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CosmeticStatureLengtheningFrequentlyAskedQuestions (FAQ’s)(Pleasereadthisdocumentcarefullyasitcontainsthe answerstomostofyourquestions) Figure1:Exampleofa52yearoldphysicianwhounderwentfemurand tibialengtheningforaheightgainof4½inches(11cm).Heisstanding nexttohiswifeforreferencebefore(left)andafter(right)the lengtheningsurgery.ThelengtheningwasperformedwiththePrecice methoddiscussedbelow. DrorPaley,MD,FRCSC DirectorPaleyAdvancedLimbLengtheningInstitute, WestPalmBeach,Florida. [email protected] Forfurtherinquiriespleasecontactoneofourpatientco-ordinators: [email protected] [email protected] [email protected] [email protected] (LumaisanInternationalpatientcoordinatorandalsospeaksandwritesinArabic) (BernadettaisanInternationalpatientcoordinatorandalsospeaksandwritesin Polish) ForadministrativeorfinancialinquiriespleasecontacttheInstituteAdministrators [email protected]:ChiefFinancialOfficer [email protected]:ConciergePracticeManager Tobookaconsultationappointmentpleasecontactmyassistant: [email protected] Tobookasurgerydatepleasecontact [email protected] PaleyAdvancedLimbLengtheningInstitutephonenumbers: 844714-5293(TollFree)and561844-5255(Main) Address:KimmelBuilding,90145thSt.,WestPalmBeach,33407,Florida,USA FrequentlyAskedQuestions(FAQ’s)(boldletters) Whorequeststhisoperation? Themajorityofpeoplewhoseekthissurgeryareunhappywiththeirbodyimage. Bodyimageisthewayweperceiveourselves.Asitrelatestoheightitisthewaywe perceiveourownheightandourbodyproportions(limblengthrelativetotrunk length). Isthereanameforthiscondition? ThepsychologistthatIworkedwithforover20yearsandwhoevaluatedalmostall ofmypatientswiththisconditionbetween1988and2008,Dr.WalterWindisch, calledthisconditionHeightDysphoria(Dysphorialiterallymeansunhappy,the oppositeofeuphoria).Inotherwordsunhappywithyourheight.Anothertermthat hasbeenusedisoneIcoined;HeightNeurosis. SomepatientsalsohaveBodyDysmorphicDisorder.Theyusuallyalsoneed pyschologicsupportandmedicationbutmaybecandidatesforthissurgery. Psychiatricconsultationiswarrantedinthisgroup. Whatisthenormalrangeofadultheightinthepopulation? When assessing distribution of height in the population, we consider the normal bell curve. We divide people by distribution around the mean (average). Normal height is considered ± 3 standard deviations (SD) from the mean. Stature below 3 SD from the mean in persons without a medical condition such as dwarfism or growth hormone deficiency is considered constitutional short stature. A physician defines the normal range of height between the 5th and 95th percentiles. The lower limit of so-called normal stature for men is 5'5" (166 cm) and for women is 5'0" (153 cm). Percentile SD HeightWomen HeightWomen HeightMen HeightMen (in) (cm) (in) (cm) 95 +3 68.5 174 74 188 90 +2 67.5 171 73 185 75 +1 66 167 71.5 181 50 Mean 64.5 163 69.5 176 25 −1 63 160 68 172.5 10 −2 61.5 156 66.5 169 5 −3 60 153 65 166 WhatistherelationshipofheighttoHeightDysphoria Whileaperson’sactualheightisrelatedtotheconditionthereisnoheightthreshold underwhichyoucannotsufferfromheightdysphoria.Mostofuswouldassumethat youcouldonlysufferfromHeightDysphoriaifyouare‘short’.Theproblemisthat theperceptionofwhoisshortvariesfrompersontoperson.Thatthresholddiffers alongracial,nationalandculturallines:5’10”istallinIndiabutshortinHolland. Thefollowinganecdoteillustratethepoint:AmanflewallthewayfromHollandto seemeregardingstaturelengthening.Hewas5’11”tall.Hesaidthatsincehewasa teenagerhehassufferedfromfeelingshort.Heistheshortestmaleinhisfamilyand evenhissisterishisheight.Allofhisfriendsaremuchtaller.Heremindedmethat theDutcharethetallestpeopleintheworld.Heisthesameheightasme.Ihave neverperceivedmyselfasshortnorhaveanyofmyfamilyorfriends.Itherefore haddifficultyconsideringhimforstaturelengthening.Isenthimforpsychologic evaluation.Thepsychologistreportshowedhesufferedfromthesamebodyimage problemasalloftheotherpatientswehadevaluated.Despitehisseeminglytall heighthesufferedfromHeightDysphoria. WhenwestudiedtherelationshipofstartingheighttothediagnosisofHeight Dysphoriawefoundthatpatientsstartingheightvariedfrom4’10”to5’11”for malesand4’6”to5’8”forwomen.Whilemoreofthepatientswereatthelowerend ofthisspectrum,thefactthatsomewereattheupperendclearlydemonstratedthat heightisnottheprimaryproblem.Theprimaryproblemisthepsyche’sperception ofheightandproportion.Wecallthisbodyimage.StatureDysphoriaisabodyimage disorder.Thepatientperceivesthemselvesasshortirrespectiveoftheactualheight andirrespectiveofhowothersseethem. Isthereaheightthresholdabovewhichstaturelengtheningisnot appropriate? Basedontheabovefindingstheanswershouldbeno.Ihavelearnedtoremovemy personalbiasregardingheightfromtheevaluation.Itisthepatient’sperceptionthat counts.Asregardsrisksoftheproceduretheyarenogreaterifyouaretaller.Infact theyshouldtheoreticallybelesssincethepercentincreaseinlengthofalonger boneisless. Whatmethoddoweuseforstaturelengthening(seefigures1,2,3)? AtthePaleyInstituteweusethemostcuttingedgetechnologyavailableintheworld today.Weuseimplantablelimblengtheningforstaturelengthening.Thisinvolves insertingatelescopicintramedullarynail(tube-likedeviceintothemarrowcavityof thebone).ThebestdeviceavailabletodayisthePRECICEfromEllipseTechnologies. ItiscurrentlytheonlyFDAapproveddeviceonthemarket.ThePrecicehas excellentratecontrolandpatientsclaimhaslittlepainassociatedwiththe lengtheningprocess.ThePreciceistheonlydeviceonthemarketthathasareverse mechanism.Theabilitytogoreverseisaveryimportantsafetyfeature.Weare currentlyusingthePrecice2.2whichistheneweststrongestversionofthisdevice. Figure2:FemurLengtheningwithPrecice Figure3:TibiaLengtheningwithPrecice . HowmuchheightcanIgainwiththePrecice? Mostpatientsdesire3inches(7.5cms)ofstaturegainandsomemorethanthat.The ThePRECICE2.2(developedthroughcollaborationofEllipsewithDr.Paley)isnow FDAapprovedforuse.ThemaximumthePrecice2.2canlengthenis8cms.Patients whowantmorethanthisshouldconsiderasecondlengtheningoftheotherbone (femurfirstandthentibiasecondorviceversa).Thetotalheightgainwithtwo lengtheningsisupto14.5cms(8cmsinthefemursand6.5cmsinthetibias.