5/11/2014€¦ · · 2014-05-125/11/2014 1 dror paley, md paley advanced ... 5/11/2014 15...
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DROR PALEY, MD
Paley Advanced
Limb Lengthening Institute
St. Mary’s Hospital
901 45th St.
West Palm Beach, Florida 33407
www.PaleyInstitute.org
Paley Institute
Disclosure
• I am a consultant to Ellipse Technologies
• I receive royalties from SN Orthopedics and
Pega Medical and Springer
Congenital Femoral
Deficiency (CFD)
• Formerly called PFFD (proximal femoral focal
deficiency
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CFD
• Formerly called PFFD (proximal femoral focal
deficiency
• Occurs 1:40,000 births
CFD
• Formerly called PFFD (proximal femoral focal
deficiency
• Occurs 1:40,000 births
• Cause unknown
• Most are not hereditary
CFD
• Formerly called PFFD (proximal femoral focal
deficiency
• Occurs 1:40,000 births
• Cause unknown
• Most are not hereditary
• May be associated with Fibular Hemimelia
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CFD
• Formerly called PFFD (proximal femoral focal
deficiency
• Occurs 1:40,000 births
• Cause unknown
• Most are not hereditary
• May be associated with Fibular Hemimelia
• If bilateral or more than one limb affected
may be hereditary or related to virus, drugs,
radiation, syndrome
Classification of CFD
• Paley Classification created in 1996
• Now used by most pediatric orthopedic
surgeons
• Paley Type determines treatment
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Steps
• Step 1: determine Paley type
• Step 2: predict limb length discrepancy (LLD)
at skeletal maturity using Multiplier method
Paley et al, JBJS 2000
Paley Growth iPhone App
FREE
Steps
• Step 1: determine Paley type
• Step 2: predict limb length discrepancy (LLD)
at skeletal maturity using Multiplier method
• Step 3: work out length correction strategy
• Pelvic Osteotomy or Superhip 1cm
• Lengthening 1 5-8cm
• Lengthening 2 5-8cm
• Lengthening 3 5-8cm
• Growth plate closure(epiphysiodesis) 5cm
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Steps
• Step 1: determine Paley type
• Step 2: predict limb length discrepancy (LLD)
at skeletal maturity using Paley Multiplier
method
• Step 3: work out length correction strategy
• Step 4: outline reconstructive life plan
Planned age for each procedure
Reconstructive Life Plan
Surgery Length Gain
1. Pelvic Osteotomy or Superhip 1cm
2. Lengthening 1 5-8 cm
3. Lengthening 2 5-8 cm
4. Lengthening 3 5-8 cm
5. Growth plate closure(epiphysiodesis) 5 cm
6. Hemi-epiphysiodesis (PRN)
Total 15-30 cm 6-12 in
Customized Treatment
for Each Patient
• Step 1: determine Paley type
• Step 2: predict limb length discrepancy (LLD)
at skeletal maturity using Multiplier method
• Step 3: work out length correction strategy
• Step 4: outline reconstructive life plan
All determined at the first consultation visit
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External Fixation Time
• Distraction Phase (lengthening time)
External Fixation Time
• Distraction Phase (lengthening time)
• Consolidation Phase (bone healing time)
Rule of Thumb 1
• Total Ex Fix time = 1month for each cm.
e.g. 5cm lengthening = 5 months with ex fix
e.g. 8cm lengthening = 8 months with ex fix
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Rule of Thumb 2
• Distraction Time = Consolidation Time
• Distraction + Consolidation Times
=Total Ex Fix time
e.g. 8cm lengthening = 8months Ex Fix time
Distraction time = 4months
Consolidation time = 4 months
Soft Tissue Releases
It is important to lengthen key
muscles and tendons during
surgery!
