- Dr. Paley was born in Israel, March 25, 1956, and grew up in Canada. He graduated Medical School (1979) and orthopedi... moreDr. Paley was born in Israel, March 25, 1956, and grew up in Canada. He graduated Medical School (1979) and orthopedic surgery residency (1985) at the University of Toronto. After fellowships in hand, trauma, pediatric, and Ilizarov surgery, he introduced the Ilizarov method to North America in 1987. He was full professor and chief, pediatric orthopedics at the University of Maryland at Baltimore, 1987-2001 and then became the Director of the Rubin Institute,Sinai Hospital at Baltimore, 2001-2009. Since 2009, he has been the Director of the Paley Advanced Limb Lengthening Institute in West Palm Beach, Florida, and also holds academic positions as Adjunct Professor of Orthopedics at the University of Toronto, and Professor of Orthopedics at the University of Vermont. Dr. Paley is best known for his landmark research in the field of limb lengthening and deformity correction. His textbook Principles of Deformity Correction is considered the Bible of deformity correction surgery. This book is published in English and Chinese. He is also the author of 5 other books, 50 book chapters, 140 peer reviewed journal articles, 54 video productions, and the iPhone app PaleyGrowth. He has presented over 2000 lectures at international meetings in six languages. He was the founder and first President of the LLRS in 1989, cofounder of ASAMI International in 1993 and ILLRS in 2012. He is the President of the International Limb Lengthening and Reconstruction Society and recently chaired its international meeting in Miami, Nov 4-7, 2015. He has received international awards from orthopedic and non-orthopedic groups including a Gubernatorial Citation for his humanitarian work and 8 honorary international society memberships (Italy, France, Poland, UK, Venezuela, Chile, Germany, Thailand). His Paley Foundation helps children and doctors from developing countries through mission trips (e.g. Haiti, Nicaragua) and foreign physician training efforts. Dr. Paley is known as an innovator who has changed orthopedic surgery by his ideas, including: deformity planning prinicples, the Multiplier method of discrepancy/limb length/height prediction, reconstructive procedures for congenital deficiencies (superhip, superknee, and superankle, ulnarization). He has also helped develop ,new external fixators (including the new Drive Rail monolateral external fixator, Paley Frame computer dependent external fixator, Paley Pin the latest innovation in external fixation pin technology) and implantable lengthening devices (Precice2 implantable lengthening nail). At the Paley Institute he continues to treat patients from over 85 countries and all 50 US States, and to innovate new procedures and devices that will benefit generations of future patients and surgeons. He is married to Jennifer and has three grown children and one step-son.edit
ObjectivesThe purpose of this study was to compare the results and complications of tibial lengthening over an intramedullary nail with treatment using the traditional Ilizarov method.MethodsIn this matched case study, 16 adult patients... more
ObjectivesThe purpose of this study was to compare the results and complications of tibial lengthening over an intramedullary nail with treatment using the traditional Ilizarov method.MethodsIn this matched case study, 16 adult patients underwent 19 tibial lengthening over nails (LON) procedures. For the matched case group, 17 patients who underwent 19 Ilizarov tibial lengthenings were retrospectively matched to the LON group.ResultsThe mean external fixation time for the LON group was 2.6 months and for the matched case group was 7.6 months. The mean lengthening amounts for the LON and the matched case groups were 5.2 cm and 4.9 cm, respectively. The radiographic consolidation time in the LON group was 6.6 months and in the matched case group 7.6 months. Using a clinical and radiographic outcome score that was designed for this study, the outcome was determined to be excellent in 17 and good in two patients for the LON group. The outcome was excellent in 14 and good in five patient...
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External fixation is widely used in orthopaedic and trauma surgery. Infections around pin or wire sites, which are usually localised, non-invasive, and are easily managed, are common. Occasionally, more serious invasive complications such... more
External fixation is widely used in orthopaedic and trauma surgery. Infections around pin or wire sites, which are usually localised, non-invasive, and are easily managed, are common. Occasionally, more serious invasive complications such as necrotising fasciitis (NF) and toxic shock syndrome (TSS) may occur. We retrospectively reviewed all patients who underwent external fixation between 1997 and 2012 in our limb lengthening and reconstruction programme. A total of eight patients (seven female and one male) with a mean age of 20 years (5 to 45) in which pin/wire track infections became limb- or life-threatening were identified. Of these, four were due to TSS and four to NF. Their management is described. A satisfactory outcome was obtained with early diagnosis and aggressive medical and surgical treatment. Clinicians caring for patients who have external fixation and in whom infection has developed should be aware of the possibility of these more serious complications. Early diagno...
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ABSTRACT Deviation of the mechanical axis (MAD) results primarily in deformities of the long bones, which result in the development of secondary osteoarthritis of the hip, knee, and/or ankle joints. Orthopedic surgeons have utilized many... more
ABSTRACT Deviation of the mechanical axis (MAD) results primarily in deformities of the long bones, which result in the development of secondary osteoarthritis of the hip, knee, and/or ankle joints. Orthopedic surgeons have utilized many different procedures to correct these deformities to prevent secondary osteoarthritis. However, these techniques generally result in low patient comfort and lack accuracy. A comprehensive technique termed “fixator-assisted nailing” (FAN) was developed by Dror Paley in 1993 and was first described by Paley et al. in 1997. Its goal was to combine the accuracy and minimal invasiveness of external fixation with the convenience of internal fixation. Internal fixation prevents the recurrence of the deformity and allows early mobilization of joints and quicker rehabilitation.
