I've been thinking about LL for a while now. In particular, I was thinking about going to see Dr. Guichet about getting a femur lengthening for 3". I was not worried by the cost or even time/difficult recovery. But what concerns me is the prospect of debilitating knee/ankle/foot pain for the rest of my life.
Looking at the biomechanics I have come to the conclusion that misalignment of the joints is possibly inevitable with leg lengthening. This is due to the fact that legs are not straight lines. Legs have a natural inward angulation to them. When we grow as children, our entire legs including all of the joints are remodeling with every step we take to keep the axes of our joints flat and functionally correct. This same process does not happen when you are an adult doing LL. By lengthening one segment in isolation, it throws off the entire structure.
Whether this is going to be significant or not in terms of pain or disability I'm sure will vary from one person to another. I'm sure some people could get this done and never really notice it, either because they aren't doing anything demanding, or maybe their prior alignment was very favorable to the misalignment so they don't notice it.
What I have decided is that as much as I'd like to be 3" taller, it's not a viable option for me unless there is a better technique or something I'm not thinking of.
I've attached a very (VERY) crude diagram to show what I mean. Basically what you see is that in the "before", as well as the "LL non weight bearing" pictures, the joint lines are perfectly horizontal, as they are meant to function. However, once LL has occurred, the only way to maintain normal feet spacing when weight bearing is to then abduct the legs (open them outwards) ie. "LL weight bearing", which then puts ALL the joint lines on angles.
These joints are not meant to function with their axes on these abnormal planes. This is the source of x-legs and I believe the chronic knee and ankle pain many people experience even years post LL once their short term contractures and soft tissue trauma are dealt with.
Opinions and further thoughts are very welcome. In particular I'm wondering if there are any LL procedures that can circumvent this issue. It seems inevitable to me. Further diagrams also would be nice if there is something I'm not thinking of. 
Thanks all for the great forum and all the wonderful discussion. Whether I can get LL or not, I've enjoyed and appreciated it all.
How LL (inevitably?) misaligns joints, creates x-legs, and causes joint pain
Quote from: Medium Drink Of Water on April 08, 2015, 04:11:43 AMYou can avoid this by lengthening tibiae instead of femurs. The tibia is a vertical bone so lengthening it doesn't change the angle of anything.
I was thinking about this as well. I think lengtehing the tibia reduces the risk of this problem because it is more vertical than the femur. But it is not 100% vertical either. As per my (again, crude) diagrams, the tibia/fibula have a slight inward angle too.
If I stand straight or bend my unoperated knees a bit with my feet naturally apart, my midline of my knees are clearly slightly lateral to the ankles.
ie.:
The theoretical advantage I wonder of doing tib/fib is that if you can control the lengthening in both segments, perhaps if you can lengthen the fibula more than the tibia, you can compensate for this a bit. But it will still throw off the mechanics again. And I understand tib/fib lengthening comes with it's own set of unique risks due to the more complex joint interactions at the knee/ankle. Furthermore, as in the xray below, the tibia can have some interesting natural curvatures to it. This means that the outcome in terms of angulation will vary largely on where it is nailed and where it is broken.
The only way I imagine to maintain full, normal mechanics at the knee and ankle would be to lengthen both the femur and the lower leg, and to somehow do the lengthening more on the outside than the inside of BOTH segments in proportion (which I think is impossible). This would then only throw off the hip a bit, but being a ball/socket joint, I think that would be fine. I can post a diagram to show later.
Quote from: theuprising on April 08, 2015, 06:50:59 AMThis has been discussed a few times on the forum, if you read the Dr Birkholtz thread he states this is the reason he doesn't like big lengthening's along the anatomical axis (femur). It is something that those who do LL have to take into consideration.
Thanks. I might have read that already. I'll look again.
Quote from: programdude on April 08, 2015, 05:11:55 AMGiven my muscle pain in my left leg that has proven hugely inconvenient. Permanent pains down the road are pretty scary prospects. That being said, the people who check back in and are fine seem to outweigh anyone who checks back in with horrible issues(and usually the latter are mysteriously under-documented).
I hope you do okay. To be clear I don't think this kind of tiny misalignment would usually cause "horrible issues". I think it would cause the kind of nagging stiffness and achiness that a lot of the diaries I've read seem to end with. This is the sort of stuff you take a tylenol for and keep going. It's sort of stuff most 65-70 year olds have to deal with due to wear and tear. But it's not the sort of stuff most 30 year olds need to worry about.
Quote from: SAD on April 08, 2015, 08:48:22 AMMaybe if you're bow legged to start, you'll end up ok.
