Q & A With Dr Franz Birkholtz

Everyone,

I have been emailing with Dr. Birkholtz and he's answered a ton of questions I've thrown at him.  I'm really impressed with the answers he's given so far, and I'll paste his responses here in no particular order.  I AM NOT being paid to promote him, or have any deal with him whatsoever- one of the answers he gives even shows he is against doing this sort of practice.


How many cases of Cosmetic Leg Lengthening have you done?
I perform legengthenings for non-cosmetic reasons all the time (appprox 100-200 per year), and am comfortable with distraction osteogenesis as a technique. I arranged to have Precice brought into our country recently, and because I believe that standard exfix techniques have a risk profile too high for CLL, we've not done many CLLs. In fact only 2, one LON tibia (6cm) and one bilat LRS femurs (5cm limited due to knee stiffness). With Precice I believe we can now safely offer CLL widely.

What were the outcomes of the 2 CLL surgeries you did?
My 2 CLLs: LON tibias 6 cm and very happy. femoral LRS, frames came off recently, so too soon to tell.

How much would it cost for bilateral femur lengthening using PRECICE?  What would this pricing include?
Pricing for CLL in our unit is 40K euro for bilat femoral Precice. This includes everything except complications, incl meals and accommodation for 4 weeks. (See forum for details).  Physio is included and they will provide you with a home programme.

How much does PRECICE removal cost?  What about PRECICE nail replacement?
Ballpark figure for Precice removal would be around 4K euro. Should a precice have to be replaced it would cost approx 15K.

How much is a consultation?  Would it be possible to send you x-rays and then consult with you over a skype call instead of flying out to SA for only a consultation?
I will not charge you anything for an email or skype consultation. We will definitely need to see xrays for measurement purposes. These should be done according to a standardised protocol which we can send through via email.

There has been a long ongoing debate in our forums of the healing time of PRECICE vs. Betzbone, Albizzia, etc.  Some arguments against PRECICE are the lack of weight-bearing it provides, which will slow down healing because you will most likely be confined to a wheelchair.  Some arguments against the Betzbone is the twisting motion of the rod, which seems to affect consolidation as well.  What is your take on this?  Which do you recommend more?
I think the controllability of the Precice is its key feature. I bieve that with IM nail lengthenings weight bearing is less important than the quality of the osteotomy in providing good regenerate. For this reason I think Precice is the superior product.

Do you work on minimizing scars?
We always operate in such a way as to minimize scars (subcut sutures where possible etc).

How do you prevent ballerina feet that usually comes from tibial lengthening?
Ballerina foot is a euphemistic term for a serious complication of equinus contracture. We have developed special orthotic devices to prevent this. Sometimes we include the foot into the exfix frame and occasionally we perform a percutaneous tendon achilles lengthening upon frame removal to correct this.

Do you have any pictures of your guesthouses I could look at?
Guesthouse price quoted is for a guest room next to the hospital in the office building where my office is situated. Of course accommodation in the area varies somewhat in terms of price and quality. My suggestion would be to use the rooms initially until a bit more mobile (4 wks incl in price) and then spend a couple more weeks in a local hotel or guesthouse with more amenities. The Centurion Hotel may work well for this. You can find them via Forever Resorts SA. This would be approx 100 euro per day for bed and breakfast.

Would it be possible to work out a discount from promoting your services on several different forums at all? sorry guys, I had to ask! 
Wrt endorsements diaries etc, I think we should be careful about linking endorsements to monetary value. I know other surgeons do that, but ethically I would prefer for my patients to endorse me(or criticize me) independently!

Dr Birkholtz, I'm curious to know whether you prefer LON or LATN for combination internal/external methods. Would you say one is "better" than the other for most cases?

Quote from: Kilokahn on November 25, 2013, 02:56:18 AMDr Birkholtz, I'm curious to know whether you prefer LON or LATN for combination internal/external methods. Would you say one is "better" than the other for most cases?

