Quote from: Maison on June 29, 2023, 08:41:06 AMHowever, as far as I can tell from this forum, most of the doctors who offer external techniques in cosmetic limb lengthening are surgeons from Turkey, India, and other less developed countries.
Thus, the dilemma is that when a patient chooses Ilizarov in favor of low price and embolism risk management, choosing a country that is too cheap will increase the risk of osteomyelitis.
You can get externals in developed countries. Aside from a few big ego docs with an agenda, you can get what you want if you ask for it. I talked to two different (American) doctors about otoplasty (cosmetic ear surgery); a simple outpatient procedure that isn't very painful and doesn't take very long. The first one said there was absolutely no way he'd do it under local anesthesia - I had to pay more than double his own fee for an OR and an anesthesiologist that I didn't need - his way or the highway. I took the highway a couple of blocks west to a different doc who offered a choice.
QuoteGenerally speaking, the risk of osteomyelitis is higher than the chance of dying from embolism. There have been several osteomyelitis patients on this forum, and I think most of them were external.
It's not a roulette wheel. If you and your doctor conduct yourselves as you should thoughout the process you can beat these "odds" that appear in publish-or-perish studies.
QuoteFurthermore, Rozbruch, one of the top physicians, also stated
Internal limb lengthening devices are associated with fewer complications than alternative methods of limb lengthening.
https://journals.lww.com/jbjsoa/Fulltext/2020/12000/Motorized_Internal_Limb_Lengthening__MILL_.22.aspx
If he's talking about less severe complications, over which the patient and doctor have a lot of control, then that doesn't mean much.
QuoteIf the risk of embolism in nail insertion were significant, no physician in the world would perform internal procedures. In reality, however, the internal technique is still widely practiced.
Actually, they would continue to do the surgery. Plenty of riskier stuff than internal LL goes on every day.
QuoteWith "vent," surgeons can reduce the risk of fat embolization.
Now you're on the right track. Think about why the numbers for any complication are what they are, and think of ways you can improve your chances instead of following numbers blindly. Doctors follow the numbers because that's what they have; they don't know what will happen with each patient and can't control patient behavior/genes/environment or their own natural skill.
What method of Limb Lengthening is best? Internal Nail vs LON vs External Frames
Quote from: Medium Drink Of Water on June 29, 2023, 06:31:31 PMYou can get externals in developed countries. Aside from a few big ego docs with an agenda, you can get what you want if you ask for it. I talked to two different (American) doctors about otoplasty (cosmetic ear surgery); a simple outpatient procedure that isn't very painful and doesn't take very long. The first one said there was absolutely no way he'd do it under local anesthesia - I had to pay more than double his own fee for an OR and an anesthesiologist that I didn't need - his way or the highway. I took the highway a couple of blocks west to a different doc who offered a choice.
It's not a roulette wheel. If you and your doctor conduct yourselves as you should thoughout the process you can beat these "odds" that appear in publish-or-perish studies.
If he's talking about less severe complications, over which the patient and doctor have a lot of control, then that doesn't mean much.
Actually, they would continue to do the surgery. Plenty of riskier stuff than internal LL goes on every day.
Now you're on the right track. Think about why the numbers for any complication are what they are, and think of ways you can improve your chances instead of following numbers blindly. Doctors follow the numbers because that's what they have; they don't know what will happen with each patient and can't control patient behavior/genes/environment or their own natural skill.
Rozbruch compared LON and PRECICE, concluding that the overall costs are similar given that PRECICE requires fewer surgical procedures. In developed countries, the cost of hiring a skilled surgeon may exceed the cost of the device.
https://pubmed.ncbi.nlm.nih.gov/30278015/
Although the classic Ilizarov method requires fewer surgeries, it is widely recognized that patients need to use external fixators for an extended period, which significantly inconveniences their daily lives.
https://journals.lww.com/jbjsoa/Fulltext/2020/12000/Motorized_Internal_Limb_Lengthening__MILL_.22.aspx
The cases compared in this study are all from the US and the UK. However, osteomyelitis was still observed in external method.
This implies that even the most skilled surgeons in developed countries cannot entirely eliminate the risk of osteomyelitis associated with external procedures.
In my opinion, if budget is not a constraint, the internal method is preferable. However, if there are surgeons who can perform the external method of surgery generally safely and at a relatively reasonable cost, it would be beneficial to share that information.
