Treatment process

In order to ensure optimal and consistently good treatment quality, standardized procedures have been introduced at ZEM-Germany that cover all important aspects. These include scientifically-recognised questionnaires that record both the orthopaedic surgical problem and the social environment, i.e. the family and professional situation. Photographic documentation for measuring arms or legs supplemented by a gait analysis or functional video allows side-to-side differences or abnormalities in movement patterns to be identified. In the course of a comprehensive examination, the range of motion of all joints on both sides is measured and accurately documented. The data obtained in this way already provide an initial assessment, so that proper X-ray examinations can then be arranged, which then form the basis of the consultation and treatment.

X-ray diagnostics

If the lower extremities are involved, which is most often the case, an X-ray of both legs is taken in a standing position using a long standing radiograph with the world's first full-sized image detector made by Fuji-film. A special stand for standing leg X-ray exposures with integrated leg length compensation and weight control, which went into operation in 2020, was developed especially for ZEM-Germany. All important geometric parameters (see leg geometry) of the legs can thus be measured with only two correctly adjusted X-ray images while aligning the spine. As there are no artifacts caused by movement, this examination is also suitable for children. If there are indications of torsional deformity, computerized tomography (CT scans) allows the torsion angles of the bones to be measured accurately.

After completion of the examinations, all diagnostic parameters are tabulated and graphically processed so that a comprehensive analysis of the individual problem and a well-founded treatment recommendation is now possible.

In a detailed information and consultation session, the examination results and all findings are first explained and the X-ray images are projected on large monitors. This is followed by a discussion of various treatment options with subsequent evaluation and final treatment recommendation. Minor shortening can be compensated for with shoe inserts or sole lifts. In the case of additional deformities, however, this is usually not sufficient in the long term. Especially in young patients, it is therefore usually more beneficial to address the root cause of the problem and eliminate shortening and deformity through surgery. Due to the high degree of specialization, the reputation of the diagnostics and consultation at ZEM-Germany are known far and wide, and we are frequently consulted for second opinions.

The examination findings and our treatment recommendation, including the X-rays if requested, are also sent by post within one to two weeks. Of course, you can bring relatives or people you trust to the consultation.

Operation preparation

About 2-4 weeks before an operation, a second outpatient consultation takes place at ZEM-Germany, during which any needed further information is obtained and to provide sufficient opportunity to clarify all remaining questions directly with the surgeon. The hospital stay, the surgical intervention and the entire subsequent treatment are discussed in detail with regard to all special features, so that every patient is well-prepared and can start the treatment with confidence.

The preparation for the operation can be carried out by your family doctor or directly before the inpatient admission in Munich, whereby the individual particularities are taken into account. In most cases, an inpatient admission on the day of the operation is sufficient. Our partner clinics have the highest standards of hygiene in all areas. Rooms of various categories are available and the ZEM team will be happy to help relatives find a hotel. Depending on the procedure, an inpatient stay of 2 to 6 days should be expected.

Operation

The operation itself takes place in a modern equipped operating theater under general anesthesia. The aim is always to achieve an optimal treatment result in terms of length, leg alignment and rotation (see leg geometry). A preoperative planning technique developed at ZEM-Germany (reverse planning method) is used in a standardized manner and usually enables a complete correction of all deviations from normal during the course of a single operation. Axial and rotational deformities can be corrected intraoperatively in many cases. Leg lengthening always requires careful bone cutting and subsequent slow stretching so that new bone tissue can form in the resulting gap and the soft tissues can grow along with it. In the vast majority of cases, fully implantable distraction nails can be used, so that external fixators have become the exception for many years. With new instruments (Tube II system), consisting of thin-walled tubes, intramedullary nail operations can also be carried out in a way that is gentle on the tissue and typically through miniature incisions, so that hardly any scars remain.

At ZEM-Germany, patients benefit from minimally invasive surgical techniques developed here that are gentle on bone and soft tissue - the result of a high degree of specialization and many years of experience.

Clinic stay

On the 1st day after the operation, you can get out of bed with the support of the physiotherapy team. If necessary, you will be instructed in the use of crutches. If there is a need for limb lengthening, instruction in the use of the light and easy-to-use control device, which are loaned to you, takes place as early as the 3rd day after the operation. On the 4th or 5th day after the operation, discharge from the clinic is usually already possible. It is possible to wear normal clothes, shower and bathe, and weight can be put on the operated leg with the help of crutches. The low risk of infection and the high level of comfort during treatment are the significant advantages of fully implantable distraction systems.

Lengthening phase

A central focus of treatment at ZEM-Germany is shortening of arms and legs. No other center has more experience in this field with fully implantable, electromagnetic lengthening nails. With a light electronic control device, the surgically-divided bone is pulled apart by approx. 1 mm/day (in the case of simultaneous upper (femur) and lower leg (tibia) lengthening even by approx. 2 mm/day) at the push of a button. The lengthening process only takes 90 seconds 3 times a day and is completely painless. Unpleasant to painful, however, is increasing pressure on the joints which occurs during lengthening, and may require painkillers to treat. To ensure a safe course of treatment, regular outpatient check-ups are necessary, usually every one to two weeks at ZEM-Germany.

Consolidation phase

The bony healing of a surgical corrective measure usually takes about 3 months. In the case of lengthening, however, this phase can be considerably longer depending on the extent of the lengthening. The new bone created during the lengthening is not immediately ready for full weight-bearing at the end of the lengthening process. Continuing prescribed exercises at this point quickly leads to clearly visible success. The time it takes for the bone to fully consolidate is usually two to three times as long as the lengthening period itself. After that, walking is possible without any aids, and in many cases a light occupation can be resumed. The regrown bone now increasingly adapts to the stress and becomes more and more stable, so that later it is no longer distinguishable from the naturally grown bone.

Remodeling phase

With the return to full weight-bearing, the gait pattern increasingly normalizes, mobility quickly returns to normal with continued self-exercises, so that the first sporting activities become possible. Only strenuous sports need to be avoided during this phase. The implants remain in the bone during this phase, but this is not a problem as they are not noticeable, cannot be seen from the outside, and usually do not interfere with normal function.

Implant removal

Bone implants should generally be removed again when they have served their purpose, otherwise problems may occur in the course of life. This also applies to distraction nails. Only in very old people, when no adverse consequences are expected, can implants remain in the bone. Usually, bone implants are removed about 12-18 months after implantation, either as an outpatient procedure or during a short hospital stay of about 2-3 days. Following the operation, full weight-bearing is possible again immediately.

Final examination

At ZEM-Germany, a final examination is routinely carried out on all patients for quality control purposes, which is important for both the patients and the payers. Here, as at the beginning of the treatment, a standardized questionnaire as well as a photographic and video documentation is carried out. Arms or legs are clinically examined and carefully measured on special final X-rays. A comparison with the findings before surgery makes it possible to check the success of the treatment yourself. The results of the final examination can also be very important for later insurance inquiries after accidents. The treatment at ZEM-Germany is completed when the final examination is carried out.