Dr Franz Birkholtz (Pretoria, South Africa)

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Thank you for your responses so far 

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Oh okay, thanks .

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Hey, thanks for your time Dr. Birkholtz, this thread has been an interesting read.

If you know anything about other LL doctors and also don't mind sharing your thoughts on them, what are your opinions on Dr. Mitkovic in Nis, Serbia?

Also, what things do you usually recommend your patients do to prepare in the months leading up to the surgery? Stretches, exercises, diet, supplements?

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Greetings Dr Birkholtz. Primarily, I'd like to thanks your contributions to this thread in shedding light on certain hazy issues found within the limb lengthening world. It is refreshing to see a weighted opinion from a professional. If you may, would you please answer the following queries -

1) Is the placement of the break relevant in regards to recovery or even the look of the soft tissue surrounding it? For example, if one was to break and lengthen the center of the calf muscle vs just above the ankle.

2) I have noticed many issues with gait are often blamed on soft tissue. While this is an issue, I often think that minor misalignment may factor strongly into this, especially when viewing video footage where genu valgum (which I assume is different when the bone misaligns than simply being 'knock kneed') is present to some degree. Do you believe this is possible? Can genu valgum be corrected in its entirety an osteotomy or a 'guiding plate'? Can it be avoided in the current form of leg lengthening?

3) Soft tissue is one of the largest issues in regards to limb lengthening. Is there a medical consensus on why soft tissue doesn't adapt the same way it does during natural bone growth? We are all aware that after growth plates fuse no more growth can occur even under the same hormonal conditions but why does the same issue of growth of soft tissue occur where they technically have no 'end point' similar to plate fusion? Could one not accurately reproduce the hormonal conditions in soft tissue growth to mimic that found in natural growth? I believe I have read some studies that refer to issues with cell reproduction of soft tissue in regards to this.

4) A second question regarding soft tissue, after leg lengthening, does the body ever truly recover to the stretching even several years after combined with consistent physical therapy (if lengthened to reasonable standards rather than over lengthening leading to plastic deformation which I assume is permanent), creating new tissue as found in someone with legs of that natural length or does the body just adapt and become more flexible rather than truly recovering, with the soft tissue always being stretched to accommodate the new bone?

5) What are your thoughts on maintaining the ratio naturally found prior to leg lengthening? For example, lengthening both segments by 10% meaning they maintain the ratio or is falling in a biomechanically sound ratio just as acceptable?

6) Is there truly such thing as 100% recovery in regards to cosmetic leg lengthening when the soft tissue is stretched any amount reasonable or not or will it always limit maximum athletic potential even if its imperceptible?

7) What do you believe is the future of cosmetic leg lengthening? Personally, statistical evidence and measurements of patients would be the most important at this point. If I were to go forward with this surgery, I'd hope to do so in a decades time which by then I hope there have been improvements, with as much knowledge as possible and with a reputable surgeon such as yourself.

Thank you in advance for taking the time to read and hopefully reply to these questions. Regards.

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Quote from: Franz on February 08, 2017, 07:15:12 PMGood question. This differs from country to country. Ellipse was bought out by Nuvasive, so they now distribute globally. In South Africa the company sells their products through a distributor. On initial launch there was an intensive training programme. Even now we have a representative in theatre with every case. Most importantly to ensure that there is optimal safety and attention to detail. It facilitates communciation and eliminates errors. I see everyone in the surgical team as equally important. The surgeon is strengthened by the team around him or her.

I like this about Precice. There have been some problems with Fitbone and the representatives didn't come or came very late and patients had to have many surgeries like Helloworld and Musicmaker. In Penguinn's case with Precice everything was fixed during the initial surgery. Precice isn't perfect but it's the best one in the market.

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Quote from: Jack1066 on February 10, 2017, 12:54:09 PMHey, thanks for your time Dr. Birkholtz, this thread has been an interesting read.

If you know anything about other LL doctors and also don't mind sharing your thoughts on them, what are your opinions on Dr. Mitkovic in Nis, Serbia?

Also, what things do you usually recommend your patients do to prepare in the months leading up to the surgery? Stretches, exercises, diet, supplements?

I prefer not to comment on other doctors out of professional courtesy. It is certainly not up to me to evaluate whether a doctor is good or safe. I hope you understand.

I am a firm believer that the two most important preparations are flexibility and mindset. Improving flexibility and core strength is key. This is achieved through regular pilates or yoga, supplemented by a stretching programme.
Mindset is a little more difficult. I think regular sessions of meditation and/prayer (depending on your personal beliefs) will serve to calm and centre the spirit. This is needed to endure the sometimes brutal process that lies ahead.

Lastly a good balanced diet with ample amounts of protein and vegetables will provide the building blocks needed for recovery. Think of what you would ideally want to feed a healthy growing child.

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Dr Birkholtz,

Based off your experience would you be able to answer the following questions

1. How long does one have to stay in Africa before being able to travel back home

2. How long before someone makes a recovery. My definition of a recovery is the ability to walk without any help and the ability to walk completely normal without a limp of any kind.

This is assuming that the patient does internals.

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Quote from: 682 on February 10, 2017, 10:13:57 PMGreetings Dr Birkholtz. Primarily, I'd like to thanks your contributions to this thread in shedding light on certain hazy issues found within the limb lengthening world. It is refreshing to see a weighted opinion from a professional. If you may, would you please answer the following queries -

1) Is the placement of the break relevant in regards to recovery or even the look of the soft tissue surrounding it? For example, if one was to break and lengthen the center of the calf muscle vs just above the ankle.