You are the administrator here, and a neutral view is desired, but you appear to favor the external method.
With all due respect, I suspect that your own experience with external surgery may have influenced your opinion. It seems to me that you place more value on personal experience than on medical literature.
Quote from: GrowGrow123 on June 28, 2023, 03:29:20 AMYou're doing God's work with all the facts! It baffles me that there are people on this forum who legitimately believe external methods are better than internal methods or that tibia's are safer than femurs despite the litany of evidence to the contrary.
I think some people are just looking for any justification for why they are opting for a riskier method instead of just being honest with themselves that price is the only reason. Nothing wrong with choosing a certain method because it's the only financially feasible option, but people should definitely be aware of the risks and not go in with eyes blind.
Thank you.
I agree with you about people trying to justify their decision. I understand the financial aspect...if you want to cheap out on this surgery, that is your choice. The problem is people publicly justifying their bad decisions, not necessarily lying to other people, but lying to themselves. I think a lot of them want to make themselves feel better...the issue is other people read/watch that and think "Oh, maybe I should do the same thing then?" and they wind up hurting themselves in the process, which could've been entirely avoided. I'm all about safety, but also harm reduction.
Quote from: Medium Drink Of Water on June 28, 2023, 03:59:55 AMThe part about method affecting maximum length achievable.
I agree, internals don't necessarily cap you out at 8cm...depends on what internal nail we're talking about. But PRECICE 2.2 has a max of 8cm, so maybe he was talking about that.
Quote from: Medium Drink Of Water on June 28, 2023, 03:57:51 AMWhat's the coefficient of determination? Is one even provided? I'm using statistics too here; knowledge of the science of statistics to be precise. Studies with sigma 3 confidence frequently get debunked, and this one can't even hold a candle to that. This is only a small step up from anecdotal stories.
"Statistical analysis was performed with the use of STATISTICA 13 Software (Tibco Software Inc., Palo Alto, CA, USA). The Shapiro–Wilk test was performed to determine the normality of the data. Due to the small groups of patients and the lack of normal distribution, the Kruskal–Wallis ANOVA test and Mann–Whitney U test were used to calculate the statistical relationships between the demographical and clinical data. The χ2 test (2 × 3) was carried out to assess the differences in dichotomous variables. The significance level was adopted as p < 0.05."
Quote from: Medium Drink Of Water on June 28, 2023, 03:57:51 AMI've personally met more than 39 LL patients. The reason I'm using anecdotes is because they're what I have. I'm offering them up as a way of illustrating an important point to consider: patient and doctor behavior matter A LOT. That idiot patient you mentioned in the OP is a perfect example. The method isn't to blame for what he did. What other stupid stuff happened that the study's authors didn't know about? I personally witnessed a lot of ridiculous patient behavior, and that was IN THE HOSPITAL. 
I have lots of anecdotal observations of recklessness and malfeasance which is why I don't trust the numbers.
Why do your 39 anecdotal stories carry more validity than Dr. Szymon Pietrzak, Dr. Tomasz Parol, Dr. Jarosław Czubak, and Dr. Dariusz Grzelecki at the Gruca Orthopedic and Trauma Teaching Hospital, and their study published in the Journal of Clinical Medicine?
I'm not going to 100% and completely disregard someones personal experiences. Isn't that what this forum is about with the patient diaries? Why after providing study after study, digging up more research the more I look, nothing is ever good enough to compare to your anecdotal experiences? What exactly do you need in order to admit, "External fixation is not the safest way to do cosmetic limb lengthening."? What criteria must be met before you change your mind?
What have you seen that makes you believe externals are safer and better than internals for cosmetic limb lengthening? What is your reasoning?
Quote from: Medium Drink Of Water on June 28, 2023, 03:57:51 AMThe literature is inadequate to use as a tool for making a judgment about that. A broken leg after LL (in cases in which the LL was even a factor) is due to insufficient regenerate. Does the literature tell us why the quality of internal patients' regenerate is so much better than that of external patients'? No; it doesn't even make the claim that there is a difference. That's you taking the ball and running out of the stadium and past the city limits with it. The study only covers three instances of fractures with no information about what caused them. Did the doctors take the devices off before there was enough regenerate? Did the patients do something stupid?