This prevents damage to muscles,
joints and growth from limb
lengthening
Physical Therapy
1-2 hrs/day
Must maintain 45°
or more of knee flexion
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Botox Injection
Quads: 10u/kg body wt.
prevents muscle spasm & pain during PT
Post-op Course
• 3 days in hospital
• Start lengthening on day 7 at 1mm/day
• Followup every two weeks
• Slow lengthening rate if knee motion
decreases
• Stop lengthening if knee motion <45°
The External Fixator Used must have Knee Hinges
to protect knee from pressure and dislocation during limb lengthening
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Specialized Physical Therapy is Critical to the Process
• Passive stretching of knee to 90°
• Passive abduction of hip
• Strengthening of hip abductors
• Strengthening of quads
• Other special limb lengthening
exercises
At the Paley Institute we prefer to start lengthening
between ages 2-4 years old
Preparatory Surgery
• Before lengthening assess for hip and knee
instability, contractures, & deformities
• If present then perform surgery to correct
these before lengthening
• This is called PREPARATORY SURGERY
which can start as early as age 2
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Two year old boy with CFD type 1b:
about to undergo Preparatory Hip & Knee Surgery
Problems of knee and hip deformities
have to be resolved before lengthening
Dec 9, 2009
Preparatory Surgeries:
Superhip and Superknee procedures (see part 2)
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Jan 4, 2010
1st Lengthening
Feb 1, 2010 March 8, 2010
Lengthening Fixator with Hinge across the Knee Joint
which allows Knee Motion Exercises
After 8 cm lengthening
April 14, 2010
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Long Term Experience and Results
The next two patients (one boy and one girl)
have CFD treated during CHILDHOOD by Dr. Paley
They both had Lengthening Reconstruction Surgery
They are now both young ADULTS
They now have EQUAL LEG LENGTH.
Boy CFD 1a Girl CFD 1a
Hip Instability/Dysplasia
is Treated by Pelvic
Osteotomy
Dega
This prevents the hip from dislocating out of joint
during lengthening of the femur
CFD/PFFD
severe deformity
type 1b
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CFD/PFFD
severe deformity
type 1b
Patho-anatomy of Femur
• Proximal femur is flexed 90° and internally rotated
45°
• Distal femur is externally rotated
• If proximal femur is cartilaginous junction is bone to
cartilage (neck type)
• If proximal femur is ossified, junction is cartilagenous
(subtrochanteric type)
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After Superhip & Superknee Procedures
CFD/PFFD
severe deformity
“SUPER HIP” Procedure
First Superhip by Paley 1997
Super Hip Procedure
• Extra-articular soft tissue releases to correct:
flexion, abduction and ext. rotation
CONTRACTURES of HIP JOINT
• Special subtrochanteric osteotomy to correct:
varus, flexion and ext. rotation
BONY DEFORMITIES of the FEMUR
• Pelvic osteotomy to correct lack of femoral head coverage ACETABULAR DYSPLASIA
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Before Superhip After Superhip
femoral neck deformed
& not ossified femoral neck no deformity
& ossified
Sept 21, 2009
Age 4: LLD =11cm
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Oct 5, 2009
First Lengthening Age 4
osteotomy
Oct 28, 2009
First Lengthening
Dec 8, 2009
Goal of Lengthening Achieved: 8cm = 3 ¼” LLD = 3cm
Jan 15, 2010
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During Lengthening in Physical Therapy
May 20, 2010
Last X-rays before removal of fixator
Removal and rodding of femur: 8months after surgery
June 14, 2010
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Six Months after removal: LLD = 3 cm
June 14, 2010
Conclusion
Each type of CFD has its own
treatment
