosion results which can produce an non bacertiel infection etc. Normally a type of surgical steal is used that is both easy to manufacture and as far as possible stable. The nail developer can not just take another material since different features are needed. The problem is this type of steal can produce corrosion. Of course there are other types which are corrosion free but these are very hard to manufacture and to modify and also very expensive. So far the Betzbone is the only nail which does not need any sealing because better material is used. Thus it does not produce corrosion.

Some may say the sealing used is very good but as soon as the telescopic mechanism starts automatically the sealing gets weakened and leaky.

I hope this answered your question

Nice regards

Nader Maai

Like (0)

G

GP203

Member

Posts: 497

Joined: May 2014

Posted on May 28, 2014, 5:48 pm

#45

If you have further question I will be glad to help!

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M

MAN-OF-STEEL

Member

Posts: 475

Joined: Mar 2014

Posted on Jun 17, 2014, 2:41 am

#46

This is great info....so how can one really choose between Dr. Betz or Dr. Guichet???
It seems that many patients from Dr Guichet are able to walk without crutches barely 6-8 weeks after lenghthening 7cm and this without breaking screws or bending nails.
I would like to book with Dr. Betz, but screw breakage or longtime on crutches seems to be a dilemma. Could you please explain it to me so I can know more about Dr. Betz?

Many thanks

Like (0)

G

gettingtaller

Member

Posts: 399

Joined: May 2014

Posted on Jun 21, 2014, 8:52 am

#47

Quote from: MAN-OF-STEEL on June 17, 2014, 02:41:44 AMThis is great info....so how can one really choose between Dr. Betz or Dr. Guichet???
It seems that many patients from Dr Guichet are able to walk without crutches barely 6-8 weeks after lenghthening 7cm and this without breaking screws or bending nails.
I would like to book with Dr. Betz, but screw breakage or longtime on crutches seems to be a dilemma. Could you please explain it to me so I can know more about Dr. Betz?

Many thanks

This is not about the surgeon but more about the patient. If you have fast bone consolidation then you'll be waking without crutches in 6 weeks no matter which surgeon you use. Guichet has a reputation for recommending intense pre and post operative exercise and physio. I think this creates a 'perception' that you wil recover faster. From personal experience I don't think this is true. Every body is different, but most bodies just require some basic regular exercises during and after lengthening to get you off crutches faster eg IT band stretches, hip flexor stretches and crutch walking, biking to stimulate bins growth. Also, I think guichet's focus on making his patients spend a fortune at the isokinetic before and after the op is totally unnecessary. I did almost no preop preparation and nor did many of my ll friends and we're all recovering well - we just stay in top of our regular stretching and physio.

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H

hanshi

Member

Posts: 433

Joined: May 2014

Posted on Jun 29, 2014, 8:33 pm

#48

Dear Dr. Betz,

Thank you for joining this forum. With regard to your postings i do have a few questions which seem to be very important when doing LL with an internal method.

Quote from: Augustin on February 27, 2014, 11:13:06 PM
It is true that I had broken screws and also some broken nails. But why this happened? Did you ever ask what the patient did that he had a bent or broken nail? In most cases it was because of too much activity and too early maximum weight bearing in connection with a related osteoregeneration. In such a case every material becomes tired.

Quote from: GP203 on May 22, 2014, 08:44:07 PMMy lengthening device is a full weight bearing system, also a very big advantage over the other lengthing systems.

Hence the highest standard for a lengthening system used also for cosmetic purposes is the stability. My lengthening system is the only one on the market which can provide this standard!

a) Could you please explain the difference between full weight bearing and maximum weight bearing?

b) Are there any limitations in the weight bearing capacity of your system with regard to body weight?

c) Is the weight bearing capacity different between 11 and 13 mm nails? If yes, how much?

d) How much activity would be considered too much?

e) Except for too much activity and maximum weight bearing, what other reasons could there be for nails or screws breaking?

Looking forward to your reply.