(8cmsis notwelltoleratedinthelowerleg(tibia)andexceeding6.5cmscanleadtomore seriouscomplications).Mostpatientswillnottoleratemorethan5cmsinthetibias. Ofcoursethecostoftwolengtheningsisnearlytwicethatofonelengthening.The AlthoughthePrecicecanlengthento8cms,noteverypatientcansafelyachievethis much.Wewillonlyallowlengtheningtothetoleranceofthepatientsboneandsoft tissues. HowlongwillIbeoncrutches? Thisquestionisdiscussedagaininalatersection.Asaquickreference:an8cm lengtheningtakesnearlythreemonthstocompletethelengtheninginthefemurand anothertwomonthsforthebonetohealenoughtoallowfullweightbearingwithout crutches;totalof5months.A5cmfemorallengtheningtakesnearlytwomonthsto completethelengtheningandanothermonthtoallowforfullweightbearing withoutcrutches.Forthetibiaa5cmlengtheningtakesnearlythreemonthsto completethelengtheningandanothertwomonthsuntiltheboneishealedenough toallowforcompleteweightbearingwithoutcrutches. Whatisthesafeamountthatcanbelengthenedandwhycanmorelengthnot bedone? Thelimitsoflengtheningarethesofttissues.Theriskofcomplicationsfrom lengtheningincreasewithincreasedlength.Upto5cmsisalowrisklengthening. Between5-8cmsismediumriskandover8cmsishighrisk.Forexampletoachieve 10cmsoflengtheningitismuchsafertolengthenthefemurandtibiaeachby5cms thantolengtheneitherboneby10cms. WhataretheadvantagesofthenewPrecice2.2 ThePrecice1wasdevelopedbyEllipseTechnologyworkingwithateamof orthopedicsurgeonsincludingDr.Paley.Precice1wasdesignedforthetreatmentof leglengthdiscrepancy.Dr.PaleywasthefirstsurgeonintheUStoinserttheP1on Dec.1,2011.ThePrecice2wasspearheadedanddevelopedbyDr.DrorPaleyand EllipseTechnologieswiththespecialconsiderationsofthestaturelengthening patientsinmind.Assuchitisthefirstimplantablenailtobedesignedtowardsthe requirementsofthestaturelengtheningpatient.TheP2wasfirstusedbyDr.Paley inNov.2013.TheP2canlengthenupto8cmsforimplantdiametersof8.5mms, 10.7mms,and12.5mms.TheP28.5mmnailwasdesignedwithsmallerdiameter bonesinmind.Thesearenormallyfoundinchildren,patientswithdwarfismand morepetiteadults(oftenseeninthebonesofmanyAsianwomen).Thestrengthof theP2isupto4timesstrongerallowingforincreasedweightbearing.Furthermore, thedriveshaftconnectionstrengthhasbeenincreasedinstrengthbyuptothree fold,whichreducedtheriskofnailmechanismfailurewhenapatientmakes excessivebone,thuspreventingthecomplicationsofprematureconsolidation (bonehealing)whichcouldarrestthelengtheningprocess.Inshort,thePrecice2 permitsgreaterlengtheningwithastrongernail,strongerdriveshaftwithalarger diametersizerangetoaccommodateallsizepatients.MostrecentlytheP2was modifiedtostrengthenthejunctionbetweenthetwotelescopingendsofthedevice. Thisjunctionhadaspecialweldedconnectionpiececalledacrown,whichwas foundtooccasionallyfailandincreasedtheriskofnailbreakage.Dr.Paleyidentified thisweaknessandmodifiedthePrecicedevicewiththecompanytomakethenail evenstronger.ThenewP2.1cameoutinDec2014andtheP2.2cameoutinMay 2015,replacingallpreviousP2s.TheP2.2nailisevenstrongerandmoreresistant toanyfailureorbreakage. WhatisthecostofsurgeryandphysicaltherapybythePrecicemethod? Thecostofsurgerywithphysicaltherapyis$90,000(Precice2.2)forbilateral femorallengtheningand$100,000forbilateraltibiallengthening(Precice2.2).For individualswhoundergofemorallengtheningfollowedbytibiallengtheningwe offerapackagepriceof$180,000(Precice2.2)ifthetwolengtheningsare performedsixormoremonthsapart.Ifthetwolengtheningsarestaggeredtwoto threeweeksapartsuchthattheirphysicaltherapyoverlaps,thereisfurthercost savingswithatotalpriceof$175,000.Insomeselectindividualswewillconsider simultaneousfemurandtibialengtheningatonesurgeryforatotalcostof$165,000. Pleasenotethatthereisahigherriskforfatembolismwhichcanleadtodeathif bothfemurandtibiadevicesareinsertedatonetime.Althoughwehaveneverhad thiscomplication,itremainsaserioustheoreticalrisk.Itremainssafertodothetwo lengtheningsurgeriesonseparatedatesseparatedbyatleasttwotothreeweeks apart. Arethereanyadditionalunexpectedcostsfromtheinitialsurgery? Thepricingforthefemurandtibialengtheningincludesalladditionalancillary proceduressuchasiliotibialbandreleaseandbicepstendonlengtheningforfemur lengtheningandgastro-soleusrecessionifneededfortibiallengthening.Theseare donetoPREVENTcomplications.Theneedforthisisdeterminedatthefirst consultation.Dr.Paleyperformsthreemusclelengthtests(Obertest,Popliteal Anglemeasurement,andElytest)todetermineiftheiliotibialband-fascialata, hamstrings,andrectusfemorismusclesaretootight.Itisnotpossibletoadvisea patientofthiswithoutseeingthemfirst.Thegreatertheamountoflengtheningthe morelikelyistheneedforsuchsofttissuereleases.Forexample,everypatientwith an8cmlengtheningrequiresaniliotibialbandreleasewhileonly50%requirethisif lessthan5cmsiscarriedout.FortibiallengtheningiftheAchillestendonistootight asdeterminedbytheSiverskioldtest(physicalexamination)thenagastro-soleus recessionisrequiredpriortolengthening.Ifthesestructuresaretightbefore surgeryandnotprophylacticallylengthenedthenmuscle/jointcontracturesthat requirelatermoreexpensivesurgeryarerequired(inthelayliteraturetheseare referredtoasduckassdeformityfortightiliotibialbandandfascialata,and ballerinafeetfortightAchillestendon).Prophylacticanteriorcompartmentrelease maybedoneatthetimeoftibiallengthening.Thisisdonetopreventcompartment syndrome.Thenormalcostofthesereleasesisbuiltintotheglobalfeeforthe lengtheningsurgery. Fortunatelycomplicationsthatrequiresurgeryareuncommon.Wehadtwopatients inthepast50thatexperiencedunexpectedcomplicationsthatrequiredadditional unplannedsurgerytofix.Thisleadtoadditionalcostsofabout$30,000eachtofix thecomplication.Thisriskisabout4%.Wethereforeadvisetokeepabout$30,000 inreserve. Willinsurancepayforcosmeticstaturelengtheningsurgery? Cosmeticsurgeryofanykindisnotcoveredbymedicalinsurance.Costisthe numberonelimitingfactorformostindividualsseekingcosmeticstature lengthening.Notonlywillinsurancenotpayforthesurgery,but,ifacomplication arisesthatrequiresadditionalsurgery,insurancewillnotpayforthecosts associatedwithtreatingthecomplication. CanIgetthesurgerycheaperinothercountriesandisitsafe? ThePaleyInstituteistheSAFESTplaceintheworldtohavethissurgery. Costsvarybycountry,center,surgeonandtechnique.Thecostofthedevice contributesalottothecostoftheprocedure.Externalfixatorswhileexpensive whennewcanbereused.Thereforethecostofreusedexternalfixatorsisvery cheap.Theexperienceundergoingthissurgerywithbulkypainfulexternalfixators, withalloftheircomplicationsincludinginfections,jointstiffness,andscarscannot