The sample size is small. Could it be more thorough? Yes. The more information we can collect, the better. But what's it going to take? What do you need in order to be satisfied?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342054/
What about the 795 patients? Granted, this study is hardly a study. They didn't even observe the patients themselves, all they did was look at other studies and pooled them together. But every single metric we're looking at points to externals being, on average, less safe. What metric are you using to determine that externals are better?
Quote from: Medium Drink Of Water on June 28, 2023, 03:57:51 AMSorry, I thought you were conflating monorail and LON. You have three instances of specific devices and methods separated by slashes here:
hence my incorrect assumption.
I should have been more specific and precise(lol). You are completely correct about monorails not necessarily meaning LON. Oftentimes that is how monorails and LON is done in regards to cosmetic limb lengthening. When you look at the Turkish clinics, that's what they often do. Is anyone aware of a Doctor in the United States doing cosmetic limb lengthening with monorails + LON, like what they're doing in Turkey? I don't know of a single one. What about in Europe? Turkey is the only place I'm aware of that does it, but maybe if you found some random Orthopedic surgeon somewhere in Romania he'd do it...
Quote from: Medium Drink Of Water on June 28, 2023, 03:57:51 AMPaley of course has lots and lots of credibility and I agree with those statements.
But external-only is by far the least invasive method of LL and that should count for something, based on nothing more than conjecture from my own common sense. I'd rather have broken legs and some serious body jewelry for several months than have my legs cut wide open and my bone marrow reamed out by a giant nail, and then cut back open again to take the nail out, with the bone marrow never coming back. Especially after the entire process is long over with and the frames are gone but the marrow isn't.
That is incorrect. Unless you are a child.
( https://www.leukaemia.org.au/blood-cancer/understanding-your-blood/bone-marrow-and-blood-formation/ )
"Bone marrow is spongy tissue in the middle of certain bones. Most blood cells are made in your bone marrow. This process is called haemopoiesis.
In children, haemopoiesis takes place in the long bones, like the thighbone (femur). In adults, it’s mostly in the spine (vertebrae) and hips, ribs, skull and breastbone (sternum). You may have a bone marrow biopsy taken at the back of your hip (the iliac crest)."
Dr. Paley also talked about it but I can't find the source, but I do recall him mentioning that (paraphrasing) "the pelvis makes most of your blood supply, and your bone marrow will regenerate after the nail is removed". Since I can't find the source, take it for what you'd like. Regardless, has anyone heard of this being an issue? How many thousands of patients have had their femurs reamed, and where do we see complications resulting from that? I have not seen or heard anything in regards to that.
I have heard of fat embolisms being a risk, which is specifically why the bone marrow is reamed in order to prevent that.
How do we quantify "less invasive"? Tibias(tibia + fibula) require two bones to be cut, femurs only one.
Quote from: Medium Drink Of Water on June 28, 2023, 03:57:51 AMProblems that occurred more frequently (or exclusively) with externals in this tiny study but could occur with internals shouldn't be attributed to externals in general based on such a weak correlation and with zero causal linkage established.
Infection of course is a bigger worry with externals. But I think these "odds" are not what they appear to be. Based on anecdotal observations and basic knowledge of microbiology I further conject that environment and behavior affect the risk of infection occuring and that if you have the time and can take care of yourself properly, externals are the best.
Why are externals the best?
Quote from: Medium Drink Of Water on June 28, 2023, 03:57:51 AMIf you don't, but have plenty of money, internals is the second best choice.
LON is a last resort but it's all there is for some peope.
I don't have evidence to support the contrary. But non-robust, non-experimental correlational studies aren't strong evidence and are barely a blip on the weak evidence radar. We're still in the "use your common sense to figure it out" phase in the process of achieving enlightenment about CLL, and this topic doesn't advance us out of it in any appreciable way. We need real experiments or at the very least massive amounts of correlational datapoints to start generalizing.
Making big, sweeping proclamations about what is better and why, and saying any divergenet proposition is a lie, based on this dearth of evidence is arguably misinformation too.
So why can you say the same, based entirely on your own personal experiences and without any evidence, that externals are the best? Why can you say externals are best but I can't say the opposite?
