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Q & A With Dr Franz Birkholtz

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Franz
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Posted on Mar 23, 2014, 6:31 pm
#51
Quote from: Polycrates. on March 23, 2014, 10:30:52 AMDoctor,

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)?

Dear Poly,

You are absolutely right. The ratio is normally 0.8, ie tibia 80% of the length of the femur give or take.
There is probably a very good biomechanical reason for this. Having said this, I am not aware of any long-term negative effects if the tibias are longer than normal.

F
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KiloKAHN
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Posted on Mar 24, 2014, 6:11 pm
#52
Hi Dr Birkholtz,

For prospective patients looking to lengthen tibias, do you think it's always the case that lengthening with a TSF is better than lengthening with the traditional Ilizarov frames?
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Franz
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Posted on Mar 25, 2014, 8:26 am
#53
Quote from: Kilokahn on March 24, 2014, 06:11:20 PMHi Dr Birkholtz,

For prospective patients looking to lengthen tibias, do you think it's always the case that lengthening with a TSF is better than lengthening with the traditional Ilizarov frames?

Very good question. The TSF or TLHex devices are hexapod circular external fixators. They allow very accurate threedimensional computer based corrections. This means that the likelihood of deformity is less. They are however quite expensive. A compromise would be to use TSF or TLHex rings, but with Ilizarov distaction components. This is cheaper and allows us the ability to slot in the hexapod struts to optimize the alignment should it be necessary. This is done in the office. Because we use the hexapod struts short term, there is the option to use second hand components for this phase. Of course anything that goes into the bone must be new!
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Taller
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Posted on May 19, 2014, 3:19 am
#54
Hello Dr. Birkholtz.

I hope you had a wonderful weekend. Also, I had a few questions about biomechanics involving LL and athletic recovery and was wondering if you'd be willing to answer them for me. I am a dedicated runner and accept that I will possibly lose some degree of athletic ability from this surgery. However, in order to create the best biomechanical ratio for speed and comfortable running, along with optimum heat desipitation, would you recommend the lengthening of the femurs or tibiae? I was hoping that improved bodily ratios could help me counterbalance the loss of muscle strength after LL. What do you think? Also, how much athletic recovery do you believe is possible after cosmetic LL for 4CM versus around 7CM on tibiae and how much for these same amounts on the femurs? Thank you so much for your time and help. They mean a tremendous deal to the members of this forum.
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Franz
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Posted on May 21, 2014, 9:12 am
#55
Quote from: Tall on May 19, 2014, 03:19:10 AMHello Dr. Birkholtz.

I hope you had a wonderful weekend. Also, I had a few questions about biomechanics involving LL and athletic recovery and was wondering if you'd be willing to answer them for me. I am a dedicated runner and accept that I will possibly lose some degree of athletic ability from this surgery. However, in order to create the best biomechanical ratio for speed and comfortable running, along with optimum heat desipitation, would you recommend the lengthening of the femurs or tibiae? I was hoping that improved bodily ratios could help me counterbalance the loss of muscle strength after LL. What do you think? Also, how much athletic recovery do you believe is possible after cosmetic LL for 4CM versus around 7CM on tibiae and how much for these same amounts on the femurs? Thank you so much for your time and help. They mean a tremendous deal to the members of this forum.

For optimal function the tibia to femur ratio should be around 0.8. Unfortunately every persons response to lengthening is different and matching predicted outcomes to patients accurately is almost impossible to do consistently. I think it is dangerous to expect CLL to improve athletic ability. If anything, it tends to diminish.
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theuprising
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Posted on Jun 14, 2014, 3:33 am
#56
Dr Birkholtz what is your opinion on lengthening individuals who have mild bow legs. Are you able to both lengthen and correct the bowing
or is it 2 separate operations?
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Franz
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Posted on Jun 17, 2014, 9:50 pm
#57
Quote from: theuprising on June 14, 2014, 03:33:26 AMDr Birkholtz what is your opinion on lengthening individuals who have mild bow legs. Are you able to both lengthen and correct the bowing
or is it 2 separate operations?
Usually relatively mild deformities can be addressed with the lengthening surgery, especially during exfix techniques where we can use advanced computer based hexapod fixators like the TSF or TL-Hex. It can even be done with internal nails, using a small acute correction of deformity. This is not always possible with nails though.
Ilizarov/Hexapod based deformity correction with lengthening is what we do all the time for malunions in the practice. We do upwards of 150 circular fixators per year, placing us in the top bracket of surgeons as far as numbers are concerned.
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gettingtaller
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Posted on Jun 21, 2014, 8:54 am
#58
Quote from: Franz on May 21, 2014, 08:18:45 AMBoth. Larger lengthenings have more complications both during lengthening and longer afterwards.
Hopefully you will be OK. Sounds like youre doing very well so far.

In lay mans terms, what kind of complications? Is there a risk my legs will fall off in the next few days? Appreciate the kind response, but would be grateful for specific examples.
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Franz
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Posted on Jun 26, 2014, 6:24 pm
#59
Quote from: gettingtaller on June 21, 2014, 08:54:55 AMIn lay mans terms, what kind of complications? Is there a risk my legs will fall off in the next few days? Appreciate the kind response, but would be grateful for specific examples.
I think you will appreciate that complications are very difficult to predict and individualize and every person would be different. For this reason, it is impossible to put accurate percentages to the complications.
In general, longer distractions have higher complication rates. Potential complications related to longer distractions may include the following:
increased pain during and after distraction
increased muscle stiffness
increased joint contractures and stiffness
a shift in the mechanical axis of the limb, leading to malalignment
delayed union of a regenerate
nonunion of a regenerate
bending of a regenrate, resulting in malalignment
increased articular pressures
increase in long-term arthritic changes
decrease in function and sporting ability
higher infection rates (if using exfix)
higher potential for failure of instrumentation
longer recovery period

I hope this helps?
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Wannabegiant
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Posted on Jun 27, 2014, 3:18 pm
#60
Quote from: Franz on June 27, 2014, 02:37:34 PMLengthening and consolidation in externals takes 1.5 - 2 months per cm. this means 7.5 - 10 months in frames.
Comfortable running should be possible 6-9 months after frame removal, but is difficult to predict.

Interesting, about how long after frame removal are you allowed to jump? similar timeframe as running? (external only)
And what about working out the legs, doing leg press etc?

Also we have a diary here of a patient who did 9 cm in 10 months externals only, so with that in mind i assume it is possible but uncommon to heal faster than 1.5 - 2 months per cm. Since 9 cm in 10 months is ca 33 days per cm, ie slightly more than a month/cm

Thank you for all the info Dr. Franz
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