Yeah, I was thinking this perhaps might be true as well.
I would love to hear what Dr. Guichet would have to say about this, since as I understand it, he is now the foremost and most reputable femur lengthener out there. Is anyone in contact or consult process with him that can ask?
As much as this concept of misalignment and x-legs (genu valgum) worries me, I still wish I could get the surgery. I guess one has to weigh how much the psychological pain of being short is relative to the physical pain of having possible chronic joint aches. I'm not sure how to weigh that now.
Also making it difficult to decide, you have the rare specimen like ShyShy who seems to have developed some mild x-legs but yet is functioning well with them. Here's his xray at 1" lengthening and you can already see it developing:
Here's his final picture and it's somewhat evident, but hard to fully judge in this posture:
I honestly don't know what to do with this realization. I will always dream to be taller. I may always wish to lengthen. We all have that drive. But would we regret it when our knees still ache 5-10 years from now?
I would say the solution is to stick to tibias. But tibias are on a slight angle too, so that's not going to stop this effect completely. Also, the complexity of tibia lengthening is greater, as you have to worry about the tibiofibular joints, and the articulation with the ankle which is a more complex joint than the knee/hip. Sometimes with tibias, people get abnormal rotation of the feet (intoeing, outtoeing), and a lot of the people that really get butchered seem to be tibial surgeries. Plus tibias are slower.
How do you guys feel about all of this? How does it affect your decision making process? What are the odds any of us will end up as functional as ShyShy once we too have some degree of x-legs (genu valgum) or intoeing/outtoeing?
I've read so many diaries and almost all of them seem to end with "my knees/ankles still get stiff and/or sore but I'm moving on with my life now so I'm not going to be posting further." What percent do you think tolerate this misalignment without any pain or discomfort at all?
The more I think about this issue the more distraught I become because I can think of no real good solution. 
Quote from: programdude on April 08, 2015, 05:44:10 PMThe best you can do is research the complications and weigh the risks. It comes down to how serious your height neurosis is. Remember theres worse things that can happen than joint pain too.
Yeah I know about the worst that can happen. Nonunions. Nerve damage. Avascular necrosis. Broken nails. But knowing that I'd be going with a top surgeon like Guichet if I did anything, I'm not really worried about that stuff. What bothers me mentally is the idea that even in a best case scenario I may not be able to avoid chronic joint pain, and that this is not going to be predictable. I don't have bowlegs. So my alignment would be worsened by going to x-legs.
For reference I found Dr. Birkholz's discussion on the mechanical axis here:
http://www.limblengtheningforum.com/index.php?topic=137.msg6963#msg6963
To quote the most relevant passage:
Question: "So your saying if anyone does 8cm on their femurs they WILL get knee pain and arthritis in the future?
Answer: "No, they will get a change in alignment. This may lead to knee pain and arthritis. It is very individual, but we cannot really predict who will and who wont."
I am thinking internal femurs may be not a good tradeoff. Yes they're faster and simpler. But even done perfectly, they create the greatest shift in mechanical axis.
I'm going to look a bit further into tibial. I see the Guichet and Precise nails can both be used in tibias, though I've never seen diaries with anyone getting either. Those seem like the best tibial options for those of us who don't want or can't afford a cage and wheelchair. Again I haven't found any diaries/experiences for either though. If anyone has any good links on the subjects I'd appreciate it.
I think femur is just going to be off the table for me. I want the height, speed, and ease, but not the inevitable misalignment. The best case scenario with femurs is still too risky. With tibias I'm worried by the stories I read of intoeing/outtoeing. But at least with tibias, theoretically if it's done well, the mechanical axis is almost perfectly preserved.
Things like ballerina ankle on tibial lengthening also don't worry me because it's a soft tissue issue which should eventually stretch out and resolve if you are young/healthy/diligent and do adequate pre-stretching. It's the bone misalignments that are most worrisome, because those are not physio-correctable. And the bone misalignments seem unavoidably greatest with internal femurs.
Overall, looking at the situation, I think I would rather take a few months extra and do internal tibias, even settling for a smaller growth, if it comes with a probability of less mechanical axis disruption. I expect I will eventually in a year or so be going for consults on this. I already know I will never be happy at my current height. I can raise these questions with the surgeons I'm looking at (Paley, Guichet) then. But that's a long time from now. If anyone is having any interactions with their respective surgeons before then and can see what they say, it could be helpful to a lot of us.
I wish there was some perfect solution. I wish we could all be tall and not have to take these giant risks. But in a way we're lucky because LL has never been more advanced or safer. We just have to do our homework now to find and pick the safest routes, since there are so many choices.