Quote from: NailedLegs on June 30, 2023, 02:11:05 AM
Dr. Paley also talked about it but I can't find the source, but I do recall him mentioning that (paraphrasing) "the pelvis makes most of your blood supply, and your bone marrow will regenerate after the nail is removed". Since I can't find the source, take it for what you'd like. Regardless, has anyone heard of this being an issue? How many thousands of patients have had their femurs reamed, and where do we see complications resulting from that? I have not seen or heard anything in regards to that.
According to Dr. M on his TikTok page, the marrow completely regenerates 2 weeks after rod removal and doesn’t pose a risk.
Quote from: Body Builder on June 29, 2023, 07:19:02 AMThe term best is a very subjective one.
I don't know what is considered as best for every single LLer, but the safest and cheapest way is objectively the external tibias.
Lon is the worst way imo because it combines both the cons of externals.and internals without being better than both the other methods in anything.
Why are external tibias the safest?
Quote from: Maison on June 29, 2023, 11:50:51 PMAlthough the classic Ilizarov method requires fewer surgeries, it is widely recognized that patients need to use external fixators for an extended period, which significantly inconveniences their daily lives.
Yep, externals are for people who have a lot of time and an environment conducive to be wearing those frames.
QuoteThe cases compared in this study are all from the US and the UK. However, osteomyelitis was still observed in external method.
This implies that even the most skilled surgeons in developed countries cannot entirely eliminate the risk of osteomyelitis associated with external procedures.
Of course the risk is higher. There's no denying that when you have pins going in and out of your legs, something is more likely to get in there than with a device that's sealed inside. I have not been arguing that there is no risk just because I didn't get one. But I do contend that patient health and hygeine have a big impact on whether this happens or not and that aggregated numerical data aren't especially useful in determing the odds of an individual case. Do you disagree with that?
QuoteIn my opinion, if budget is not a constraint, the internal method is preferable.
You have your opinion and I respect that opinion. I may have done all internals if I'd had the money in 2007. My objection to the OP was the certainty and boldness of his claims based on what I thought was flimsy evidence.
QuoteYou are the administrator here and a neutral view is desired
I am not the administrator here. I was a regular poster in the beginning who was given very limited moderator powers to lend the credibility of an elder stateman to a new David forum competing with the old Goliath forum whose name is still auto-censored here as a relic of that battle, since none of the original LL Forum founders had even had LL at the time. I didn't even ask to be a mod, it was suddenly added to my account one day. The administrator is so neutral as to be almost completely hands-off. He hasn't posted here in years and doesn't check the forum much, which is why we have such a big troll problem here.
QuoteWith all due respect, I suspect that your own experience with external surgery may have influenced your opinion.
I was always advocating for pure externals even before I had LL. The admin of the old forum was kind of annoyed by my posts, and I suspected the fact that he'd had LON was making him more defensive of the method than he should've been. 
Was I making a virtue out of a necessity because I couldn't afford internals back then? It's possible that that colored my opinion, but the low-invasiveness of externals compared to the shudder-inducing brutality of not one but two major surgeries for internals was always on my mind when I was weighing the pros and cons of everything.
QuoteIt seems to me that you place more value on personal experience than on medical literature.
I do, for two reasons:
1. I know what I saw, and I know more about what I saw than just a few numbers on a page with no backstory about how they came to be. If my anecdotal observations of fellow patients were quantified and distilled down to raw data, they would paint a different picture from the truth.
2. I know a bit about scientific literature. The people who write it often have an incentive to publish it: it's how they maintain their prestige over their workhorse colleagues. The publish-or-perish mentality is what it's called, and it's being increasingly criticized as more and more studies thought to be good are reviewed and discredited as garbage. Most often this is because of small sample sizes and correlations assumed to be causative, two red flags being waved proudly in the OP.
Quote from: NailedLegs on June 30, 2023, 03:44:50 AMWhy are external tibias the safest?
Quote from: Body Builder on June 29, 2023, 08:10:12 AMAnd by far the most important risk of LL is embolism which is fatal in many cases and it is almost completely linked to internal methods, not externals.
He expressed concern about embolisms associated with internals.
Paley comments on fat emboli as follows
To date, we have never had a patient die of FES (fat embolism syndrome).
We have however had 2 patients require prolonged ICU treatment prior to discharge
In both these cases the patients had a history of vaping which they failed to disclose.