becomparedtohavingtheproceduredonewiththenewest,safesttechnologywith fewscarsandlittlepain.Manypatientschoosetogooverseasfortreatmentonly becauseofcost.Therearemanycenterswhereyouputyourselfatriskofdisaster andpermanentdisability.Ihavehadtofixthecomplicationsofsurgeryofmanyof thesepatientsthathadlengtheningdoneoverseas.Sincethissurgeryisvery lucrativeitisopentoabuseallovertheworldincludingintheUS.Itisverydifficult fortheconsumertodiscernwheretogo.Alllimblengtheningsurgeonsorcenters arenotthesame.Justbecauseitischeaperdoesnotmeanthatthepatientwillget thedesiredresult.Ihavecometotheconclusionthatinmanycasesyougetwhat youpayfor.WhilethecostintheUSishigherthesafetyfactorisalsoproportionally higher.Inthepast5yearsIhaveseenandoperatedupon20Americanandforeign patientswhowenttohavecosmeticstaturelengtheningatoverseaslessexpensive centers.Thecosttoreconstructand‘rescue’theirlimbswasashighorhigherthan thecosttoundergotheprocedureatthePaleyInstituteinthefirstplace.Thefinal resultalthoughimprovedafterIoperateduponthesepatientsisnotasgoodasifI haddonethesurgeryoriginally.Finally,thePreciceisthemostadvancedmethod andsafestmethodforcosmeticlengtheningwithlesspainandlowercomplications thanothermethods. HowexperiencedisthePaleyInstituteatlimblengthening? ThePaleyInstituteisthemostExperiencedPlaceintheworldtohavethissurgery. Dr.DrorPaleyisthemostexperiencedlimblengtheningsurgeonintheworldfor bothstaturelengtheningandforlengtheningforlimblengthdiscrepancy.Hehas performedover20,000limblengtheningsurgeriessince1986.Hehasthebesttrack recordofsuccesswithalltypesoflimblengthening.Thisisveryimportantas regardssafety. Whatisthemostimportantconsiderationwhenchoosingalimblengthening surgeonandcenter? SAFETYisnumberONE.EXPERIENCEisnumberTWO. Limblengtheningcanleadtomanycomplications.Unlikeothercosmeticsurgery, limblengtheningcanleadtochronicpainanddisability.Thereforethemost importantfactortoconsiderisNOTCOST,butratherSAFETY.Therearemany centersaroundtheworldofferingstaturelengtheningatcheaperpricesthanatthe PaleyInstitute.Therearenoothercentersofferinglimblengtheningassafelyasat thePaleyInstitute.SAFETYisthemostimportantconsiderationwhenchoosing wheretogo.SafetycomesfromEXPERIENCEandorganization.AtthePaley Instituteweprovidethemostexperiencedlimblengtheningteamintheworldwith thebestsafetytrackrecordintheworld.Themultidisciplinaryorganizedteamof surgeons,anesthesiologists,medicaldoctors,nurses,physicianassistants,physical andoccupationaltherapists,orthopedictechnologists,etc.allofwhicharededicated tothelimblengtheningprocessmakethisprocesssafe,secureandasstreamlinedas possible. CanIgetfinancingtohelppayforthesurgery? Wedonotprovidefinancing.However,wecangiveyouthenameofoneortwo financingcompaniestocontactdirectly.ForthisinfopleasecontactJessica jsousa@lengthening.usinourfinancialdepartmentwhocanconnectyouwith financingcompaniesthatmaybewillingtomakeloansforthistypeofsurgery. Whatiscoveredinthecostofsurgery? 1) Hospitalstayforupto4days.Thereisasurchargeforpatientsstayinglonger thanthis 2) Allhospitalchargesrelatingtotheoperatingroomandrecoveryroom 3) Implantcosts:TwoPRECICE2.1lengtheningrods.EachPrecicecosts $15,000Thereforejustthecostoftheimplantsforbilateralimplantable lengtheningimplantsis$30,000. 4) Anesthesiologistfees 5) Surgeonsfees 6) Surgeryassistantfees 7) Hospitalistfees(internalmedicinedoctoravailableduringtheentirehospital stay) 8) Radiologistfees(includestheirreadingfeeofallthex-rays) 9) Allx-rays:upto11weeks(surchargeafter11weeks) 10)Allofficevisits:upto11weeksfemurs;upto14weeksfemursplustibias combined(surchargeafter14weeks) 11)Transportationtoandfromtheofficeandhospital(5daysperweek)for officevisitsifyoustayatoneoftheapprovedextendedstayhotels(seelist below) 12)Wheelchair,walker,crutchesandbedsidecommodeasneededforpost surgery;providedaspartofdischargefromhospital. Whatiscoveredinthephysicaltherapyfees? 1) Daily(5daysperweek)onehourofphysicaltherapyatthePaleyInstitute outpatientrehabcenter(thereisnoPTonweekends);upto11weeks femursandtibias(surchargeafter11weeks);femurplustibiaoverlappedup to14(surchargeafter14weeks). 2) TransportationtoandfromthePTcentertoextendedstayhotelsonthe approvedlist.PTislocatednexttoourofficeandonthegroundsofthe hospitalcampus. Whatisnotcovered? 1) Medicationsandpharmaceuticals(e.g.painmedicine,anticoagulants, supplementse.g.calcium,bonehealthnow,VitD) 2) AccommodationsinWestPalmBeach 3) TraveltoandfromWPB 4) Traveltothehospitalonweekends(althoughthehotelshuttleswillusually providethisforfree) 5) FoodandothersuppliesduringthestayinWPB 6) EntertainmentorInternet 7) Homehealthaids(nurses,homemaker,etc) WhendoIhavetosendthepaymentanddoIneedtoleaveadeposittohold thesurgerydate? Fullpaymentisduetwoweeksbeforesurgeryorthesurgerywillbecancelled. Paymentcanbemadebywiretransferorcertifiedcheckbutnotbycreditcard.A non-refundabledepositof$10,000isdueatleasttwomonthsbeforesurgery.The depositcanbemadebycreditcardonthephoneorbywiretransfer.Wewillnot holdasurgerydateformorethan3dayswithoutadeposit.Cancellationorchangeof surgerydatebythepatientortheirfamilywithlessthantwomonthsnoticeresultsin lossofthedeposit.Thedepositisfullyrefundableifchangesorcancellationof surgeryaremorethantwomonthsbeforethebookedsurgerydate.Thedeposit moneyispartofthetotalfeeandwillbecreditedtothetotalamountdueifitisnot lostduetolatecancellationorchanges.Inthecaseoflatecancellation,rebookingof surgerywillrequirenewdeposit. HowmuchmoneyshouldIkeepinreserveincaseofacomplication? Complicationsalthoughinfrequentcanoccurandmayrequiresurgerytotreatand topreventanegativeoutcome.Anexampleisprematureconsolidationofthebone whichrequiresrebreakingthebone(nocasesexperiencedsincetheP2).Anotheris nerveentrapmentwhichrequiresnervedecompression(onecaseexperiencedwith Precicesince2011).Anotherismusclecontracturewhichrequireslengtheningof muscles,tendonsorfascia(onecaseexperiencedsince2011).Finallytherecanbe failureofbonehealingaftertheendofthedistractionphaserequiringrepairof nonunion(nocasesexperiencedsince2011).Thecosttotreatmostofthese complicationsrangesfrom$12-$35,000. Whatisthelikelihoodofcomplicationsthatwouldrequireadditionalsurgery? Thelikelihoodofcomplicationsthatrequireadditionalsurgeryfortreatmentisless than5%. CanIhavelengtheningofthefemurandtibiatogetheratthesametimetosave timeandexpenseandtogetmorelengthandbetterproportions? Lengtheningofthefemurandtibiaallowsforgreaterheightgainandbetter proportionsofthefemursandtibias.Lengtheningbothbonesismuchmore involvedandmoreexpensivethanlengtheningonlyonepairofbones. Options Cost Dothefemurandtibialengthening $165,000 surgeryatthesametimeinone surgery Maximum LengthGain Risk 5cm+5cm= 10cmtotal HighestRisk for FatEmbolism &death Dothefemurandtibialengthening $175,000 surgerythreeweeksapartintwo surgeries 5cm+5cm= 10cmtotal MorePain Dothefemurandtibialengthening $180,000 surgeryayearapartintwo surgeries. 