Paley classification determines the
type of treatment
Follow a Reconstructive Life Plan
Specialized Centers are best equipped
to treat CFD
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UNSATISFACTORY RESULTS after
Lengthening for Fibular Hemimelia are due to:
RECURRENT or RESIDUAL
foot deformities
Naudie et al., JBJS 79B 1997
Choi et al., JBJS 72A 1990
100% 50% 10%
Recurrence of Foot Deformity
Paley et al study 1999
Superankle Procedure
Soft tissue releases combined with
Osteotomy of Supramalleolar and/or
Subtalar Coalition
First procedure to prevent recurrence
of foot deformity and to give a stable
ankle
Developed by Paley in 1996
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Jan 10, 2011
Removal of Ex Fix (6months postop) 3rd Lengthening age 14: Femur and Tibia
Age 16 : Equal leg length
No pain, plays soccer
Recommendations
1. Type 3: Superankle: STR (complete analge
resection) + SM and/or ST osteotomy +
lengthening
2. Serial Staged Lengthenings
± epiphysiodesis
3. Ankle arthrodesis if cannot
otherwise stabilize ankle
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Recurrent Foot Deformities
• <10% following
superankle procedure (STR + Osteotomy)
• In these 10% the foot deformity can be
corrected with the 2nd staged lengthening
Why amputate a childs foot
Our worst cases (<10%)
are like a painless, plantigrade ankle arthrodesis
Worst case analysis is:
painless plantigrade stiff foot or ankle arthrodesis
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Deformity Correction in Adults:
Fixator-Assisted Nailing (FAN)
and
Fixator-Assisted Locked Plating
(FALP)
John E. Herzenberg, MD, FRCSC
Clinical Professor, Orthopedic Surgery, University of Maryland
Director, International Center for Limb Lengthening
Sinai Hospital - Baltimore, Maryland USA
VuMedi Seminar May 5th, 2014
Advanced Limb Reconstruction Techniques
Disclosures:
Unpaid consultant for Smith+Nephew,
Orthofix, Ellipse.
Support for “Baltimore Limb
Deformity Course” from
Smith+Nephew, Orthofix, Ellipse.
External fixation for
deformity correction:
Accurate, but is it
comfortable?
2
Internal fixation done poorly Internal fixation done well
Fixator Assisted Internal Fixation:
The accuracy of external fixation
AND the patient convenience of
internal fixation.
(Best of both worlds)
Options: Nails, Plates
Fixator Assisted Nailing
Nailing (FAN)
Fixator
Assisted Plating
(FAP)
3
t = amount of translation needed
Intra-operative x-ray confirms correction prior to fixation
Reamings
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Fixator-Assisted Nailing
(FAN)
• Advantages: • Accurate correction
• Patient never sees
fixator
• Disadvantages:
• Technically challenging
• Not widely done
How to make this technique
easier for of the surgeon?
Fixator Assisted Locked Plating
(FALP)
LDFA 86°
MPTA 104°
20° valgus
Lateral MAD 15° procurvatum
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Trapezoid wedge resection to shorten bone
Temporary stabilization with simple external fixators.
Alignment check with image intensifier and grid.
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Take home message:
1. Fixator Assisted Nailing (FAN)
is technically demanding
2. Fixator Assisted Plating is
relatively easy.
3. FAP allows accurate correction
and patient comfort (no long
term external fixator)
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Correction of Nonunions and
Malunions
Trevor M. Owen, M.D.
Assistant Professor – VTC School of Medicine
May 12, 2013
Disclosure
• Nothing to disclose
Disclaimer
• Plates, Screws, Rods, & Wires are the
mainstay of my practice.
• External fixation is widely applicable but
should be used only in appropriate cases.
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Overview
• Nonunion
• Workup
• Management
• Malunion
• Management
Nonunion Workup
• Why did the nonunion develop?
