Q&A With Dr Jean-Marc Guichet

The hyper fast track is a logics. It relates to more than only the pre-op or post-op training. It relates to the optimization of care for the patient. It is multifactorial.
- The blood loss needs to be controlled. A large blood loss and hematoma prevents feeling well and being able to do sports. It decreases local oxygenation of the scar and healing tissues thus slows down healing and increases infectious risks. This has been published widely in medical journals. For a bilateral procedure, it can be of several hrs of hemoglobin, but we have regularly only 1 to 2 hrs of Hb loss. It requires a know-how, but it allows the patient to stand up in operating room and walk, like we did recently, and also to do bike within a few hours after anaesthesia awakening.
- Pain control is required to be able to move after a major orthopaedic surgery and to do muscle activities (walking, stairs, biking). We can secure this know-how too, and if your patients are doing it, first it is because it is possible, and second because they do not have sufficient pain to prevent it.
- Returning to full activity is necessary to drain the local surgery area, to prevent clotting, and to reactivate the muscles for a normal life, not the one of a ill person. I suppose it is what all patients want... Deluding the body is one of the most important thing in this matter: the body feels no pain, is in good shape and returns to full activity, thus dos not feel the heavy surgery.
- Of course there are further reasons why it is important to return to normal activities fast. 20 years ago, having a hip replacement required heavy pain and 2 to 3 weeks in hospital. Currently, the hospitalization in some clinics is only 2-3 days: is it a bad thing? Who would complain? In lengthening procedures and also in cosmetic procedures, a fast recovery is essential. We need however to consider that is cannot be instant full recovery of the full muscle force: during natural adolescent growth, 6 cm of gain is achieved in approx. 5 years (i.e. 60 months). during a lengthening, we obtain it in 6-8 weeks (30-40 times faster). If we train for sports competition, we need to train far more for a more demanding procedure like lengthening, mainly if we want to recover fast.

Yes, it depends on where you go (London, Milan) and services and standard you want (residence, hotel, etc.). 75000 Euros is generally what most patients plan for. Some patients plan for 100000 Euros, but is it not needed. Of course, security is necessary not to be short of money.

Detailed and informative replies. Thank you very much Dr Giuichet.

Quote from: Dr Guichet on April 09, 2016, 09:27:25 AMYes, it depends on where you go (London, Milan) and services and standard you want (residence, hotel, etc.). 75000 Euros is generally what most patients plan for. Some patients plan for 100000 Euros, but is it not needed. Of course, security is necessary not to be short of money.

Which city have your most profrofessional team and Which city do you suggest among these two cities?
Please anser me.Please

Dear Dr.guichet: What is your opinion of doing 6 centimetres in the tibia? So many surgeons say that is the max you go in the tibia. What are your thoughts on it? Thanks. Jay

Quote from: Dr Guichet on April 09, 2016, 09:27:25 AMYes, it depends on where you go (London, Milan) and services and standard you want (residence, hotel, etc.). 75000 Euros is generally what most patients plan for. Some patients plan for 100000 Euros, but is it not needed. Of course, security is necessary not to be short of money.

Dr Guichet,

Thank you for the information and detailed response,
may i ask how long in the foreseeable future would you see yourself practicing ?
I know this is a  strange question , however, there are people like me that needs to save for a couple of years before being able to afford time off and the surgery......

I still have approximately 20 years of remaining work.... I began very early in life in this field when I was a student. I designed the Albizzia in my early orthopaedic residency. I hope, in the remaining time, to develop further the field of lengthening and to allow patients to have an easy procedure and a very fast uneventful recovery! Making access to the ultimate Dream of patients means creating new routes which do not currently exist, and with support of patients, it is a wonderful goal.

The max. gain is not the problem. The calf is fare less flexible than the quadriceps and thus the risk is tip toeing for several months.