8cm+6.5cm= 14.5cmtotal SmallestRisk Greatest LengthGain Option1isthehighestriskandIwouldnotrecommenditsincethereisamuch higherriskoffatembolismwhichcanevenleadtodeath.Ihaveonlyperformedthis optioninonepatient.Fortunatelyhedidnothaveanycomplications. Option2isthesaferwayofachieving10cmlengtheninginonetimebyoverlapping thetwosurgeries.Thetreatmenttimeisalittlelongerthenoption1byaboutthree weeks.Thecostisreducedcomparedtooption3sincethephysicaltherapyisdone atthesametime. Option3isthesafestwayandallowsgettingthemostlengtheningsincethefemur andtibialengtheningaredoneatdifferenttimes.ItrequiresmorePTandmore time.Wegiveadiscountonthesecondlengtheningof$10,000sothetotalislower thanthenormalfemurplustibiacosts. Althoughfemurandtibialengtheningcanbedoneatthesametimeweprefernot insertthefemurandtibiarodsinthesamesurgeryduetothetheoreticalincreased riskoffatembolismsyndromefromreamingthemedullarycanalofmorethantwo bonesatatime.Toinsert4rodsatthesamesurgerywouldincreasethechanceof fatembolismanddeath.Wehavedonethissuccessfullywithoutcomplicationbutdo notrecommendit. Howarethescarsfromsurgery? WeuseaminimallyinvasivemethodtoputthePrecicedeviceintothebones.Ahalf inchincisionismadeatthehiparea,and4or5quarterinchincisionsaremadeon thesideofthethigh.Thesescarsaresosmalltheyarenotverynoticeable.Mostlook nobiggerthanamosquitobite. Howpainfulislimblengthening? Immediatelyaftersurgery,thereispostsurgerypain.Mostpatientshaveepidural anesthesiaorPCA(patientcontrolledanalgesia).Weofteninjectalongactingslow releaselocalanestheticintothewounds(Exparel)whichlastsfor96hours.These methodsofferexcellentpostoperativepaincontrol.Patientsareswitchedtooral painmedicationinpreparationfordischargefromhospital.Afterdischargeall patientsreceiveaprescriptionfororalpainmedication.Duringthefirsttwoweeks aftersurgerymostpatientsstillfeelsomepostsurgicalpain.Oncethisisgonethe comfortlevelisgreatlyimproved.Themostpainfultimesareduringstretching exercisesduringphysicaltherapyandwhengoingtosleep.Weoftenprescribesome medicationtohelpwithsleep.Mostpatientsdonotcomplainofmuchpainduring thedaytime.TheactuallengtheningprocessofthePreciceisusuallypainless.Most patientshavelittletonopainduringthemajorityofthelengtheningprocess. WhatcanIdotoprepareforsurgery? a) Education: (i)Readallprintedmaterialsweprovide. (ii)Bookaconsultationandhaveyourquestionsansweredinperson (iii)Emailusanyadditionalquestions b)Physicalpreparation: Stretchingexercisesmayhelp. Forfemurlengthening: 1) iliotibialband;lieonyourside,extendyourhipsoyourthighisinlinewith yourbodyandflexyourknee.Inthatposition,tryandbringtheflexedknee towardstheground.Alsocandocrosslegstretcheswiththehipstraight. ThesestretchestheITband. 2) quadricepsandespeciallytherectusfemorismuscle(bendkneewith straighteningofhipatsametime.Canbedonestandingpullingfootbehind buttandleaningbackorkneelingwithleaningback). 3) Hamstrings:kneestraighteningwhileflexinghip. Fortibiallengthening: 1) Achillestendon:heelcord;maximumdorsiflexion(footup)withfullknee extension(straight). c)Stopsmokingandexposuretosecondhandsmoke. d)Stopallanti-inflammatorymeds. e)Socio-economicpreparation: Organizeyourlifesoyoucanputitonholdforatleastthreemonths.Youwillneed tostayinWestPalmBeachforatleast9weeks.Youmaynotbeabletogobackto worksinceyouwillstillbewheelchairdependentwhenyoureturnhomeforatleast onemonth.Prepareyourfinancessoyoucannotonlyaffordthissurgerybutalso affordanypossiblecomplicationsfromthissurgerythatcanarise.Thesearenot commonbutcanbecostlywhentheydooccur. Bepreparedtobesinglemindedandnotdistractedduringtheprocesssoyoucan devoteallyourenergiesandattentiontothelimblengtheningprocessand rehabilitation. VisitWestPalmBeachandcheckoutwhereyouwillstayandthelayoftheland. Arrangeforsomeonetocomewithyouorbepreparedtohirehomehealthtohelp you(seeseparatesectiononthis). Organizealeaveofabsencefromyourjobsothatyoudon'tfeelthepressureofthe needtogetbacktowork. DoIneedapsychologicalevaluationbeforesurgery? NO FormyfirsttwentyoneyearsIusedapsychologisttoevaluateallmypatients beforesurgery.Aftermorethan20yearsIhavegottenfairlygoodatdoingthis evaluationmyself.Thepurposeofthisevaluationistomakesurewearenot operatinguponpatientswithabodydysmorphicpsychosisaswellastomakesure thatpatientshaverealisticexpectationsandhavethepropersupportrequiredto undergothisprocedure. DoIneedtobookaconsultationbeforesurgery? RECOMMENDED Althoughtheinformationprovideviaemailisveryeducational,itispreferabletobe assesseinperson.Thishelpsyoubecomeaspreparedaspossibleforthesurgery. Wehavefoundthatpatientswhodonotcomeforaconsultationarenotasprepared forthesurgeryandhavemuchmoredifficultywhentheyundergothisprocedure. Wemakeexceptionstothisonlyforpatientscomingfromoverseasandbookthe consultationtheweekbeforesurgery.Pleasenotethatthisisnotoptimalsincethese patientsarelesspreparedforsurgerythanthosethatcomeinforaconsultation wellinadvance. Whatisinvolvedintheconsultationandhowmuchdoesitcost? Theconsultationstartswithaspecializedstandingx-raycalledanEOSscan.Thisis alowradiationdosescanofyourentirebodyfromheadtofootinabiplanarfashion (frontandsideatthesametime).Thismaybedonethenightbeforethe consultationiftheconsultationisfirstthinginthemorning. YouwillmeetwithDr.Paley’sphysicianassistant(ServandoorJohn)orassistant orthopedicsurgeon(Dr.Packer).Theywillbeginbyobtainingadetailedhistory. Yourheight,weightandarmspanwillbemeasured. Dr.Paleywillthencomeinandevaluateyouandyourx-raysincludingaphysical examinationofrangeofmotion,muscletightness,etc.Hewillexplaintheprocedure andadvisethebeststaturelengtheningstrategyforyouaccordingtoyourspecific heightincreasegoals.Thiswillalsoincludeconsiderationofyourproportions.Dr. PaleywillmeasureyourboneproportionsfromtheEOSscan.Thenormal proportionofthetibiatofemurlengthsis0.80+/-0.02.Iftheratioisgreaterthan 