Dr Franz Birkholtz (Pretoria, South Africa)

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Hi Dr.Fraz

I underwent limb lengthening in India and did 6.3 CM using LON in tibias.
It's been 8 months since first surgery and 5 months since frame removal. I have equinus in my right foot. I have been doing stretchings and physiotherapy daily. I don't see any improvement in ballerina. I thought of undergoing ATL surgery.
But, the experience of few patients who underwent ATL is bad. I am confused now.

I consulted couple of doctors too and some say I have to go for ATL to fix the issue.
One of doctor says, he will put fixator on me to correct the equinus foot. But, I spoke to one patient who also had fixator with Dr.Paley for correcting his Equinus. The patient says that the fixator fixed only like 60%. He says he still have tightness and he has to stretch it every morning. He is considering to go for another surgery if necessary to fix the equinus.

I heard from both the forums that ATL causes permanent weakness and even Dr. Paley says not to go for it. Few doctors say it is ok to go for it. There is one LL vetaran "Body Builder" who went for ATL and says not to go for it. His doctor seems to have over lengthened his tendon. Now, he is planning for another surgery to shorten it. He advises LL patient against ATL.

I have to take decision to go for either fixator (or) ATL.
Fixator:
It may not completly correct the issue. 2 surgeries again.
ATL:
It will correct the Equinus. But,  leaves tendon permanently weak.

Could you please give me your advise ?

Thanks in advance.

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Hope you are not having  very busy day , doctor:
In case of delayed consolidation what can be done?
some doctors say that ATL is not a good option becuase it has permanent bad effects on the tendon, but others say that is not wrong , in your opinion which position is more correct ?

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With regards to the two posts on Achilles tendon lengthening in this thread:

Achilles tendon lengthening is probably the best way to het rid of of improve a resistant ballerina foot. Correction with a frame post-CLL has a chance of recurrence. It is very useful for other indications of equinus contracture.

Equinus contracture after CLL can he devastating. Not performing TAL because of fear of weakening is nonsensical. If you remain with the contracture the function is nonexistent anyway.

My advice: get checked out by experienced surgeon and then follow their advice.

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Dr Birkholtz,

When it comes to the Safest procedure, in your opinion which one is it?

Initially I was under the impression that it was precise in the fémurs. Lately I have been seeing that the best option are externals not only for long term safety reasons but also for aesthetic and athletic reasons.

What are your feelings when it comes to these two methods?

Sometimes I know that doctors can have biases when it comes to their preferred methods but biases out of the way and considering aesthetic and athletic goals what is the best option for a patient?

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Quote from: Franz on March 08, 2017, 03:22:49 PMWith regards to the two posts on Achilles tendon lengthening in this thread:

Achilles tendon lengthening is probably the best way to het rid of of improve a resistant ballerina foot. Correction with a frame post-CLL has a chance of recurrence. It is very useful for other indications of equinus contracture.

Equinus contracture after CLL can he devastating. Not performing TAL because of fear of weakening is nonsensical. If you remain with the contracture the function is nonexistent anyway.

My advice: get checked out by experienced surgeon and then follow their advice.
Dr Birkholz.

I've done atl and i have a reduction of plantar flexion in my both feet but especially in the left one where I had more equinus and my tendon lengthened more.
Also, the tension is really bad and the feeling of walking is not as it used to be.
Also, from the most patients who did atl I heard about the same symptoms. So how can you say that the fear of weakening is nonsensical while I live with tis weakening every day after I did atl?
I am really asking about your opinion because you are a respectable doctor.

Finally on he other month I am planing to do an achilles tendon shortening surgery to get back most of the tension and the power I lost due to tendon lengthening.
Do you think that this new surgery won't improve my current situation?

Finally, isn't tendon overlengthening a very usual complication of atl? If yes (and thats what I think it happened with my case), how can a doctor be sure which length he should give to the achilles tendon after atl so as to not have a big loss of power and tension?
Because if there is no way to measure precisely what length you should give to the tendon then the risk of overlengthening is another one major reason to avoid atl in my opinion.

I would like to hear your opinion with much interest.

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Hi Dr. Franz,

It's quite well known that femur lengthening can correct varus deformity slightly. If a patient with a varus deformity undergoes femur lengthening and has no complications during lengthening, do you think he'll be better off physically than before surgery?

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Hi Dr Franz,

Thank you for being so active in the thread and community. I have learned a lot just by reading your answers to different patients here. However, I have a couple of questions that I couldn't find answers from your previous threads. It would be great if you could address my concerns and hopefully educate others as well.

1, I read around and hear other patients said that LON and LATN has higher rate of getting knees pain than doing external only, is that true?

