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Q & A With Dr Franz Birkholtz

F
Franz
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Joined: Nov 2013
Posted on Feb 18, 2014, 6:58 pm
#41
Quote from: TheRisingShorty on February 18, 2014, 02:50:21 PMHey Dr.Birkholtz,

Just wondering if Precice 2 has any mechanical/functional advantage over Precice other than giving longer length?

Precice was modular and when it failed it usually did it at the joint between the modular sections. In precice 2 this has been adressed, making the nail much stronger. Eventually omce they run out of stock on precice, i think they will convert to only having precice 2.
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K
KiloKAHN
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Joined: Sep 2013
Posted on Feb 19, 2014, 1:57 am
#42
Quote from: Franz on February 18, 2014, 06:55:32 PMLRS(monorail) fixators are strong and we fully weightbear on them. They have not snapped yet. The issue with LRS is the risk of malalignment.
An option to consider might be LATP (lengthening and then plating), where the exfix is converted to a locking plate internally after distraction. Cost would be similar to LON. This eliminates the risk of anterior knee pain.
Any infix(nail or plate) following exfix has a risk of infection.

With LATP is the main benefit over externals a somewhat reduced fixation time? The frames still have to stay on with the plate until the bones consolidate, right?

Also, I've read in a few sources that there is a higher risk of refracture with externals than with LON/LATN. Say I lengthened 5 cm and it took 10 months wearing the fixator before it was removed. Would this mean that even after fixator removal I wouldn't be able to bear significant weight until months afterward? I don't plan on doing barbell squats at the gym right after, but I'm wondering if I'd still have to be careful not to run or anything like that for a long while afterward so as to avoid refracturing the bone.
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Franz
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Posted on Feb 19, 2014, 7:43 am
#43
Quote from: Kilokahn on February 19, 2014, 01:57:59 AMWith LATP is the main benefit over externals a somewhat reduced fixation time? The frames still have to stay on with the plate until the bones consolidate, right?

Also, I've read in a few sources that there is a higher risk of refracture with externals than with LON/LATN. Say I lengthened 5 cm and it took 10 months wearing the fixator before it was removed. Would this mean that even after fixator removal I wouldn't be able to bear significant weight until months afterward? I don't plan on doing barbell squats at the gym right after, but I'm wondering if I'd still have to be careful not to run or anything like that for a long while afterward so as to avoid refracturing the bone.

LATP has the advantage of shorter frame times, as the plates serve the purpose of stability during consolidation.

We allow full weight bearing throughout exfix only treatment. The frames are removed when bone consolidation is complete. After removal the bone is strong, but we do suggest protected weight bearing for 6 weeks. The refracture rate quoted is really when the frames are removed too early before full regenerate consolidation. Once consolidated completely, the bone is stronger than before the surgery!
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shawty
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Posts: 98
Joined: Mar 2014
Posted on Mar 11, 2014, 10:40 pm
#44
Quote from: Franz on November 26, 2013, 09:28:21 PMLong frame times do not necessarily equate to permanent muscle damage. We encourage early functional rehab including full weight bearing which promotes muscle function.
New bone (regenerates) are often wider than the original bone. This is a good thing. It means your surgeon knows what he's doing and you're creating good quality bone. Will have no effect on function.

Hi Dr. Franz,

On doing externals only, you bypass the need for an internal nail, correct?  Does this make it a less invasive process?  How is the healing time on this vs LON/LATN? Is is significantly longer?  I like the idea of using no nails through the knee. Are there issues of nonunion or the bone not growing straight for a smaller length gain such as 5cm. I apologize if you've already answered these questions within the forum, but I'm really interested in doing externals only for a 5cm gain. What was the price for this? Thanks!
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T
TRS
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Posted on Mar 12, 2014, 5:22 pm
#45
Hey Dr.B!

Can you please clarify this question raised by thetallerman?