0.82yourtibiasarerelativelylongcomparedtothefemursandfemorallengthening maybepreferable,whileiftheratiosarelessthan0.78thentibiallengtheningmay bepreferable.Thismustbetemperedbytheamountoflengtheningdesiredsinceup to8cmcansafelybedoneinthefemursandusuallyonly5cminthetibias.Dr.Paley willgointotheseandotheraspectsoflengtheningindetailsandtryandanswerall yourquestions. AftertheconsultationwithDr.PaleythePAorDr.Packerwillstaytoanswerany additionalquestionsthatmayremain.Theywillthentakeyouovertothephysical therapydepartmentforatour.Ifpossiblewewilltryandintroduceyoutoother staturelengtheningpatientsiftheyarearoundatthetime.Wecannotguaranteethis astheseotherpatientsarescheduledforPTindependentlyofourconsultation schedule.Wealsomustrequestpermissionfromthem.Werespectandguaranteeall patientsprivacy. CanItakeatourofthePaleyInstituteinadvanceofthesurgery? Atourispartofeveryconsultation.Readabove. HowdoIbookaconsultation? PleasecallthePaleyAdvancedLimbLengtheningInstitute844714-5293(TollFree) 561844-5255(Main)[email protected] makesappointmentsfornewpatientconsultationsinmyoffice. HowdoIbookasurgerydate? PleasecontactRebecaMonesoursurgeryscheduler.YoucaneithercallthePaley AdvancedLimbLengtheningInstitute877765-4637(TollFree) 561844-5255(Main)[email protected] asurgerydateshewillaskyoutomakeadepositonyourcreditcardasexplainedin aprevioussection. HowdoIprotectmyprivacyregardingmyconsultationandsurgery? AtthePaleyInstituteweareHIPPAcompliant.Wecannotandwillnotreleaseyour nameormedicalinformationtoanyoneunlessyouauthorizeit.Theonlyexception tothisisminorpatients WillIneedtocomeinthedaybeforesurgery? Youwillhaveapreoperativevisitwiththesurgeryteamtogoovertheconsentform andallofthepaperwork.Youwillalsohaveanappointmentwithourpreoperative nurseandanesthesiologist.Youcandiscussyouranesthesiaandpostoperativepain managementinadvanceofthesurgery.Youwillbegiveninstructionsforsurgery. Youshouldnoteatordrinkaftermidnightandyoushouldcomeintwohoursbefore yourscheduledsurgerytothepreopareaintheKimmelbuildingonthecampusof St.Mary’sHospital,90145thSt. Howlongisthehospitalization? Thehospitalizationisusually3-4nights.AtSt.Mary’sHospitalthisisinaprivate roomonthenewlyrenovatedsurgicalcareunitintheWaters3Pavilion. Whatwillhappenduringthehospitalization? Aftersurgeryyouwillbetakentotherecoveryroomforanhourortwobeforegoing toyourroom.Ifyouhavefamilyorfriends,ourpatientliasonCandicewillkeep theminformedduringthesurgeryandthenorganizeforDr.Paleytospeaktothe familyafterthesurgery.Shewillthenbringthefamilyorfriendsintotherecovery room(PACU)afterthesurgerytobebesidethepatient.YouwillhaveanIVanda Foleycatheter(bladdercatheter).TheFoleywillremaininplaceuntiltheepidural catheterisremoved.IfnoepiduralthentheFoleycanberemovedoneortwodays aftersurgery.Whileinhospitalyouwillstartonabloodthinnertopreventblood clots.Thenurseswillmakesureyouarecomfortableandpositionedinsuchwaysas topreventpressuresores.Youwillhavebloodtestdrawneachmorningtocheck yourbloodlevel.Ifyourbloodlevelislowatransfusionmaybeordered.Each morningthesurgicalteamwillcomebytocheckuponyou.Thiswillinclude physicianassistants,nursepractitionersanddoctors.TheepiduralorPCAwillbe discontinuedusuallyaftertwodays.Aphysicaltherapistwillcomeeachdaytostart teachingyoutomovearoundandtobecomemoreindependent.Youwilllearnskills suchastransferstoandfromwheelchairandbedsidecommode,etc.Onceyouare mobileenoughyouwillbedischargedfromhospitalwithinstructions. WillIrequireabloodtransfusion? Somepatientsloseenoughbloodtorequireabloodtransfusionbeforesurgery. Thereforeautodonationisanoptionbutnotrequired.Weusebloodfromtheblood bankifneeded.Thelossofbloodoccursnotonlyduringsurgerybutalsoafter surgeryforacoupledays.Thetransfusionifneededalmostalwaysoccursoneor twodaysaftersurgery.Therisksfromthisareveryminimal.Twenty-fivepercentof ourpatientsrequiretransfusion. WillIleavethehospitalwithawheelchair,walker,and/orcrutches? Yes.Youwillbegivenawheelchairandawalkertotakewithyou.Ourcasemanager EmilyWardwillorganizeallofthisforyou.Ourinpatientphysicaltherapistswill teachyouhowtodotransfersfrombedtochairtotoilet.Youwillstartwalkingwith awalkerandlatertransitiontocrutchesasanoutpatient. WhatmedicationswillItakeafterdischargefromthehospital? Bloodthinnertopreventbloodclots:Xarelto10mgdaily(approximately$313.99 permonthtimes4months) Painmedicine(asneeded):Percocet5/325#90pillsan8-10daysupply (approximately$44.97);werefillthisasneededduringthelengthening. Musclerelaxant(optional):Valium5mg#90pillsonemonthsupply (approximately$24.00) WherewillIstayafterdischargefromhospital? Thereareseveraloptions. 1) Themostcommonplacetostayisatoneofourextendedstayhotelswhich areon45thSt.Thisisafewmileswestofthehospitalonthesamestreetas thehospital.Thecostofstayatthesehotelsisusuallybetween$63-99per night.Costmayvarywithseasonandavailability.Highseasoniswinterand lowseasonissummer.Pleasebookasfarinadvanceaspossibleespeciallyin season.AlwaysaskforthePaleyrate. (Shuttleserviceprovidedtohospital) HomewoodSuitesByHilton–561-682-9188 ResidenceInnByMarriott–561-687-4747 SpringhillSuitesByMarriott–561-689-6814 (NearAirport,shuttleservicenotprovided) DoubletreeByHilton–561-689-6888 2) Rentingacondominiumorhouse. 3) Stayingatanotherhotel. Istransportationavailabletoandfromthehospitaltoplaceofresidence? Wheelchairtransportationvansareavailabletotakeyoutoandfromthehotelto thehospitalonlyifyoustayattheextendedstayhotelslistedabove. HowlongdoIneedtostayinWestPalmBeach? Youneedtostayuntiltheendofthedistractionphase(lengthening).The distractionphaselengthforfemurlengtheningisonedayforeachmmofplanned lengthening.E.g.65mms=65days.Wedon'tstartlengtheningforbetween0-7days dependingontheageofthepatient.Thereforeifwedon'tstartlengtheninguntilthe 5thday,70daysfor65mmsand85daysfor80mms.Tibialengtheningis¾mmper daycomparedto1mm/dayforfemurlengthening.Fortibialengtheningthe distractionphasefor50mmis10weeksplusoneweekbeforewestartlengthening. WillIneedhelptolookaftermyself? Yesyouwillneedhelpforthefirsttwotothreeweeks.Youeitherneedtocomewith someonewhocanhelplookafteryouorelseyouwillneedtohireahomehealthaid forthefirsttwotothreeweeks.Wecanhelpyouarrangeforthis.Thehourlycostof thisisapproximately$18/hr.Inthefirstweekafterdischargefromhospitalyouwill requiremorehoursofhelpandlesshelpastimegoeson.Youneedtobudgetforthis