Best regards

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GP203

Member

Posts: 93

Joined: May 2014

Posted on Jul 24, 2014, 12:52 pm

#49

Dear hanshi
I am really sorry I could not reply earlier since I was very busy at the university. I hope this clarifies everything.

a)   The difference between full weight bearing and maximum weight bearing is as follows. When we say that someone is allowed to do full weight bearing this means that they are allowed to walk carefully without crutches. They shall not carry anything heavy or stand on one leg for a long time. They shall also not jump or take 2,3 stairs at once. Or jumping down a wall or any other risky actions. You have to understand that when standing on one leg due to the leverage the forces do not just double but they get 7 times bigger. Thus we say that one should walk carefully. But still we recommend the crutches during the whole lengthening phase since the crutches help to better the walking performance. And of course crutches signal your environment to be careful.
Maximum weight bearing on the other hand means basically that the patients can behave as if they did not have any surgery. Thus the patients are allowed to do extreme sport activities (football, paragliding, alpine skiing etc.)
b)   Of course the lighter a patient is the easier the nail can handle the weight. The Betzbone is the most stable lengthening device on the market and as stated somewhere above due to the ingredients of our nail it is very hard to break. But in order to lengthen without any problems one should try not to be too obese. Another issue is that the surgery is easier and saver if the patient is not to heavy.
c)   Of course the bigger the diameter of the nail the more stable it is! This is due to basic physics. We always try to use the biggest possible nail, without destructing the marrow whole. Thus we have to watch for the anatomical realations. For about 70% of all nailing producers we use an 11mm diameter nail and so far we can happilly say that we do not experience such a big difference between the 11mm and 13mm diameter nail.
d)   Well this is hard to answer. I mean if you are exercising 8 hours a day and your body is handling everything fine then this is ok. It is really an individual issue. But please keep in mind that when exercising this much the human body also needs time to recover!
e)   Well as in every manufactured product there is a risk that the material is not perfectly processed but we check every part of nail separately and do a functional test during surgery. Another reason why screws may bend and eventually break is to fast uncontrolled movements. This is very rare. The biggest issue is actually when patients don’t have a proper bone healing and thus the nail experiences too much stress for a too long time and this might result in bending or even breaking.

I hope I could help.
Nice regards
Nader

Edit Post

Dear hanshi
I am really sorry I could not reply earlier since I was very busy at the university. I hope this clarifies everything.

a)   The difference between full weight bearing and maximum weight bearing is as follows. When we say that someone is allowed to do full weight bearing this means that they are allowed to walk carefully without crutches. They shall not carry anything heavy or stand on one leg for a long time. They shall also not jump or take 2,3 stairs at once. Or jumping down a wall or any other risky actions. You have to understand that when standing on one leg due to the leverage the forces do not just double but they get 7 times bigger. Thus we say that one should walk carefully. But still we recommend the crutches during the whole lengthening phase since the crutches help to better the walking performance. And of course crutches signal your environment to be careful.
Maximum weight bearing on the other hand means basically that the patients can behave as if they did not have any surgery. Thus the patients are allowed to do extreme sport activities (football, paragliding, alpine skiing etc.)
b)   Of course the lighter a patient is the easier the nail can handle the weight. The Betzbone is the most stable lengthening device on the market and as stated somewhere above due to the ingredients of our nail it is very hard to break. But in order to lengthen without any problems one should try not to be too obese. Another issue is that the surgery is easier and saver if the patient is not to heavy.
c)   Of course the bigger the diameter of the nail the more stable it is! This is due to basic physics. We always try to use the biggest possible nail, without destructing the marrow whole. Thus we have to watch for the anatomical realations. For about 70% of all nailing producers we use an 11mm diameter nail and so far we can happilly say that we do not experience such a big difference between the 11mm and 13mm diameter nail.
d)   Well this is hard to answer. I mean if you are exercising 8 hours a day and your body is handling everything fine then this is ok. It is really an individual issue. But please keep in mind that when exercising this much the human body also needs time to recover!
e)   Well as in every manufactured product there is a risk that the material is not perfectly processed but we check every part of nail separately and do a functional test during surgery. Another reason why screws may bend and eventually break is to fast uncontrolled movements. This is very rare. The biggest issue is actually when patients don’t have a proper bone healing and thus the nail experiences too much stress for a too long time and this might result in bending or even breaking.

I hope I could help.
Nice regards
Nader

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H

hanshi

Member

Posts: 152

Joined: May 2014

Posted on Jul 26, 2014, 8:28 pm

#50

Dear Mr.Nader,

Thank you for trying to answer my questions. Please tell me, are those answers your own or did you get them from Dr. Betz? I was looking for his answers. Anyway,

Quote from: GP203 on July 24, 2014, 12:52:00 PMDear hanshi
I am really sorry I could not reply earlier since I was very busy at the university. I hope this clarifies everything.