2, I am 165 cm and thinking about lengthening 4cm on tibia and 5 cm on Femur. I am thinking of using external fixator only (Ilizarov Apparatus). Can I do both tibia and femur at the same time to reduce the total duration of the treatment? If so, how long will it take and what are the disadvantages of doing so? How long will the fixator stay on?

3, I have bow legs and I would like to correct my bow leg while doing the LL, will this an option and will this have a higher chance of complication than doing them separately?

4, I know you have the price mentioned earlier, but I just want to get the most updated figure. How much will it cost to do 4cm on tibia and 5 cm on Femur using external fixator only?

Thank you Dr Franz.

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Hi Dr. Birkholtz,

I continue to be grateful to you for being so thorough with your responses, and the time you are giving to inform this audience. I have two questions that relate to your specific practice:

In the literature Stadiometer posted here from you, there is a mention of a 7-day step down program from the hospital. I think this is a huge difference maker of your practice and approach to this procedure in relation to other Drs., and I'd like to expand on this a bit. Specifically:

- Is it essentially a transition period after the 4-5 day post-operative period so the patient can be more or less self-sufficient once they leave the hospital and go to whatever secondary lodging they choose (guesthouse, etc.?)
- If that is the case, do you believe a personal caretaker is required after the 7 day period (counting about 11-12 days total post surgery)?
- If a personal caretaker is still required, are such folks readily available in SA?

Additionally, I really believe in post-operative physical therapy. From a surgery I had for a sports-related injury, great PT made a huge difference in my recovery. If I wanted to purchase additional PT sessions, and/or do PT 7 days a week, would this be possible (or recommended by you)?

Many thanks in advance!!

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In case delayed consolidation, would you recommend the insertion of nails? Which is the common protocol here?

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Dr Birkholtz, somebody posted the comment below in another thread concerning yourself,

Quote from: jbc on March 18, 2017, 08:31:10 AMDr. Birkholtz (Orthopedic surgeon) should be able to clear this up. However, I continue to believe they're 2 different doctors. I do admit to this being a really strange coincidence, however, the qualification and graduation dates don't match. Their professional organizations (Association of Plastic and Reconstructive Surgeons of South Africa and Health Professions Council of South Africa, respectively) should be able to verify this as well.

In addition to that, I guess someone can just call the hospital where Dr. Birkholtz (Orthopedic Surgeon) works and ask

https://goo.gl/TL2Scs

First one (plastic surgeon):

I am a South African trained plastic and reconstructive surgeon, and a full member of the Association of Plastic and Reconstructive Surgeons of South Africa.

I completed my pregraduate studies at the University of Pretoria in 1992. I then worked for three years in Namibia, where I gained valuable surgical experience. It was during this time that I had the honour of working with Prof Alistair Lamont. He introduced me to the fascinating discipline of plastic and reconstructive surgery.

I started my plastic surgery training at the University of Pretoria in 1996 and completed my specialization in 2001. During this five year period, I had extensive exposure to and developed a keen interest in micro vascular reconstruction as well as cosmetic surgery.

I have been in full time private practice at the Kloof Medi Clinic in Pretoria since 2003. I am still involved at the Pretoria Academic Hospital on a session basis and have been a guest lecturer at the University of Zurich for the past two years.

The discipline of plastic and reconstructive surgery has its roots in the time of the great world wars. During this period surgeons had to develop and come up with ingenious methods of reconstructing all the disfigured soldiers. This is a far cry from the modern concept of plastic surgery being portrayed by Hollywood.

Second one (Orthopedic surgeon):

Dr Birkholtz qualified from the University of Pretoria as a medical doctor in 1997 and comes from a family of doctors. He started his post-graduate career in Orthopaedic Surgery in 2000. During his time as a registrar (resident), he created the Limb Reconstruction Unit at the Pretoria Academic Hospital (later Steve Biko Academic Hospital). During this time he developed his skills and understanding of the Ilizarov method and limb lengthening and reconstruction surgery in general. He also developed a keen interest in complex trauma. He qualified as an orthopaedic surgeon in 2006 and holds both the MMed (Orth) degree from the University of Pretoria and the FCOrth(SA) qualification from the College of Orthopaedic Surgeons of South Africa. He is fully registered with the Health Professions Council of South Africa. The private practice was started in 2006 and rapidly developed into a highly renowned practice both locally and internationally, especially catering for complex trauma and limb reconstruction cases. With the addition of Dr De Lange, the practice was turned into the Walk-A-Mile Centre and has continued to grow from strength to strength.

Could you please clarify to put to rest some of the more imaginative minds on this forum, thank you.