Quote from: NailedLegs on June 30, 2023, 02:11:05 AMI agree, internals don't necessarily cap you out at 8cm...depends on what internal nail we're talking about. But PRECICE 2.2 has a max of 8cm, so maybe he was talking about that.
Yeah maybe. I thought he was looking at the range of the datapoints and assuming the highest one in the dataset was the maximum possible.
QuoteThe significance level was adopted as p < 0.05."[/b]
It's the industry standard in an industry that ends up retracting a lot of its assertions. Plenty of studies with that level of confidence have proven a lot of false stuff.
QuoteWhy do your 39 anecdotal stories carry more validity than Dr. Szymon Pietrzak, Dr. Tomasz Parol, Dr. Jarosław Czubak, and Dr. Dariusz Grzelecki at the Gruca Orthopedic and Trauma Teaching Hospital, and their study published in the Journal of Clinical Medicine?
They don't. No doctor will read my posts and change his mind. Most doctors won't read them period. They don't know who I am and they don't know what I saw. Despite all my rage I am still just a rat in a cage. But think for yourself and think about the degree to which your interests align with theirs. They deal in odds while patients deal in individual circumstances. Circumstances under your control can allow you to do better than the calculated odds, as may have happened in my case (or maybe not; sample size of 1 after all).
QuoteI'm not going to 100% and completely disregard someones personal experiences. Isn't that what this forum is about with the patient diaries? Why after providing study after study, digging up more research the more I look, nothing is ever good enough to compare to your anecdotal experiences? What exactly do you need in order to admit, "External fixation is not the safest way to do cosmetic limb lengthening."? What criteria must be met before you change your mind?
What are the consequences of the trauma of shoving those nails in there and pulling them out again, long-term? The answer to that question is what I want to hear.
I had LON with an Ilizarov fixator. Not sure which doctors do that now but I'd imagine (almost) any that offer ring fixators will do the nail too. I know one clinic in Russia, possibly the Ilizarov clinic, won't do the nailing.
QuoteThat is incorrect. Unless you are a child.
The long bones of an adult contain yellow marrow. It's not normally useful but the body has the ability to transform it into red marrow in some circumstances. I don't know anything more than that, but I'm assuming that if the body would go to the trouble of doing that, it needs the red marrow for some reason. If that happens, internal patients are left without the backup marrow. Consequences? Dunno.
QuoteHow do we quantify "less invasive"? Tibias(tibia + fibula) require two bones to be cut, femurs only one.
Why are externals the best?
I'd say let's not quantify by counting the number of bones involved but by the amount of stuff that "invades" the body. And you can do internal tibias so it's not like 1 vs 2 contributes to internal devices' superiority.
QuoteSo why can you say the same, based entirely on your own personal experiences and without any evidence, that externals are the best? Why can you say externals are best but I can't say the opposite?
You can and did, but as long as there's room for doubt, claims like that are debatable.
Quote from: Medium Drink Of Water on June 30, 2023, 04:29:38 AMYep, externals are for people who have a lot of time and an environment conducive to be wearing those frames.
Of course the risk is higher. There's no denying that when you have pins going in and out of your legs, something is more likely to get in there than with a device that's sealed inside. I have not been arguing that there is no risk just because I didn't get one. But I do contend that patient health and hygeine have a big impact on whether this happens or not and that aggregated numerical data aren't especially useful in determing the odds of an individual case. Do you disagree with that?
You have your opinion and I respect that opinion. I may have done all internals if I'd had the money in 2007. My objection to the OP was the certainty and boldness of his claims based on what I thought was flimsy evidence.
I am not the administrator here. I was a regular poster in the beginning who was given very limited moderator powers to lend the credibility of an elder stateman to a new David forum competing with the old Goliath forum whose name is still auto-censored here as a relic of that battle, since none of the original LL Forum founders had even had LL at the time. I didn't even ask to be a mod, it was suddenly added to my account one day. The administrator is so neutral as to be almost completely hands-off. He hasn't posted here in years and doesn't check the forum much, which is why we have such a big troll problem here.
I was always advocating for pure externals even before I had LL. The admin of the old forum was kind of annoyed by my posts, and I suspected the fact that he'd had LON was making him more defensive of the method than he should've been.