ifyouarecomingalone.Attheveryleasteveryoneneedshelpforthefirsttwo weeksafterdischargefromhospital.Ifyoudonothaveanyonewithyouthiswill costyouatleast16hoursadayofhelpat$18perhour(fortwoweeksthecostcan beuptoabout$4000). Howmuchweightbearingisallowedduringlengthening? Duringdistractiontheboneendsareheldseparatedbytheimplantablerod.This rodissecuredtothebonebyscrewsateitherend.Thediameteroftherodranges from8.5-10.7-12.5mms.Thescrewshaveadiameterrangingfrom4-5mms.With enoughrepeatedloadingthescrewsofanyimplantwillbendorbreak.Noimplant ofanymakeordesignisimmunetothis.Theheavierthepatientthegreaterthisrisk. Thisistrueofanyimplantablelengtheningnailnomatterwhatthematerialitis madeofandnomatterwhatyouaretoldbythemanufacturerorthesurgeon. WepermitfullWBwhenweseecompletebridgingoftheboneonthex-ray.Atthat pointtheboneistakingtheloadandprotectingtherod.Duringthelengtheningwe allowWBusingcrutchesorawalkerandunweightingthelegsusingthearms.The amountofWBalloweddependsonseveralfactors:theweightofthepatient,the diameteroftherodandthebonebeinglengthened.Forthelargestdiameter Precice2,12.5mms,weallowupto75lbs(34kgs)oneachleg.Thismeansthat whenapatientisstandingontwolegswithtwocrutchesonthegroundtheycan takeupto150lbsor(68kgs).However,whenwalkingandtransferringloadfrom onelegtotheotherapatientMUSTUSETWOCRUTCHESonthegroundand unweightthemselvestothe75lbs(34kgs)weightwitheachstep.Patientsmust NEVERwalkwithonecrutchduringthedistractionphasenomatterhowmuchthey weigh.Duringtheconsolidationphasethesamerulesapplyuntilthesurgeon increasestheWBquota.ToknowhowmuchWBisbeingdoneapatientcanstand onabathroomscaletillitreachesthedesirede.g.75lbsnumber.Forthesmaller diameterrods10.7mmsand8.5mmsnomorethan50lbs(23kgs)isallowedperleg. AmIallowedtodrive? Patientsundergoingimplantablelimblengtheningcandriveoncetheyarenot takingnarcoticsduringtheday.Theydohoweverneedtobeabletogetinandoutof thecarontheirown.Standupwithcrutchesorwalkerandtransfertoawheelchair ontheirownforcompleteindependence.Theymustlearnandbeabletodothis whileabidingbytheWBrestrictionsabove. HowoftenwillIhavephysicaltherapy? Daily,5daysaweekfortheentiredistractionphase.(7daysaweekmaybe availableforanadditionalpaymentof$220persession-pleaseinquireregarding this) DuringconsolidationphasethepatientneedstocontinuewithPTbutlessoften(2-3 daysperweek).Thisisusuallydoneclosertohomesincemostpatientsdepartfrom WestPalmBeachtoreturnhome.Ifyouplantostaylocallyforsometimewecan arrangephysicaltherapyatourcenter.Theadditionalcostofthisisasnotedabove andcanbepaidonaweeklybasis. Dailyhomeexercisesarerequiredbythepatientthroughoutbothdistractionand consolidationphases. Whodoestheactuallengtheningandwhere? Thelengtheningisdonebythepatientortheirhelperattheirplaceofresidence duringthelengthening.Thelengtheningisdonein¼mmincrements,4timesaday forthefemurand3timesadayforthetibia.Forsimultaneousfemurplustibiaboth bonesarelengthenedonly3timesaday.Thelengtheningisdoneusingaspecial devicecalledtheERC(ExternalRemoteControl)device.Ourorthopedictechnologist trainseachpatienttodothisuntiltheyarecomfortableusingtheERCdevice.Each patientreceiveanERCtotakewiththem.TheERCmustbereturnedattheendof thelengtheningtoavoidbeingbilledbyEllipseTechnologiesforthis$10,000device. TheseisnochargefortheERCtothepatientaslongasitisreturned. HowoftenamIseenbythedoctororphysicianassistant? EverytwoweeksatthePaleyInstituteoffice. WhenwillIhavex-raysdone? Everytwoweeks,x-raysofeachbonebeinglengthenedaretaken. OnceIamdonelengtheninghowsooncanIgohome? Immediately. Whatisthefollow-upafterIgohome? Sendmonthlyx-raystoDr.Paley.Thebestwayistoemailtheseto dpaley@paleyinstitute.org.Ifyoucannotfigureouthowtoemailx-raysmailthedisc to: PaleyInstitute,KimmelBuilding,90145thSt.WestPalmBeach,Florida33407 WhencanIresumefullweightbearingwithoutcrutchesorawalker? Afterreviewingthex-rays,Dr.Paleywillemailyouhowtheylookandwhetheryou canresumefullWB.Thisusuallyhappensafteroneortwomonthsfromtheendof distraction.MostpatientscanreturntofullWBonemonthaftera5cmfemur lengtheningandtwomonthsaftera5cmtibiallengthening.Mostpatientscanreturn tofullWBtwomonthsafteran8cmfemurlengthening. WhencanIreturntosports? Youhavetoregainyourmotionandthenyourmusclestrengthbeforereturningto sports.Ifyouworkhardatthisyoucangobackasearlyassixmonthsaftersurgery. Thisisindividualizedbythedoctorforeachpatient. Whataretheresultsfrominternallengtheningofthefemurandtibia? Ihaveperformedimplantablelengtheningofthefemurfor17years,andhaveused theAlibizzia,theISKDandnowthePrecice.Ihavetheworld’slargestexperience withtheISKD(morethan300cases)andthePrecice(morethan400cases)devices. Todateallofmypatientshaveachievedthegoalsoftreatmentandhavereturnedto fullactivitiesincludingsports.Anarticleofourpublishedresultsisavailableupon request. DoIneedtohavethenailsremoved? Yes.Allofthesenailsshouldberemoved.Removaltimingisnotcritical,butmost oftenisdoneoneortwoyearsaftertheoriginalsurgery.Thereasontoremovethe nailsisthattheyaremadefromtitaniumandsincetheyhavemovingpartsand generatemetalionsoverthecourseofmanyyears.Whiletheyareinertandthereis nourgencytoremovethemitisrecommendedtoremovethemoneortwoyears afterinsertion.ThePrecicealsohasarareearthmagnetinside.Thisissealedfrom thebodyinsideawaterproofchamber.Itispossiblethatafteryearsthissealcould leakandtherareearthmagnetwouldbeexposedtobodyfluids.Assuchitis preferabletoremovethisdevicebeforethiscouldhappen. WhatisthecostofremovalofthePrecicedevices? Thecostofremovalisseparateandisnotincludedinthetreatment.Thecostof removalis$17,500fortwofemurPrecices,$22,500fortwotibialPrecices (includingtibio-fibularscrewsandfibularrods)and$27,500forsimultaneous bilateralfemurandtibialPreciceremoval. HowsooncanIhaveanotherlengthening(e.g.bothtibias)? Ifyouchoosetohaveasecondlengtheningdone.Anintervalofsixtotwelve monthsisrecommendedbetweenlengthenings.Itispossibletooverlapthefemur andtibialengtheningsandthisoptioncanbediscussedwithDr.Paley. Whatarethemainrisksandpotentialcomplicationsthatcanoccur? Noonewantsunexpectedproblems,complicationsandcosts.ForthesereasonsIam veryconservativeregardingmanyaspectsofthelimblengtheningprocess.Itryand anticipateproblemsandpreventcomplications.Manycomplicationsleadto additionalsurgeryandthereforetoadditionalcosts.Thefollowingisalistofsome ofthepotentialcomplications: FatEmbolism Thisisacomplicationthatisveryrareandwhichcanbepreventedbyventingthe