Download Cosmetic Stature Lengthening Frequently Asked

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