Yes,absolutely. The choice of osteotomy site will determine the rate and quality of bone growth, as well as the final appearance of the limb. As a general rule, the preference in the femur is proximal. In the tibia we also prefer proximal as that creates the most reliable bone formation.

2) I have noticed many issues with gait are often blamed on soft tissue. While this is an issue, I often think that minor misalignment may factor strongly into this, especially when viewing video footage where genu valgum (which I assume is different when the bone misaligns than simply being 'knock kneed') is present to some degree. Do you believe this is possible? Can genu valgum be corrected in its entirety an osteotomy or a 'guiding plate'? Can it be avoided in the current form of leg lengthening?

Genu valgum is, as you rightly put, a knock-kneed alignment of the limb. It is accepted that the term applies to the more severe cases which would be pathological and may cause long-term issues like arthritis. It is possible to control for and prevent malalignment. With some techniques like Ilizarov only and Monolateral only techniques, it is easier to develop malalignments. The surgeon can usually pre-empt and treat this if they are experienced.

3) Soft tissue is one of the largest issues in regards to limb lengthening. Is there a medical consensus on why soft tissue doesn't adapt the same way it does during natural bone growth? We are all aware that after growth plates fuse no more growth can occur even under the same hormonal conditions but why does the same issue of growth of soft tissue occur where they technically have no 'end point' similar to plate fusion? Could one not accurately reproduce the hormonal conditions in soft tissue growth to mimic that found in natural growth? I believe I have read some studies that refer to issues with cell reproduction of soft tissue in regards to this.

The main difference in soft tissue adaptation to growth during normal growth vs CLL growth, is the rate at which it occurs. It seems like one of the ways that soft tissue adapts to growth is because of a constant distraction force which triggers gene expression and provides soft tissue growth. In normal growth, this rate of elongation is quite slow and as a result the tissues grow at the optimal rate and can 'keep up'. In limb lengthening we have to speed up the process because the bone will consolidate prematurely if we stretch too slowly. If we could drop distraction rates down to 0.1-0.3mm per day, we will probably have soft tissues that will adapt better. In addition there is probably some form of genetic trigger that switches off after normal adolescent growth, similar to a growth plate closing. Lastly, the predominant protein in soft tissue is collagen. It does become less supple as time goes on, and this is a result of aging. This causes more resistance to stretching as well.

4) A second question regarding soft tissue, after leg lengthening, does the body ever truly recover to the stretching even several years after combined with consistent physical therapy (if lengthened to reasonable standards rather than over lengthening leading to plastic deformation which I assume is permanent), creating new tissue as found in someone with legs of that natural length or does the body just adapt and become more flexible rather than truly recovering, with the soft tissue always being stretched to accommodate the new bone?

Although distraction histiogenesis does cause new tissue to form (ie grow properly), there is an element of elongation through stretching. One of the reasons why realistic lengthening goals should be borne in mind.

5) What are your thoughts on maintaining the ratio naturally found prior to leg lengthening? For example, lengthening both segments by 10% meaning they maintain the ratio or is falling in a biomechanically sound ratio just as acceptable?

As you know, the ration is around 80% and is probably best to try and maintain that as far as possible. Unfortunately logistics and money usually allows only one segment of lengthening, which means deviating from this ratio. For the majority of us, I do not believe that this will translate on its own into worse biomechanics and sporting function. If you happen to be at the top end of your sporting game, it may be different.

6) Is there truly such thing as 100% recovery in regards to cosmetic leg lengthening when the soft tissue is stretched any amount reasonable or not or will it always limit maximum athletic potential even if its imperceptible?

I think that with current technologies available, athletic potential is definitely affected regardless of lengthening amount. Whether it is noticeable in an individual would depend on factors like pre-op status, flexibility, genetics, lengthened amount, technique etc etc.

7) What do you believe is the future of cosmetic leg lengthening? Personally, statistical evidence and measurements of patients would be the most important at this point. If I were to go forward with this surgery, I'd hope to do so in a decades time which by then I hope there have been improvements, with as much knowledge as possible and with a reputable surgeon such as yourself.

I suspect we will very soon start meddling with growth genes during childhood and adolescence and be able to switch these on and off in patients with proven expected shorter stature. Would we be playing God?

Thank you in advance for taking the time to read and hopefully reply to these questions. Regards.

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Quote from: yyes on February 13, 2017, 01:59:28 PMDr Birkholtz,

Based off your experience would you be able to answer the following questions

1. How long does one have to stay in Africa before being able to travel back home

2. How long before someone makes a recovery. My definition of a recovery is the ability to walk without any help and the ability to walk completely normal without a limp of any kind.

This is assuming that the patient does internals.

For internal femurs it is recommended to stay in the area for around 90 days.
Weight bearing without crutches between 6 and 9 months. 'Full recovery' at 12-18 months.

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Thank you very much for your time and answers Dr Birkholtz, it's much appreciated.

QuoteIf we could drop distraction rates down to 0.1-0.3mm per day, we will probably have soft tissues that will adapt better.
Perhaps technology will advance to the point where some system can be put in place to stretch soft tissue prior to any surgery over the course of a year or so at a much slower rate meaning that the tissue will have been stretched at a much more reasonable speed and amount and be already be at the correct length for the increase in bone, delay union to lengthen at a slower rate (which would present it's own issues) or use stem cell/hormonal therapy to repair the damaged tissue. The future can't arrive soon enough.


QuoteWould we be playing God?
This all depends on perception I believe. In my opinion, no more so than being able to to switch off genetic signals that may result in disease or disability, of course one could argue that height itself is not in the same realm as those issues.