boneduringthereaming(drilling)ofthemedullarycanalofthebone.ThewayI ventthecanalistodrillholesattheplannedleveloftheosteotomypriortothe reamingprocess.Asthepressurebuildsupinthecanalthereamingssquirtoutthe holespreventingfatembolism.Fatembolismcanmakeapatientverysickrequiring stayintheICU.Patientscanevendiefromfatembolism.Ihaveonlyseenfat embolismtwiceinmypatients.Bothoccurredmorethan10yearsagobeforeI developedaspecialventingmethodtopreventthiscompication.Fortunatelyboth patientsrecovereduneventfully.Ihaveneverhadapatientdiefromthis procedure! DeepVeinThrombosis(DVT)andPulmonaryEmbolism(PE) DVTcanoccurafteranyorthopedicsurgeryorafteranyfracture.Fortunatelywe haveaverylowrateofthiscomplication.Preventioniskey.Weuseanticoagulants aftersurgeryinthehospitalandeachpatientissenthomewithaprescriptionforan anticoagulationdrugtobetakenuntiltheendofthedistractionphase.Thecostof thismedicinemustbebornebythepatientandisnotincludedinourcostestimate. WhileIhaveseenveryfewcasesofDVTfortunatelynoneofthemresultedinPE.PE occursiftheclotdislodgesandwanderstothelungs.Itcancauseshortnessof breath,chestpainandevendeath.Thisiswhywearecarefultoprotectagainstthis. TakingoralcontraceptivesandsmokingincreasestheriskofDVT.Allofourpatients areplacedonananticoagulant,usuallyXaraltoanewlowriskmedication.The patientneedstopayforthisdrugasanoutpatientandthecostisnotincludedwith thesurgery. Prematureconsolidation:inthiscomplicationthepatientbonebridgesthegapand preventsfurtherlengthening.Prematureconsolidation(PC)canoccurwithany methodifthepatientisaveryrapidbonehealer.Thepatientinthesecasesisableto makebonefasterthanthespeedatwhichtheboneisbeinglengthened.Theonly waytopreventthisistospeedupthelengtheningintentionallyforaweekortwo. ThePrecicenailwithitsratecontrolallowsthesurgeontodothis.Ifpremature consolidationdoesoccuritrequiresanoutpatientsmallsurgerytorebreakthebone throughatinyincision.WiththeISKDandAlbizziaprematureconsolidationwasa wellrecognizedcomplicationduetothelackofcontrolofrateoflengthening.Since lengtheninginbothofthesedevicesoccurredbymovementthroughtheosteotomy siteandsincemovementthroughtheosteotomysitecancausepainandmuscle spasm,thepatientsmusclessometimeswouldpreventthemovementandtherefore thelengtheningfromoccurring.InothercasesboththeISKDandtheAlbizziahave hadbrokenmechanismsthatfailtolengthenduringthedistractionphaseleadingto PC.Thetreatmentinthesecaseswastonotonlyrebreakthebonebutalsoto changethedevicetoanewdevice.Althoughineachsuchcasethecompany providedanewdeviceatnoadditionalcost,thepatientstillhadtobearthecostof anadditionaloutpatientsurgery.WiththePrecicethiscomplicationalmostnever occurs. Delayedorfailureofconsolidation:sloworfailedbonehealingcanoccurwithany lengtheningsurgery.Thebesttreatmentisprevention.Westartbyidentifying factorsthatmayslowhealingpriortosurgery:lowVitDlevel,smokingincluding secondhandsmoke,anti-inflamatorymedicineuse,anti-convulsantmedicationuse, menopause,othermedicationusee.g.acutane,.Wealsorecommendsupplementsto helpthebonehealfaster(www.bonehealthnow.com;orderSilical,Silical2and Boost).IfapatientsbloodworkshowsalowVitaminD,thenVitDsupplementsare recommended.Wetryandidentifythesefactorsinadvanceofsurgery.Insurgery wethereareseveralstepsthathelpmaximizethebonehealing:e.g.weusea techniqueoriginallydevelopedbyDr.Paleyin1990toallowbonemarrowto surroundtheareaofthebonecut.Thisisdonebymakingdrillholesatthelevelof theplannedosteotomybeforereamingthebone.Stablefixationisalsoimportantso thechoiceofnaillengthanddiameterareimportantaswellasthelevelofthe osteotomy.Eventhetypeofosteotomyaffectstherateofbonehealing.Cuttingthe bonewithmultipledrillholesandanosteotomeisthemostminimalinvasiveway whileusinganintramedullarysaworperforminganopenosteotomyhavehigher failurerates.Allofthesearesurgeoncontrolledparametersandarebasedon surgeonknowledgeandexperience.Choosingthewronglevelormethodof osteotomyorthewrongdiameterorlengthofimplantcansignificantlyimpactthe result.Thenextmostimportantfactoristherateofdistraction.Lengtheningtoo quicklycanleadtodelayorcompleteorpartialfailureofboneformation.Toorapid distractionwasthemostcommoncauseofpoorboneformationwiththeISKD.This isnotaproblemwiththePrecicesinceithascompleteratecontrol.Poorbone healingcanberecognizedduringthelengtheningprocess.Onceitisrecognizedthe rateofdistractionshouldbeslowed.WiththePrecisethelengtheningcanbe reducedtoanylevelorevenstopped.Ifdespitethesechangesthebonehealing remainspoor,thelengtheningcanbereverseduntilbetterboneformationisseen. Thebonecanthenberelengthened.ThiscanonlybedonewiththePrecise.Going reverseisnotpossiblewiththeISKD,AlbizziaortheFitbone.Thisisahuge advantagethatispossiblewithexternalfixationandnowwiththePrecice. Ifdelayedhealingoccursdespitealloftheabovestepswestartusingtheaccordion technique.UsinganERCdevicetheboneiscompressedonemmperdayand distractedonemmperday.Thiscycleisrepeatedseveraltimesaday.This stimulatesbonehealingandavoidstheneedforsurgery. Delayorfailureofboneformationcandelayweightbearingandincreasetheperiod ofdisabilityandrecovery.Furthermoreitcanleadtotheneedforsurgerytogetthe bonetoheal.Suchsurgeryrequiresabonegraftandisnotasmalloperationandcan bequitecostly.ThereforehavingadevicelikethePrecicethatcanpreventortreat theproblemisamajoradvance. Nerveinjury:nerveinjurycanoccurwithanylengtheningsurgerybutisusually uncommoniftherateofdistractiondoesnotexceed1mmperdayandiftheamount oflengtheningisrestricted.Ratecontrolisthemostimportantfactortoprevent nervedamage.Recognitionofnervesymptomsisimportant.Thelengtheningshould bestoppedorslowedinsuchcases.Ifanymotorsymptoms(weaknessorparalysis ofmuscles)occursanervedecompressionshouldbedoneassoonaspossible.This isasmalloutpatientsurgery.Inmostcasesitistheperonealnervethatgetsinto trouble.Itisimportantthatthesurgeonknowhowtodecompressthisnerveto preventfootdrop.Delayindecompressioncanleadtopermanentfootdrop.With thePreciceandcompleteratecontrol,nerveinjuryisveryrareandgreater lengtheningcanbeperformedsafely. Musclecontractures:musclesnormallygettightwithlengthening.Amuscle contractureoccurswhenamusclegetstightenoughtopreventajointfrommoving throughitsentirerangeofmotion.Topreventmusclecontracturesphysicaltherapy (PT)isessential.Thepatientshoulddodailystretchesofthemusclesandjointsat