How LL (inevitably?) misaligns joints, creates x-legs, and causes joint pain

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Nice one. Checkmate, OP.

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Well let's wait for the study. 

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As someone planning femur lengthening I want what Paley's saying to be true which seems to be that lengthening internal femur does not cause misalignment. However, why have other doctors been saying it does? Why have patients who were bow legged noticed change in their alignment after doing internal femurs if it supposedly doesn't alter anything? Does Paley have a deal going with Precise? This is fundamental geometry here lengthening along the anatomical axis would clearly shift the alignment. I look forward to reading his paper.

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My back is fked up someone made a post about that, I just dead ATG squats for 4 plates without proper form.  Hey if you LL you probably aren't doing worse for yourself then a power lifter + juice jus sayin.

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I don't think Dr. Paley was saying it doesn't cause a misalignment, but that whatever misalignment caused is a non-issue or won't cause premature arthritis like is thought. I'm eager to read his publication coming out though.

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Thanks again for contacting Dr. Paley, Sean. That was a helpful reply. It followed mostly along what I expected him to say: internal LL is faster, safer, more reliable, etc. But it's good to hear it direct from a guy with so much experience/expertise. I think he does have an arrangement with Precise. He installed the first Precise nails in existence, and I presume he's worked with them to create the device. He may even own some of the invention, though I really don't know and don't care too much. I trust Paley is saying what he truly believes. He seems like a very ethical man who is committed to getting the best results for his patients.

I've been thinking continually about all of this and I have a number of further thoughts.

Tibial Lengthening and the Anatomical Axis
I've looked at it in more detail, and it appears the angulation of the tibias in a healthy anatomically correct person are far more vertical than I was giving them credit for. For example, in this xray here, we see the tibias are practically perfectly vertical. The only abnormality to them is that they have a somewhat "S" shaped curvature. But from direct top to bottom it is virtually perfectly vertical. The femurs by contrast are on an approximately 7-9° angle.



Here's another interesting xray of a person with bow legs (perhaps much like YellowSpike was preop), which was fixed via a high tibial osteotomy. I find it interesting, because they probably could have gotten close to the same correction from an internal femur lengthening. But the point is, in the post op xray, the tibias are now almost perfectly vertical, as it seems they probably ought to have been. The femurs appear to be post op at approximately 5°.



The verticality of normal tibias is important because it means that well done internal tibias should properly preserve the anatomical axis of the hips/knees/ankles. It would therefore not be necessary to use Ilizarovs to keep the alignment.

I am fixated on maintaining alignment for a number of reasons which should be obvious but I'll touch on later. Internal tibias (for myself) may then be a favorable approach. Uppland, you say knee pain is a real possibility with internal tibias. The question is exactly why, and whether this is due to soft tissue pain which may resolve with physio or bone damage/deformity that is permanent. Further questions I want to answer include:

- How slow will an internal tibia be?
- Would an internal Guichet tibia be better than an internal Precise tibia, since Guichet is more weight bearing?
- How exactly is the rod drilled into the tibia? If it is inserted in any way that damages the articular surface of the tibia, that's going to be the fastest way to knee arthritis, so then this option becomes less appealing.
- Does the lack of a full nail through the fibula predispose the fibula to deformity during this procedure that could lead to ankle arthritis long term?

Internal vs External Femurs

I looked at Bluebarbie's thread and honestly I'm sorry to say I am horrified at what has been done to her. I think her thread is a perfect (unfortunate) example of why monorails shouldn't be used. The surgeons have installed the monorails on a massive angle in one of her legs, and now they have no way to correct this. They have told her "it will be fixed when the nail is inserted". But in the meantime she is developing bone callous which will start consolidating. There is no controlled or accurate way they will be able to fix this misalignment during the nailing process. What they are telling her makes no sense.

She's wealthy. If I was her, I'd be sending my xrays to Paley or Guichet and asking them what they can do to fix it ASAP, perhaps in this case via external Ilizarov. I don't mean to sound cynical or unsupportive but I think she looks like she's getting butchered, and if she doesn't do something soon she will regret it. I'm going to tell her that too.

Ilizarov externals have so many adjustable attachments to the bone it can shift the bone in almost any direction to correct misalignments like what Barbie's going through now. So for her now that might actually be a good corrective option.

But reviewing threads from people who have had them for primary lengthening in Russia, China, etc. I am beginning to understand better why the modern surgeons are less eager to rely on them. Bluecrimson in his thread was saying it can take up to 2 years to get back to "normal" from what he's seen.

They do seem to perform external femur Ilizarovs at the Ilizarov Scientific Centre in Russia. If I were to get Ilizarovs, I presume that's where I'd get them. But if the surgeons control the axis during such Ilizarovs by serial xray and approximation, it becomes such an almost artistic endeavor since it depends so much on the skill and attentiveness/awareness of the surgeon. That can be dangerous, which is probably part of why Paley doesn't want to touch them unless to correct deformity.


http://www.dailymail.co.uk/health/article-1039416/Tall-order-The-bizarre-Russian-clinic-offers-leg-lengthening-surgery-STAND-pain.html

Paley's Pending Study:
I agree with Sean that Paley's not saying the axis deviation doesn't happen. Rather, he's saying it's a "nonissue". Like everyone else, I am eager to see what he plans to publish to show this. I expect it will be reassuring. However, I don't think he will be able to truly prove that this deviation is is a nonissue. The Precise is too new a device. The only way to prove it's a nonissue would be to follow a cohort of Precise femur lengthened patients for 20 years and then show they don't have increased arthritis or knee pain rates. No one can do that though because the technique hasn't existed long enough.

