Dr Franz Birkholtz (Pretoria, South Africa)

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Hi Dr. Franz,

can you please give us a list of credible research papers to read to understand the nature of LL? We've seen papers on outcomes of LL based on clinical examinations and statements made by patients, but is there more granular research that we should know of? For example, lesions in nerves, deterioration of muscles, effect on blood vessel diameter to name a few (from my non-medical head). I think that's the only way we undecided prospective CLL patients we can quantify the odds of a good outcome.

Also, a lot of published research is on animals. Is there a way to extrapolate the results to humans?

Thank you

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Quote from: 682 on March 19, 2017, 02:52:36 PMDr Birkholtz, somebody posted the comment below in another thread concerning yourself,

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

Hehe, responded in that thread. (Still chuckling, though!)

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Quote from: yyes on March 08, 2017, 04:12:28 PMDr 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?

I think cost and logistics aside, a combination of femoral internals and tibial externals in two phase is probably the best.

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Quote from: Body Builder on March 08, 2017, 05:07:58 PMDr 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.

I am sorry if I gave offence. It was not my intention.

My point was that a permanent equinus contracture is probably worse to live with than some weakening of the triceps surae (achilles).

It is difficult to judge lengthening during surgery.

As far as I am aware, the results of Achilles shortening surgery are not very good.

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Quote from: SAD on March 11, 2017, 02:13:05 PMHi 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?

No. Slight varus does not translate into poorer physical function. The only potential issue is degenerative changes in the long term.
Lengthening will almost always diminish your physical ability (even if slightly).

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Quote from: shanefu123 on March 11, 2017, 10:28:06 PMHi 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.

Hi,

Thanks for the kind words.

1. Yes, approximately 20-25% rate of knee pain in literature. This is probably lower with newer nailing techniques like suprapatellar nailing.

2. I do not perform exfix lenghtening for CLL on the femur. On the tibia the fixator stays on for 1.5-2 months per cm lengthened.

3. Bowleg correction is easy to do with a hexapod fixator like the TSF or TLHex, both of which I have vast experience in. This is best combined with the lengthening procedure.

4. External only tibia with bowleg correction is the cost of exfix only tibial lengthening as explained in the pdf brochure posted earlier in this thread.

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Quote from: jbc on March 13, 2017, 02:45:16 AMHi 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.?) Yes absolutely
- 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)? Normally not
- If a personal caretaker is still required, are such folks readily available in SA? Yes. Anything is available in SA (sometimes at a price ;-) )

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)? PT is essential in a good outcome. The physios can typically provide extra sessions during the week. Weekends would be difficult, but again, maybe two days rest out of every 5 of active PT is not a bad idea.

Many thanks in advance!!

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Quote from: onemorefoot on March 14, 2017, 10:12:23 PMIn case delayed consolidation, would you recommend the insertion of nails? Which is the common protocol here?

I am not sure I follow the question. Do you mean with exfix lengthening?

Then we tend to default to submuscular plating and frame removal.

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Quote from: SAD on March 19, 2017, 05:13:30 PMHi Dr. Franz,

can you please give us a list of credible research papers to read to understand the nature of LL? We've seen papers on outcomes of LL based on clinical examinations and statements made by patients, but is there more granular research that we should know of? For example, lesions in nerves, deterioration of muscles, effect on blood vessel diameter to name a few (from my non-medical head). I think that's the only way we undecided prospective CLL patients we can quantify the odds of a good outcome.

Also, a lot of published research is on animals. Is there a way to extrapolate the results to humans?

Thank you

Unfortunately literature on CLL is quite sparse and on lengthening in general also. Animal studies should not be extrapolated to humans generally.

There is good ongoing research on muscle and bone lengthening.

I understand that you want to undescore your decisions based on scientific evidence. As a scientist myself, I respect that desire. The sad truth is that no paper with quantify the risk in your individual case, as it depends on too many factors: genetics, surgeon, unforeseen complications, starting height, lengthening goals, lengthening techniques, physio etc etc. Very difficult to standardise these factors to study them scientifically.

Apologies for the fuzzy answer, though.

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Quote from: Franz on March 23, 2017, 09:04:39 PMI am sorry if I gave offence. It was not my intention.

My point was that a permanent equinus contracture is probably worse to live with than some weakening of the triceps surae (achilles).

It is difficult to judge lengthening during surgery.

As far as I am aware, the results of Achilles shortening surgery are not very good.
In the only study about AT shortening, the results were quite successful as all patients said they feeling their gait normal again and the push off power restored to more than 80% compared to the uninjured foot.

Do you know something else or have a personal experience that AT shortening surgery didn't work?

Thank you for your time dr Birkholz and your precious contribution on this forum.