risk.E.g.kneejointandquadricepsmusclesforfemurlengtheningandanklejoint andAchillestendonfortibiallengthening.InadditiontoformalPTthepatient shoulddotheirownstretchesathomeseveraltimesperday.PTisessentialtothe lengtheningprocess.Itishoweverexpensive.Iwillnotconsiderdoingalengthening ifapatientisnotwillingtodoPT.Thisisnotanoptionforreducingcost.The controlledrateoflengtheningwiththePrecicemakestheriskofmuscle contracturesandmusclespasmless.ThePrecisedoesnotobviatetheneedforPT. Maintainingrangeofmotionandpreventingcontracturesduringlengthening decreasestherehabilitationtimetoreturntonormalfunctionafterthelengthening isfinished.Afixedcontractureofthekneeoranklecanleadtodisabilityandthe needformoreprolongedPTandtheexpensesassociated.IfdespiteadditionalPT thecontracturedoesnotresolveadditionalsurgerytolengthenmuscles,tendons andfasciamayberequired.Itryandanticipatethisandprophylacticallylengthen certainsofttissuestructurestopreventcontractures(e.g.iliotibialband).Ifthisis doneattheinitialsurgerytheadditionalcostissmall.Ifsofttissuelengthening surgeryisrequiredatalaterdatethecostismuchhighersinceonealsohastopay forthehospitalcosts. Fibularcomplications:withtibiallengtheningthefibulahastobelengthenedtoo. Theimplantablelengtheningdeviceonlylengthensandfixesthetibia.Thefibulahas tobefixedtothetibiasothatitlengthenstogetherwithit.Ifthefibulaisnotfixedor notfixedadequatelyitwillnotlengthenasmuchasthetibiaandwillleadtosevere consequencesincludingsubluxationandarthritisoftheankleandflexion contractureoftheknee.Themethodoffixationiscritical.Manysurgeonsonlyfix thelowerendofthefibulatothetibia.Thiscanleadthefibulatoprematurely consolidateandtopulldownanddislocatefromthetibiaatitsupperend.Itis importanttofixthefibulaatbothends.Withexternalfixationthefibulacanbefixed withthewiresofanexternalfixator.Withimplantablelengtheningthefibulamust befixedwithscrewstothetibia;onescrewattheupperendandoneatthelower end.Theangle,level,position,diameter,andtypeofscrewareallimportant.E.g.a commonmistakeistoputthescrewinhorizontallybetweenthetwobones.Thisis notstrongenoughtopreventthefibulafrompullingawayfromthetibiaattheankle. Thisisverysubtleandevenafewmillimetersofdifferenceinlengthofthefibulaat theankleleadtoshorttermand/orlongtermconsequencesforthepatient. Removingasegmentofthefibulatopreventthefibulafromnotseparatingis anothercommonmethodthatshouldbeabandoned.Itleadstoanonunionofthe fibulawhichcanleadtoastressfractureatalaterdateinthetibia.Furthermoreit usuallydoesnotpreventthefibulafrompullingawayfromthetibia.Therefore fibularcomplicationshavenothingtodowiththetypeofimplantablelengthening devicebutratherwiththemethodthesurgeonchoosestofixatethefibulatothe tibiaandthemethodofcuttingthefibulabone. Historicalperspectiveonimplantablelimblengtheningdevices: IhavebeenperformingLimbLengtheningSurgerysince1986.Thetwomain indicationsforsuchsurgeryarelimblengthequalizationforlimblengthdiscrepancy (LLD)andstaturelengtheningforshortstature.Since1986Ihaveperformedover 17,000limblengtheningsurgeries.ThisismorethananyothersurgeonintheUSor theworld.ThemajorityofthesesurgerieswereforLLD.Over1500wereforshort staturerelatedtodwarfismandcosmeticreasons. Dr.Paley’shistorywithcosmeticlengtheningforstatureisasfollows: Dr.PaleystartedwiththeIlizarovmethodforlengtheningofbothtibiasin1987and soonafterswitchedtothelengtheningovernailmethodhehaddevelopedin1990. Althoughhisresultswereexcellent,thescars,thepain,thesuffering,thepinsite infectionswerenotconducivetoacosmeticprocedure. Hesoughtafullyimplantablelengtheningsolution.WhentheAlibizzianail, developedbyGuichetbecameavailableheworkedwiththeFrenchcompanythat madethenailtodevelopatibiallengtheningAlbizziaforstaturelengthening.He startedusingthisin1996.Theseverepainexperiencedbypatientsfromthe15° rotationofthethighthroughthebreakinthebone,aswellasseveralimplant failuresleadhimtostopusingthisnon-FDAapproveddevice.In2001,whenthe ISKD,developedbyDr.ColewasapprovedbytheFDAandmarketedbyOrthofix becameavailable,Dr.PaleywasthefirstsurgeonafterDr.Coletoimplantthis device.Thisdeviceturnedoutnottobeagreatdeviceforstaturelengthening. Althoughheperformedover350ISKDimplantablelimblengthenings,morethan anyoneintheworld,thelackofratecontrolwiththisdevicecausedmany complications.TheotherproblemwiththeISKDwasfrequentmalfunctionofthe mechanism,whichforunexplainedreasonswouldfailtolengtheninthemiddleof thedistractionphase.Thisleadtoincreasednumbersofprocedurestotreat complications.Forstaturepatientsthisalsomeantincreasedcosts.Despitethishis finalresultswereexcellentinalmosteverypatientwiththeISKD.TheISKD,the AlbizziaandtheFitboneareallcontemporarydevices.Theycanallbeconsidered firstgenerationlengtheningnails.Theyallsufferfromsignificantmechanicaland otherproblems. ThefirstsecondgenerationdeviceonthemarketisthePrecice.OnDecember1, 2011,Dr.Paleyimplantedthefirst3PrecicenailsintheUnitedStates.ByNovember 2013,heperformedover155Precicecases.Atpresenthehasimplantedmorethan 400Precicenails(morethananyothersurgeonworldwide).Thesecasesinclude femoral,tibialandhumerallengtheningwiththePrecice.Theresultswiththis devicewereexcellent.Themostseriousshortcomingsofthedevicewerebreakages ofthenailoritslengtheningmechanismthatoccurredmostlywiththeP1andtoa muchlesserextentwiththeP2andP2.1.Therehasnotbeenanybreakagewitha P2.2.Dr.PaleywasthefirsttoidentifytheseproblemsandtogetherwithEllipse Technologiestheysetouttoredesignthenail.ThefirstimproveddevicewastheP2 withincreasedstrengthofthenailshellbyupto4Xandofthemechanismbyupto 3X.TheP2waslaunchedinNov2013andDr.Paleyagainwasthefirsttousethis improveddevice.Thiseliminatedtheproblemswiththemechanismfailuresand reducedthebreakagessignificantly.Dr.Paleythenrecognizedamoreminor problemintheP2withfragmentationofawasherthathelpsconnectthetelescopic partsofthenailtogether.Thisleadtofurtherdesignchangesandtheemergenceof theP2.1inDec2014andP2.2inMay2015.Sincethentherehavenotbeenany furtherbreakages.Theimprovementshaveallowedforincreasedweightbearing. HerearethelinkstofirstPRECICElengtheningsweperformedinthenews: http://newsok.com/edmond-woman-takes-steps-to-lengthen-legs/article/3634689 http://southfloridahospitalnews.com/page/Dror_Paley_is_First_Surgeon_in_US_to_P erform_Limb_Lengthening_with_New_PRECICE_Remote_Control_Device/7038/1/ http://abcnews.go.com/Health/york-man-grows-inchessurgery/story?id=15776730