Was I making a virtue out of a necessity because I couldn't afford internals back then? It's possible that that colored my opinion, but the low-invasiveness of externals compared to the shudder-inducing brutality of not one but two major surgeries for internals was always on my mind when I was weighing the pros and cons of everything.
I do, for two reasons:
1. I know what I saw, and I know more about what I saw than just a few numbers on a page with no backstory about how they came to be. If my anecdotal observations of fellow patients were quantified and distilled down to raw data, they would paint a different picture from the truth.
2. I know a bit about scientific literature. The people who write it often have an incentive to publish it: it's how they maintain their prestige over their workhorse colleagues. The publish-or-perish mentality is what it's called, and it's being increasingly criticized as more and more studies thought to be good are reviewed and discredited as garbage. Most often this is because of small sample sizes and correlations assumed to be causative, two red flags being waved proudly in the OP.
I must apologize for my previous misunderstanding, I was under the impression you were the administrator.
Now that I know you're not, I understand that you are free to express your personal opinions.
I've noticed that you generally mistrust medical papers. It's not entirely implausible that both Paley and Rozbruch, who perform cosmetic leg lengthening procedures, may be suppressing or omitting certain inconvenient aspects from their publications for profit.
However, I believe you might be overly concerned about the potential harm to the bone marrow from nail implants.
As GrowGrow123 has mentioned, bone marrow fully regenerates after the rod is removed.
Quote from: GrowGrow123 on June 30, 2023, 03:34:00 AMAccording to Dr. M on his TikTok page, the marrow completely regenerates 2 weeks after rod removal and doesn’t pose a risk.
Moreover, the gold standard surgical technique for fractures in the diaphysis of the tibia or femur is the intramedullary nail, which often isn't removed after the fracture surgery.
If, as you suggest, the nails cause irreversible damage to the bone marrow and losing marrow in the lower extremity is detrimental to adults, then intramedullary nail surgery for fractures will likely be discontinued in the future.
Quote from: Medium Drink Of Water on June 30, 2023, 05:26:25 AMYeah maybe. I thought he was looking at the range of the datapoints and assuming the highest one in the dataset was the maximum possible.
Since the mainstream internal method is PRECICE, I mentioned 8 cm, which is the limit of PRECICE. I apologize for not explaining that earlier.
Quote from: Maison on June 29, 2023, 08:41:06 AMYes, you are right, there is a risk of embolism with intramedullary nail surgery. Paley says fat emboli are about 5%.
However, as far as I can tell from this forum, most of the doctors who offer external techniques in cosmetic limb lengthening are surgeons from Turkey, India, and other less developed countries.
Thus, the dilemma is that when a patient chooses Ilizarov in favor of low price and embolism risk management, choosing a country that is too cheap will increase the risk of osteomyelitis.
Generally speaking, the risk of osteomyelitis is higher than the chance of dying from embolism. There have been several osteomyelitis patients on this forum, and I think most of them were external.
Furthermore, Rozbruch, one of the top physicians, also stated
Internal limb lengthening devices are associated with fewer complications than alternative methods of limb lengthening.
https://journals.lww.com/jbjsoa/Fulltext/2020/12000/Motorized_Internal_Limb_Lengthening__MILL_.22.aspx
If the risk of embolism in nail insertion were significant, no physician in the world would perform internal procedures. In reality, however, the internal technique is still widely practiced. With "bent," surgeons can reduce the risk of fat embolization.
Which doctors in which countries do you think are reliable for the Ilizarov procedure, for example?
I too believe that Ilizarov surgery by a good doctor is safe.
The american doctors you mentioned get much more money and much easier by doing internals with precise than doing externals. Thats the main reason they advertise it that much and say all these bs about its superiority in safety compared to hexapods.
Internals were and will always be a more risky way of doing LL and should be the first option only if someone wants to do LL on femurs. On tibias there is no reason to do internals except you can't take it to have some bulky fixators for about a year which is something I respect and I can understand. But saying that reaming your bone and doing 2 major surgeries is safer compared to just have some screws on your bone which will be removed in about a year (much less if you lengthen 5cm) without even a new surgery is the most stupid thing ever.
And I start to believe that even Paley, who I thought was the most respectable LL doctor, had become a plain merchant who wants to promote precise (which he created and takes money from its rights) and write bs only to gain more money.
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