I'm afraid not much has been clarified yet.
Quote from: GP203 on July 24, 2014, 12:52:00 PM
a)   The difference between full weight bearing and maximum weight bearing is as follows. When we say that someone is allowed to do full weight bearing this means that they are allowed to walk carefully without crutches. They shall not carry anything heavy or stand on one leg for a long time. They shall also not jump or take 2,3 stairs at once. Or jumping down a wall or any other risky actions. You have to understand that when standing on one leg due to the leverage the forces do not just double but they get 7 times bigger. Thus we say that one should walk carefully. But still we recommend the crutches during the whole lengthening phase since the crutches help to better the walking performance. And of course crutches signal your environment to be careful.
Maximum weight bearing on the other hand means basically that the patients can behave as if they did not have any surgery. Thus the patients are allowed to do extreme sport activities (football, paragliding, alpine skiing etc.)

I don't know why you are using such crazy examples. Do you really want to suggest that the people who had broken screws and nails where jumping from walls or doing extreme sport? Also walking always implies standing on 1 leg. As far as i know that is exactly what is meant by full weight bearing. It means 1 leg carries the full body weight. Since Dr. Betz cites maximum weight bearing as main culprit for the breaking failures, he must have a specific definition in mind and actually also ought to tell the patients about it.
Quote from: GP203 on July 24, 2014, 12:52:00 PM
b)   Of course the lighter a patient is the easier the nail can handle the weight. The Betzbone is the most stable lengthening device on the market and as stated somewhere above due to the ingredients of our nail it is very hard to break. But in order to lengthen without any problems one should try not to be too obese. Another issue is that the surgery is easier and saver if the patient is not to heavy.

My question was very specific and could have been answered with yes or no. Dr. Paley e.g. writes on his website that the weight bearing capacity for the Precise2 with 12.5mm is 34kg per leg. Since you and Dr.Betz assert that your nail is much superior, you have to have some data to back-up your claim. Therefore please give us a figure.

Quote from: GP203 on July 24, 2014, 12:52:00 PM
c)   Of course the bigger the diameter of the nail the more stable it is! This is due to basic physics. We always try to use the biggest possible nail, without destructing the marrow whole. Thus we have to watch for the anatomical realations. For about 70% of all nailing producers we use an 11mm diameter nail and so far we can happilly say that we do not experience such a big difference between the 11mm and 13mm diameter nail.

Here again my question was very specific. If there is a difference in the weight bearing capacity between the nails, how much is it? You are supposed to have data about this. If you don't, this would mean you are just making live experiments with your patients. I don't understand what you mean with nailing producers please explain.

Quote from: GP203 on July 24, 2014, 12:52:00 PM
d)   Well this is hard to answer. I mean if you are exercising 8 hours a day and your body is handling everything fine then this is ok. It is really an individual issue. But please keep in mind that when exercising this much the human body also needs time to recover!

Dr. Betz wrote clearly that too much activity was one of the main reasons for breaking nails and screws. Therefore your answer cannot be right unless he was wrong.

Quote from: GP203 on July 24, 2014, 12:52:00 PM
e)   Well as in every manufactured product there is a risk that the material is not perfectly processed but we check every part of nail separately and do a functional test during surgery. Another reason why screws may bend and eventually break is to fast uncontrolled movements. This is very rare. The biggest issue is actually when patients don’t have a proper bone healing and thus the nail experiences too much stress for a too long time and this might result in bending or even breaking.

Since Dr. Betz is also the manufacturer of the nail he is responsible for the quality control from start to finish. Your functioning test is just a part of it and there is no excuse for bad quality. Those fast and uncontrolled movements are not included in maximum weight bearing? If not, they must be something very specific. Please explain.
Your last sentence again contradicts the statement from Dr. Betz since he said the main reason for breaking was maximum weight bearing and too much activity. Now you mention improper bone healing. How long does the nail last before it breaks i.e. how long is "too long time " as you say.
Please keep in mind, you both say that your nail is far superior to all the others while at the same time there seem to be many cases of breaking screws and nails. I am looking for a logical unambiguous explanation for this but so far i must say it is still outstanding.

Maybe you can ask the doctor for better answers?

Best regards

Hanshi

Edit Post

Dear Mr.Nader,

Thank you for trying to answer my questions. Please tell me, are those answers your own or did you get them from Dr. Betz? I was looking for his answers. Anyway,

Quote from: GP203 on July 24, 2014, 12:52:00 PMDear hanshi
I am really sorry I could not reply earlier since I was very busy at the university. I hope this clarifies everything.