Thanks for the feedback, guys. Any other thoughts on all this would be very welcome.
Quote from: crimsontide on April 08, 2015, 06:33:14 PMi was going to post an x ray photo to show how my left leg looks... but u cant even upload a photo here
I use this free upload service with no account needed:
http://postimage.org/
Agreed though it's annoying you can't attach directly here since it means none of these photos will reliably be here in 5 years when someone else is looking to read this.
I'd love to see your xrays if you can post them there. Also please let us know how your joints feel. Hope you're doing okay enough.
Quote from: crimsontide on April 08, 2015, 06:44:01 PMif you look above, the front of my x ray looks like that... but only left leg
no aches, but getting leg fixed... its gotta be hurting my walking
This happened from external tibial extension for you? Did you ever ask your surgeon why they thought it might have occurred? I've read that the Chinese external tibial lengthening procedures allow you to control the medial vs lateral length of the tibia to try and avoid this kind of gross misalignment.
What do you think went wrong in your case? What is your surgeon offering you?
To add another example like ShyShy, here's Christopherbulder who had 7 cm femur lengthening by Guichet and says after 12 years he is "100%".
http://www.limblengtheningforum.com/index.php?topic=2046.36
It's hard to tell with all that muscle, but the alignment really does look good stationary:
Walking looks a bit peculiar, though that could possibly be just because he's so buff/bulky, rather than due to any misalignment:
I wonder if any of this (how bad the resulting misalignment will be) is predictable based on the angles of preop xrays? The femurs are just so fast and effective if there was any way to know you could get a result like this with good alignment it would still be the best option. Tibias are just so slow.
Okay. I just had a shower and after staring down at my legs for 20 minutes here's my final thoughts for now, as I have to get back to work.
This misalignment problem stems from lengthening the bones along their lengthwise axes ie. via internal implants. Internal implants offer numerous obvious benefits. In particular, they are fast, less prone to infection, and can often allow weightbearing. It is no wonder surgeons and patients find them preferrable. However, if the goal is to maintain the biomechanical axis of the legs, this is not the ideal method.
Under perfect circumstances, a more perfect result can theoretically be obtained via an external Ilizarov apparatus, since an Ilizarov can lengthen along a perfect perpendicular up-down plane to maintain the joint axes in their natural positions. Nothing is necessarily tilted with an Ilizarov, because it can function to affect change in almost any direction.
eg. With fractures:
http://www.llrs.org/images/004.JPG
Now obviously, there are downsides to Ilizarov. It is slow. It requires wheelchairs. Infection and scarring risks are high. Bone fractures/splintering can occur. And there have been a lot of people who have been butchered by crapty Ilizarov surgeons. Perhaps it is difficult to precisely control the direction of distraction with some of these devices? I'm not sure. A lot of people have gotten bent legs or broken nails out of Betz internals too.
At least theoretically, in terms of maintaining natural joint alignment, after everything we've discussed in this thread, Ilizarov seems to have the possibility of being a much better ideal outcome for someone starting with normal knee alignment. I would have to study the mechanics of the Ilizarov a bit better, but I think the outcome would depend largely on exactly how and at what angle the apparatus is fixed into the bone.
I'm curious what you guys think about this concept.
Quote from: exclide on April 08, 2015, 08:05:34 PMJeez, dude. Stop thinking so much into this. With such hypochondric attitude you should definitely forget about doing LL. The lateral shift is just about 1 mm per cm lengthened in femurs. There're no studies that actually show or conclude that it does indeed cause knee pain. And how does it even make sense? What about people who are naturally long-legged and have long femurs, do they all suffer from arthrisis? Because wouldn't it be the same, as if someone short-legged lengthened their legs (femurs)?
No it is not the same. That's the whole point of the diagram. As I said, when you grow naturally, your growth plates shift to compensate for your growth when weight bearing so that your hinge joints (knees/ankles) will remain parallel to the ground.
This does not happen in leg lengthening because we no longer have growth plates.
I don't think analyzing the risks and benefits of a $80,000-100,000 operation that requires up to 1 year off work being a "hypochondriac". I think it is stupid not to think about all this, when there are so many choices and options out there. And when this is purely cosmetic.
For anyone who actually finds this discussion or these concepts interesting, I've updated my diagram with the Ilizarov. As you can see, at least theoretically, it does offer the advantage of maintaining perfect biomechanical axis. By comparison, all internal lengthening devices will throw off the axis (by definition) to some extent unless you have a favorable (varus) misalignment to begin with.
See next post.
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