Quote from: thetallerman on March 12, 2014, 12:38:02 PMHey guys since Femurs do not run straight up and down like the tibias as seen in this picture (attached) but in fact run at a slanted angle, if you were to lengthen for example, 5 cm in them, would the actual gain be 5 cm, or it would it be more or less? Can math whizzes help me out on this and also give the reason behind their answers. Thanks guys and looking forward to the responses. It's just I would hate to lengthen a certain amount and then when I measure myself post-lengthening I don't get the amount I thought I would.
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F
Franz
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Joined: Nov 2013
Posted on Mar 12, 2014, 6:51 pm
#46
Quote from: shawty on March 11, 2014, 10:40:02 PMHi Dr. Franz,

On doing externals only, you bypass the need for an internal nail, correct?  Does this make it a less invasive process?  How is the healing time on this vs LON/LATN? Is is significantly longer?  I like the idea of using no nails through the knee. Are there issues of nonunion or the bone not growing straight for a smaller length gain such as 5cm. I apologize if you've already answered these questions within the forum, but I'm really interested in doing externals only for a 5cm gain. What was the price for this? Thanks!

Hi,
Externals only means there are no internal devices used. The consolidation time is the same, but the big difference is that exfixes are worn for the entire time. In adults this is around 6-9 months for 5 cm.
there is a small chance of subsidence and length loss, which can be compensated for by overlengthening by 5-10mm. Deformity is possible, but unlkely.
Cost is 30K USD for new frames and 25K for re-used ones.
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F
Franz
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Posted on Mar 12, 2014, 6:59 pm
#47
Quote from: TheRisingShorty on March 12, 2014, 05:22:52 PMHey Dr.B!

Can you please clarify this question raised by thetallerman?

Great question,

Yes with exfixes we lengthen along the mechanical axis which should correspond pretty much to patient height. With femoral nails, we tend to lengthen along the anatomic axis, which might not correspond perfectly to height gain (it is oblique). It is well described too that patients end up with 5-10 mm less than expected. I would suggest going 1cm beyond target length and then backing the nail up by 5mm. This would ensure quick consolidation. The downside of long lengthenings along the anatomic axis (like with precice, guichet, betzbone, iskd), is that we change the mechanical alignment of the femur, as we lengthen along a different axis. This means that intramedullary lengthenings in the femur beyond 5-6cm will inevitably lead to slight malalignment. This may in time lead to arthritis.
In short, keep to reasonable distances and go to a doc that understands this.
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T
The View
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Posts: 438
Joined: Jan 2014
Posted on Mar 21, 2014, 5:36 pm
#48
Thank you very much for taking your time to answer these questions Dr Birkholtz.

What is your opinion on quadrilateral lengthening ? Is it safe if it is kept under 5 cm (I was think 5.5(femur) + 4.5(tibia)(absolute max)) and is done using safe "less strenuous" internal devices such as precise ? What are the disadvantages of lengthening quadrilateraly compared to doing one lengthening and returning 3-4 months into consolidation for the second.
Would the inability to push your self as hard in physio with 6 broken bones be an issue ?
Would combining recovery times increase total recovery time or reduce it ?
What would you recommend.

Thank you Doctor Q & A With Dr Franz Birkholtz
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F
Franz
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Posts: 50
Joined: Nov 2013
Posted on Mar 21, 2014, 6:09 pm
#49
Quote from: The View on March 21, 2014, 05:36:03 PMThank you very much for taking your time to answer these questions Dr Birkholtz.

What is your opinion on quadrilateral lengthening ? Is it safe if it is kept under 5 cm (I was think 5.5(femur) + 4.5(tibia)(absolute max)) and is done using safe "less strenuous" internal devices such as precise ? What are the disadvantages of lengthening quadrilateraly compared to doing one lengthening and returning 3-4 months into consolidation for the second.
Would the inability to push your self as hard in physio with 6 broken bones be an issue ?
Would combining recovery times increase total recovery time or reduce it ?
What would you recommend.

Thank you Doctor Q & A With Dr Franz Birkholtz

Hi,

Quad lengthening is dangerous because it is a massive operation. You suddenly increase risk of fat embolism tremendously. Also this almost definitely means blood transfusion. It does not really save that much in cost, and might mean less total length achieved. I do not recommend it.
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P
Polycrates.
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Posts: 283
Joined: Nov 2013
Posted on Mar 23, 2014, 10:30 am
#50
Doctor,

A question for you to answer when you can. Do femur and tibia lengths of equal measurement ever occur naturally in a population? And if so, have you any idea what the rate of occurrence would be? All resources I've read state the femur as the longer of the two, without exception. Is there anything anatomically disadvantageous to having equal length bones or a tibia that is slightly longer than the femur (~1cm)?
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