Something I want to know as well!  I know Dr. Donghoon Lee prefers LATN according to this post by Walk6 in his diary: "it offers a much quicker recovery time post-frame removal. He informed me that while the frames would stay on for a bit longer during LATN than LON, because there is no nail implanted during the actual lengthening and fixation process, the bone would be much stronger after the fixators are removed and hence recovery would be noticeably smoother for LATN.

Quote from: BilateralDamage on November 25, 2013, 04:09:15 AMSomething I want to know as well!  I know Dr. Donghoon Lee prefers LATN according to this post by Walk6 in his diary: "it offers a much quicker recovery time post-frame removal. He informed me that while the frames would stay on for a bit longer during LATN than LON, because there is no nail implanted during the actual lengthening and fixation process, the bone would be much stronger after the fixators are removed and hence recovery would be noticeably smoother for LATN.

I think the two methods both work well. It needs to be done properly though. I would choose the surgeon and then go with the technique he or she advises.

Dr Franz, and about the reaming, it creates an unnatural hole where the bone marrow should be, correct?
What happens to this after the rods are removed? Will the inner cavity created, not get filled up?
Is this not an issue either?

Quote from: short_and_depressed on December 03, 2013, 11:26:57 AMDr Franz, and about the reaming, it creates an unnatural hole where the bone marrow should be, correct?
What happens to this after the rods are removed? Will the inner cavity created, not get filled up?
Is this not an issue either?

Hi there, again a good question.
In adults the long bones have very little functioning (blood-forming) marrow left, and it is basically a fat-filled cavity. Whereas this fat is not so important, what is important is that there are blood vessels that feed the bone itself in this cavity. Of course when we ream and stick a nail in there, it destroys some of the blood vessels. Hence some of the complications like delayed and non-unions we sometimes see with intramedullary nails. Once the nails are removed, the endosteal (marrow cavity surface) blood vessels are restored somewhat.
All of this is uncanny, but does not seem to translate into significant complications or problems in most individuals.
The more important potential risk involved with reaming is that of fat embolism. This is where fat is displaced into the blood stream during reaming and can cause significant respiratory problems. There are techniques to reduce this risk. Discuss this with your doctor, and if he does not know how to do this, look elsewhere. This complication can be fatal in rare instances.
The idea is not to scare you, but to give you as much info as you need to make safe decisions...
Hope this helps!
Warm regards.

Hi Dr Franz ,
I recently did LL with LON  on my tibia.. during my distraction phase i had swelling for almost 3 months on my left leg. The reason for the swelling was that my frame was installed on my left leg in a way that my calf  was pressed from below as i always use to put my leg on a soft pillow. So , calf is like a second heart that pumps blood for blood circulation and since my calf was pressed most of the time the swelling didnt went away ..

The problem is that any technique has its limitations and potential complications. It is important to have a surgeon who can prevent and manage complications well.
My adult patients spend around one and a half months per cm of length in a frame. In other words between six and nine months for 5 cms. This is a long frame time. I would not advocate this for femurs, as the risk of knee stiffness is very high.
For tibias ilizarov/Truelok/TSF frames work well and we encourage early full weight bearing on the frames.
The long frame times make LON and LATN attractive.
Apart from the reaming and potential infection risks, tibial nails have around a 50% chance of persistent knee pain. Only half of these patients improve when nails are removed.

What i mean to say is that i had swelling for 3 months on my left leg during LL through LON . Now its almost 9 months after surgery and i feel 70% numb. Is it normal?
When will i feel my skin again ?

Quote from: Machine on December 03, 2013, 07:58:00 PMWhat i mean to say is that i had swelling for 3 months on my left leg during LL through LON . Now its almost 9 months after surgery and i feel 70% numb. Is it normal?
When will i feel my skin again ?

Please bear in mind that ethically I can not dispense detailed medical advice via a forum like this without knowing your case in minute details. Hopefully what youre dealing with is a neurapraxia (stretching) of a nerve which can recover. It can take a long time in a lower limb (1yr plus). Unfortunately it may be permanent.
Lets hope for the best!