Tibia has far less vascular supply than femur, and as a result, the bone blood flow is far less thus resulting in a far smaller healing capacity. In fractures of femur, we rarely have non healing due to no bone formation. In tibial fracture, it is common, because of the vascular problem and also of the smaller quantity of bone progenitor cells. If bone healing can be secured for a 6 cm gain in femurs in 3 months, in tibias it can be ...2 years and bone grafting!

The resulting problem is bone grafting, which is almost never needed in femoral lengthening, but may be required in tibial lengthening.

The second problem of tibias is that the bone is smaller than femur and the diameter of the nail to use is generally smaller resulting in a weaker construct. So, a longer healing time and a nail less resistant mechanically... this is not optimal.

The third element is the healing time of each patient. Some patients heal fast (wide bone heavy muscular caucasian type patients) and some heal slowly (e.g. small diameter brittle bones in some asiatic type patients). Healing time is never known in anticipation, unless there was a previous fracture.

All these reasons orient the choice in an honest way toward performing first femoral lengthening, and when the healing is secured (and when we know the bone is healing fast), we can propose a tibial lengthening in a secondary time. Of course in unilateral non cosmetic tibial shortening, this does not apply.

Tibias has been preferred for a long time by surgeons using external fixators because the pins/wires are very short on the medial skinny side of tibias with respect to longer ones for the lateral aspect of the thigh, through all muscles. The stability (nor motion) is not good in femurs using external fixators and thus there were all reasons to orient the choice toward tibias rather than femur. But times have changed with IM nails as they have the same stability in femurs and tibias.

An additional element for choosing femur versus tibia: Generally females prefer to lengthen femurs (6-8 cm) first as when they wear high heals, the knee is at a reasonable level, while lengthening 8 cm tibias and using 12-15 cm high heels looks awkward...

Cosmetically, there is no real issue, as proportions for attraction is in no way related to anthropometric proportions. The best and more attractive top models are completely disproportionned... When one see images of patients with femoral lengthening, no one prefers the patient/femurs before lengthening... and I always show a patient with a 18 cm isolated femoral lengthening: everyone thinks he has been proportionally lengthening both femurs and tibias, or 6 cm on femurs! Illusion is a surprising thing.

I designed and used the first tibial nail in 1993 and since then I improved the overall technique for tibias like for femurs, but still  tibial bone is not providing results patients ideally dream of.

Is there any difference between femur or tibia using lon method.And do you have safe limit for tibia

Dr. Guichet,

So glad you have joined the forum.

There has been much discussion on the forum about the issue of athletic recovery.  Many doctors, including yourself, claim that 100% athletic recovery is a realistic goal.  I recall reading somewhere you even saying that you have had patients win sports championships after surgery. 

However, the overwhelming consensus on the forum, from people who have actually had the surgery, is that 100% recovery is impossible.  Again, we're talking about ATHLETIC recovery here, not just basic functioning.  Most often cited are losses in speed, agility, and explosiveness — and this includes patients of yours, as well. 

I am ready to get the surgery and you are far-and-away my top choice for a doctor, but I, along many others here, am hung up on the concerns about athletic recovery.  If we could see proven cases of patients who had recovered fully, it would make the decision easy for us.  I understand that many of your patients are concerned about protecting their anonymity, but of all the hundreds of patients you've operated on, I'm sure there are at least a few who would be willing to give verifiable testimonials about their recoveries.  They need not share their names.

I think that for a person who is ready to spend $80,000, it is reasonable to expect some assurances that a 100% athletic recovery is a realistic goal, beyond just the doctor's word.  I think some patient testimonials would meet this need.  An added benefit to you is that it would no doubt  save you countless hours of time responding to patient inquiries, as I'm sure the vast majority of them have to do with recovery.

Best,
Quincy

P.S.  By the way, I see that you do currently have testimonials on your site, and they're great.  However, I don't see any that speak specifically to ATHLETIC recovery.  If you had a few testimonials from patients who were high-level athletes prior to surgery and then were able to recover to the same performance level after the surgery, I think your website would be perfect.