What I'm guessing he's going to be publishing instead is a comparison of maybe 20 patients lengthened by tibial Ilizarov to 20 patients lengthened by internal Precise femur and show that the knee pain, stiffness, and range of motion is not significantly different between both groups after 1-2 years or so. That would be useful to see, but it still wouldn't completely put to rest concerns about the genu valgum deviation of internal femurs.

A genu valgum deformity/deviation will put increased stress on the lateral compartments of the knee and ankle. As  theuprising phrased it, this is again a matter of fundamental geometry. The only way to know what the long term effects are is to wait 20 years. But we shouldn't even need to do that. Most orthopedic surgeons can tell you that genu varum puts you at risk for medial compartment arthritis, and genu valgum puts you at risk for lateral compartment arthritis. I simply can't see a way around this. The weight bearing through the two knee compartments needs to be balanced to maintain the longest duration of joint health.



As I've said, I really want to be taller. But personally I'm not yet so desperate I'm willing to take the risk that an axis deviation could lead to knee/ankle/hip problems in the long run. Right now, I'm putting my hopes into the possibility of Guichet/Paley tibial internals. I'm looking into more detail at the operative techniques linked here:

http://ellipse-tech.com/precice-physicians/

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Quote from: Sean Connery on April 09, 2015, 09:02:54 PMI don't think Dr. Paley was saying it doesn't cause a misalignment, but that whatever misalignment caused is a non-issue or won't cause premature arthritis like is thought. I'm eager to read his publication coming out though.

I remember in my consultation with him he actually said that the mis alignment would fix my slight bow legs as a freebie.

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Quote from: programdude on April 10, 2015, 05:03:55 AMI remember in my consultation with him he actually said that the mis alignment would fix my slight bow legs as a freebie.

TRS could explain this better than me so if you're reading feel free to correct any details but I'll give it a shot. There is alignment issues not only from hip to knee but also from knee to ankle. In TRS case his femur lengthening resolved his hip to knee misalignment but he still had his bow leg issues which would have to be resolved through tibial realignment surgery.

What I'm saying is your bow legs will still exist it's that the femur lengthening pushed your knees together. The knee to ankle alignment will still be out.

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Quote from: maximize on April 10, 2015, 03:15:27 AM

Holy crap is that external bilateral femurs? I'd like to see her walking!

QuoteThe only way to prove it's a nonissue would be to follow a cohort of Precise femur lengthened patients for 20 years and then show they don't have increased arthritis or knee pain rates. No one can do that though because the technique hasn't existed long enough.

I think they call it 'argument from ignorance'. It has never been established that internal femoral lengthening does indeed cause knee arthrisis due to a lateral shift of the axis. But you're asking him to prove it wrong, when it's merely speculation.

QuoteThey have told her "it will be fixed when the nail is inserted". But in the meantime she is developing bone callous which will start consolidating. There is no controlled or accurate way they will be able to fix this misalignment during the nailing process. What they are telling her makes no sense.

The funny thing is that the misaligment she has developed is actually a 'good one', which follows her mechanical axis. So she can let it heal in that way and it will be OK. Though... on the right leg I'm afraid the valgus is too strong, so her feet will shift out instead. I too I'm wondering how they're going to insert the nail with such a misaligment. But could be they know something we don't.

QuoteMost orthopedic surgeons can tell you that genu varum puts you at risk for medial compartment arthritis, and genu valgum puts you at risk for lateral compartment arthritis. I simply can't see a way around this

The thing is, even when going for the 'max amounts', which I'd say is 7-8 cms, the lateral shift is quite small. You aren't going to develop a genu valgum or a 'knock knee' or 'x legs', because of a 7 mm lateral shift. To get something like on that picture you'll have to lengthen really a lot. The difference between pic 1 (normal) and pic 2 (genu valgum) is a whooping 15 degrees in tibia angle. Just imagine how much lengthening you'd need in your femurs to bring your tibias from 0 to 15 degrees. Though there's one thing I want to point out: the amount of later shift depends also on your femur angulation, females should expect a higher lateral shift.

Plus, any lateral shift that you'd get after internal femoral lengthening you could compensate by lengthening tibias externally and correcting them to a valgus. As your feet shift in when you lengthen femurs by anatomical axis, you shift them out with external tibias. Problem solved.

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Quote from: programdude on April 10, 2015, 05:03:55 AMI remember in my consultation with him he actually said that the mis alignment would fix my slight bow legs as a freebie.

I think those of you with bowlegs (genu varum) are lucky. You might be the only "ideal" candidates for internal femurs in terms of potentially improving rather than worsening the mechanical axis.