• Failure of mechanics
• Failure of biology
Nonunion Workup
• Radiographs
• Hypertrophic
• Oligotrophic
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Nonunion Workup
• Laboratory Studies
• Infection Panel
• WBC, ESR, CRP
Nonunion Workup
• Laboratory Studies
• Infection Panel
• WBC, ESR, CRP
• Endocrine Workup
• Vitamin D
• Calcium
• PTH
• TSH
• Testosterone
Nonunion Workup
• Laboratory Studies
• Infection Panel
• WBC, ESR, CRP
• Endocrine Workup
• Vitamin D
• Calcium
• PTH
• TSH
• Testosterone
Plan For Staged Reconstruction
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Nonunion Workup
• Laboratory Studies
• Infection Panel
• WBC, ESR, CRP
• Endocrine Workup
• Vitamin D
• Calcium
• PTH
• TSH
• Testosterone
50,000 Units Vit D Weekly
Plan For Staged Reconstruction
Nonunion Workup
• Laboratory Studies
• Infection Panel
• WBC, ESR, CRP
• Endocrine Workup
• Vitamin D
• Calcium
• PTH
• TSH
• Testosterone
50,000 Units Vit D Weekly
Endocrine Consult
Plan For Staged Reconstruction
Nonunion Management
• Correct all modifiable biologic factors
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Nonunion Management
• Correct all modifiable biologic factors
Nonunion Management
• Biopsy all nonunions at the time of surgery
Nonunion Management
• Biopsy all nonunions at the time of surgery
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Nonunion Management
• Non-infected, Aligned
• Non-infected, Mal-aligned
• Infected, Aligned
• Infected, Mal-aligned
Nonunion Management
• Non-infected, Aligned
• Reamed Exchange Nailing
• Compression Plating
• Bone Grafting
Nonunion Management
• Non-infected, Aligned
• Reamed Exchange Nailing
• Compression Plating
• Bone Grafting
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Nonunion Management
• Non-infected, Mal-aligned
• Stiff
• Takedown of nonunion with revision fixation
• Gradual correction and compression with external
fixator
• Mobile
• Acute correction with internal fixation
Nonunion Management
• Non-infected, Mal-aligned
Nonunion Management
• Non-infected, Mal-aligned
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Nonunion Management
• Non-infected, Mal-aligned
Nonunion Management
• Non-infected, Mal-aligned
Nonunion Management
• Non-infected, Mal-aligned
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Nonunion Management
• Non-infected, Mal-aligned
Nonunion Management
• Non-infected, Mal-aligned
Nonunion Management
• Infected, Aligned & Infected, Mal-aligned
• Staged Reconstruction
• Stage 1
• Extensive debridement with spacer placement
• Cast Immobilization vs External Fiation
• Appropriate IV antibiotics x 6 weeks
• Stage 2
• Reconstruction with internal fixation versus external
fixation
• Bone grafting
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Nonunion Management
• Infected, Aligned & Infected, Mal-aligned
Nonunion Management
• Infected, Aligned & Infected, Mal-aligned
Nonunion Management
• Infected, Aligned & Infected, Mal-aligned
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Malunion Management
Malunion Management
• Acute Correction
• Amenable soft tissues
• Acceptable shortening
• Gradual Correction
Malunion Management
• Acute Correction
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Malunion Management
• Acute Correction
• Acute Correction
Malunion Management
• Acute Correction
Malunion Management
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• Acute Correction
Malunion Management
Malunion Management
• Acute Correction
Malunion Management
• Acute Correction
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Malunion Management
• Acute Correction
Malunion Management
• Gradual Correction
Malunion Management
• Gradual Correction
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Malunion Management
• Gradual Correction
Malunion Management
• Gradual Correction
Malunion Management
• Gradual Correction
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S. Robert Rozbruch, MD Chief, Limb Lengthening & Complex Reconstruction Service
Professor of Clinical Orthopedic Surgery
External Fixation
IntegratedFixation • LON= lengthening
over nail
• LATN= lengthening
and then nailing
• LAP= lengthening and
then plating
• BTON= bone transport
over a nail
Internal lengthening
nail
Lengthening over
nail (LON)
Lengthening and
then plating (LAP)
Lengthening and
then Nailing (LATN)
Bone transport over
a nail (BTON)
Pros
• Decreased time in
external fixation
Cons
• 2 surgeries
• Still wear ex fix
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7 cm
Out of frame in 6 months
Decrease time in frame
Prevent refracture of
regenerate
Correct periarticular
deformity
Osteotomy distal femur or
proximal tibia