I'm afraid not much has been clarified yet.
Quote from: GP203 on July 24, 2014, 12:52:00 PM
a)   The difference between full weight bearing and maximum weight bearing is as follows. When we say that someone is allowed to do full weight bearing this means that they are allowed to walk carefully without crutches. They shall not carry anything heavy or stand on one leg for a long time. They shall also not jump or take 2,3 stairs at once. Or jumping down a wall or any other risky actions. You have to understand that when standing on one leg due to the leverage the forces do not just double but they get 7 times bigger. Thus we say that one should walk carefully. But still we recommend the crutches during the whole lengthening phase since the crutches help to better the walking performance. And of course crutches signal your environment to be careful.
Maximum weight bearing on the other hand means basically that the patients can behave as if they did not have any surgery. Thus the patients are allowed to do extreme sport activities (football, paragliding, alpine skiing etc.)

I don't know why you are using such crazy examples. Do you really want to suggest that the people who had broken screws and nails where jumping from walls or doing extreme sport? Also walking always implies standing on 1 leg. As far as i know that is exactly what is meant by full weight bearing. It means 1 leg carries the full body weight. Since Dr. Betz cites maximum weight bearing as main culprit for the breaking failures, he must have a specific definition in mind and actually also ought to tell the patients about it.
Quote from: GP203 on July 24, 2014, 12:52:00 PM
b)   Of course the lighter a patient is the easier the nail can handle the weight. The Betzbone is the most stable lengthening device on the market and as stated somewhere above due to the ingredients of our nail it is very hard to break. But in order to lengthen without any problems one should try not to be too obese. Another issue is that the surgery is easier and saver if the patient is not to heavy.

My question was very specific and could have been answered with yes or no. Dr. Paley e.g. writes on his website that the weight bearing capacity for the Precise2 with 12.5mm is 34kg per leg. Since you and Dr.Betz assert that your nail is much superior, you have to have some data to back-up your claim. Therefore please give us a figure.

Quote from: GP203 on July 24, 2014, 12:52:00 PM
c)   Of course the bigger the diameter of the nail the more stable it is! This is due to basic physics. We always try to use the biggest possible nail, without destructing the marrow whole. Thus we have to watch for the anatomical realations. For about 70% of all nailing producers we use an 11mm diameter nail and so far we can happilly say that we do not experience such a big difference between the 11mm and 13mm diameter nail.

Here again my question was very specific. If there is a difference in the weight bearing capacity between the nails, how much is it? You are supposed to have data about this. If you don't, this would mean you are just making live experiments with your patients. I don't understand what you mean with nailing producers please explain.

Quote from: GP203 on July 24, 2014, 12:52:00 PM
d)   Well this is hard to answer. I mean if you are exercising 8 hours a day and your body is handling everything fine then this is ok. It is really an individual issue. But please keep in mind that when exercising this much the human body also needs time to recover!

Dr. Betz wrote clearly that too much activity was one of the main reasons for breaking nails and screws. Therefore your answer cannot be right unless he was wrong.

Quote from: GP203 on July 24, 2014, 12:52:00 PM
e)   Well as in every manufactured product there is a risk that the material is not perfectly processed but we check every part of nail separately and do a functional test during surgery. Another reason why screws may bend and eventually break is to fast uncontrolled movements. This is very rare. The biggest issue is actually when patients don’t have a proper bone healing and thus the nail experiences too much stress for a too long time and this might result in bending or even breaking.

Since Dr. Betz is also the manufacturer of the nail he is responsible for the quality control from start to finish. Your functioning test is just a part of it and there is no excuse for bad quality. Those fast and uncontrolled movements are not included in maximum weight bearing? If not, they must be something very specific. Please explain.
Your last sentence again contradicts the statement from Dr. Betz since he said the main reason for breaking was maximum weight bearing and too much activity. Now you mention improper bone healing. How long does the nail last before it breaks i.e. how long is "too long time " as you say.
Please keep in mind, you both say that your nail is far superior to all the others while at the same time there seem to be many cases of breaking screws and nails. I am looking for a logical unambiguous explanation for this but so far i must say it is still outstanding.

Maybe you can ask the doctor for better answers?

Best regards

Hanshi

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