Quote from: theuprising on April 10, 2015, 05:48:43 AMThere is alignment issues not only from hip to knee but also from knee to ankle. In TRS case his femur lengthening resolved his hip to knee misalignment but he still had his bow leg issues which would have to be resolved through tibial realignment surgery.

What I'm saying is your bow legs will still exist it's that the femur lengthening pushed your knees together. The knee to ankle alignment will still be out.

If you have varus knees (bowlegged) but the horizontal plane of the knee and ankle are perfectly flat (horizontal) in this position, then pushing the knee inward will still tilt both of these planes on a slight angle like I showed in my earlier diagrams. On the plus side, the hip will now be more vertically aligned with the knee/ankle. Whether this is overall a plus or minus is hard to conceptualize. I think you'd have to look at all the exact details of an individual's particular planes/angles.

Quote from: exclide on April 10, 2015, 10:12:34 AMI think they call it 'argument from ignorance'. It has never been established that internal femoral lengthening does indeed cause knee arthrisis due to a lateral shift of the axis. But you're asking him to prove it wrong, when it's merely speculation.

As to whether this discussion is "argument from ignorance", I would strongly disagree. I will let some quotes from the following eMedicine article speak for me. If you like, the article has full journal references so you can see where they got their information from. It is a reputable medical reference site even among doctors.

Ref: http://emedicine.medscape.com/article/1251668-overview

"The anatomic axis of the lower extremity is defined by the femorotibial angle, which averages 5° of valgus."[/b] (ie. In normal people, there is a 5° femur angulation relative to the tibia.)

"During normal gait, adduction places force predominantly on the medial compartment.[4, 5, 6, 7, 8, 9, 10] For weight-bearing stresses to be shifted to the lateral tibial plateau of the knee requires the development of a valgus deformity." (ie. Usually walking stresses the medial compartment and that's usually where OA (osteoarthritis) develops. Almost the only time you will develop lateral compartment OA is when you have a valgus deformity.)

"Usually, a genu valgum deformity is the result of a dysplastic lateral femoral condyle that contributes to pathologic loading of the lateral compartment of the knee and subsequent bone and cartilage destruction. An experimental model has demonstrated that the mechanical overloading of a single compartment of the knee leads to degenerative change in that compartment.[16, 17, 18, 19, 20]" (ie. Too much pressure on the lateral compartment from a genu valgum puts the lateral compartment at risk for deterioration.)

****"A study by Khan et al in patients with early symptomatic knee osteoarthritis showed a clear relationship between local knee alignment — as determined from short fluoroscopically guided standing anteroposterior knee radiographs — and the compartmental pattern and severity of knee osteoarthritis. In this study, each degree of increase in the local varus angle was associated with a significantly increased risk of having predominantly medial compartment osteoarthritis, and a similar association was found between the valgus angulation and lateral compartment osteoarthritis in 47 knees.[14]"**** (ie. Every single degree of increased varus or valgus relative to normal alignment significantly increases your risk of OA. Varus misalignment increases medial compartment risk. Valgus misalignment increases lateral compartment risk.)

Messing with the angles of the knees/ankles is not a small matter. The mechanics can be very sensitive. But as said, fortunately, if you are starting with a good natural alignment, well done internal/LON/LATN/Ilizarov tibias should be able to almost completely avoid these problems. And if you are starting out varus (bowlegged), you may actually benefit from internal femurs.

Quote from: exclide on April 10, 2015, 10:12:34 AMThe funny thing is that the misaligment she has developed is actually a 'good one', which follows her mechanical axis. So she can let it heal in that way and it will be OK. Though... on the right leg I'm afraid the valgus is too strong, so her feet will shift out instead. I too I'm wondering how they're going to insert the nail with such a misaligment. But could be they know something we don't.

Given how many people have been crippled by shady and incompetent leg lengthening surgeries, it's possible, but I think the more likely explanation is unfortunately that they don't know what they're doing. She should seek the consult of an expert like Paley, Guichet, or the Russian Ilizarov Institute.

Quote from: exclide on April 10, 2015, 10:12:34 AMThe thing is, even when going for the 'max amounts', which I'd say is 7-8 cms, the lateral shift is quite small. You aren't going to develop a genu valgum or a 'knock knee' or 'x legs', because of a 7 mm lateral shift. To get something like on that picture you'll have to lengthen really a lot. The difference between pic 1 (normal) and pic 2 (genu valgum) is a whooping 15 degrees in tibia angle. Just imagine how much lengthening you'd need in your femurs to bring your tibias from 0 to 15 degrees.

Agreed, but that diagram is just exaggerated for illustration purposes. In real life as quoted above, every single degree of deviation counts.

Quote from: exclide on April 10, 2015, 10:12:34 AMThough there's one thing I want to point out: the amount of later shift depends also on your femur angulation, females should expect a higher lateral shift.

Very true, and that raises another interesting point: The degree of expected deviation from internal femur lengthening should be completely predictable based on preoperative radiographs and expected amount of lengthening. Based on the studies on how degrees of deviation predispose to OA, the risk of OA should also be predictable to some extent as well.