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Open reduction and internal fixation techniques do not allow early weight bearing. In an effort to develop a better method to obtain calcaneal fracture reduction and maintain it in the face of early weight bearing, a circular external... more
Open reduction and internal fixation techniques do not allow early weight bearing. In an effort to develop a better method to obtain calcaneal fracture reduction and maintain it in the face of early weight bearing, a circular external fixator was applied to seven patients in combination with a limited lateral approach and open reduction and internal fixation of the depressed subtalar joint fragments. The operative technique uses the Ilizarov circular external fixator to obtain a ligamentotaxis reduction, following which the depressed subtalar joint fragments are elevated open; then, the fixator is used to reduce the lateral translation. All displacements of the fracture fragments are corrected. This method proved successful in six patients, all of whom achieved a satisfactory result with anatomic restoration of the subtalar joint and heel. One patient went on to late partial collapse of the posterior facet. Subtalar motion was greater than 50% in four of seven patients. None of the patients complained of heel pad pain, which was attributed to the desensitization of the heel by early weight bearing. This technique has produced encouraging preliminary results in two- to four-year follow-up evaluation.
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The hip joint involvement in multiple hereditary exostoses (MHE) occurs in 30–90%, causing pain and limitation of motion by femoroacetabular impingement, coxa valga, acetabular dysplasia, hip joint subluxation, and osteoarthritis. The... more
The hip joint involvement in multiple hereditary exostoses (MHE) occurs in 30–90%, causing pain and limitation of motion by femoroacetabular impingement, coxa valga, acetabular dysplasia, hip joint subluxation, and osteoarthritis. The purpose of this study was to investigate the clinical and radiographic outcomes of ten hips in seven patients treated by surgical dislocation and corrective osteotomies between 2004 and 2009. Surgical dislocation and excision of the osteochondromas and varus intertrochanteric osteotomies were performed in all cases when the neck–shaft angle was > 150°. Common sites of osteochondromas were medial, posterior, and anterior neck of the femur. Neck–shaft angle of the femur was improved from a mean of 157° to 139°, postoperatively. On an average, the center-edge angle improved from 20° to 30° postoperatively. We believe that Ganz’s safe surgical dislocation technique is the preferred treatment of MHE. This safeguards the circulation of the femoral head an...
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Congenital pseudarthrosis of the tibia (CPT) is likely to be a primary periosteal disease and secondary bone disease. The primary goal of treatment is to obtain union, correct the diaphyseal deformity, correct any proximal fibular... more
Congenital pseudarthrosis of the tibia (CPT) is likely to be a primary periosteal disease and secondary bone disease. The primary goal of treatment is to obtain union, correct the diaphyseal deformity, correct any proximal fibular migration and prevent refracture. The pathobiology demonstrates increased osteoclasis by the surrounding fibrous hamartoma and reduced osteogenesis and bone morphogenic protein production by the bone. This leads to a loss of remodelling potential and gradual bowing and atrophy of the bone with eventual fracture of the tibia and or fibula. This recommends the synergistic use of bisphosphonates and bone morphogenic protein. The pathomechanics of CPT implicate the anterolateral bowing, narrow diameter of the atrophic bone ends and proximal fibular migration. These biomechanical factors can be addressed by means of straightening of the deformity, intramedullary support of both bones, stable fixation and reduction of proximal migration of the fibula. A summary ...
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Tibial hemimelia is a rare congenital deficiency with a wide spectrum of pathology and deformity. This paper aims to give a comprehensive review of tibial hemimelia, with a concise summary of the history, pathology, and clinical findings... more
Tibial hemimelia is a rare congenital deficiency with a wide spectrum of pathology and deformity. This paper aims to give a comprehensive review of tibial hemimelia, with a concise summary of the history, pathology, and clinical findings of tibial hemimelia, while providing treatment recommendations and a review of the current literature. Classifications and surgical treatments are discussed, including amputation, limb reconstruction, and lengthening. Type-specific treatments are also discussed, including staged distraction correction of joint contractures of knee and ankle, Weber patelloplasty, fibular centralization, knee and ankle arthrodesis, implantable articulated distractors, and the role of femoral shortening. Amputation is a simpler and easier solution for many patients; however, reconstruction options continue to evolve, improve, and provide better functional outcomes in many cases. Factors favoring surgical reconstruction include the presence of a knee joint/proximal tibi...
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Fibular Hemimelia is the most common lower extremity congenital longitudinal deficiency (frequency 1/40,000 live births). . It is associated with a constellation of deformities including foot ray deficiencies, subtalar coalition, ball and... more
Fibular Hemimelia is the most common lower extremity congenital longitudinal deficiency (frequency 1/40,000 live births). . It is associated with a constellation of deformities including foot ray deficiencies, subtalar coalition, ball and socket ankle joint, ankle joint malorientation, diaphyseal angular deformity apex anteromedial, fibular deficiency. . Congenital shortening of the tibia associated with congenital fibular deficiency is referred to as fibular hemimelia.
Congenital Pseudoarthrosis of the Tibia (CPT) is a rare condition with a reputation for recurrent fractures and failure to achieve union. A large variety of surgical procedures have been attempted for the treatment of fractured cases of... more
Congenital Pseudoarthrosis of the Tibia (CPT) is a rare condition with a reputation for recurrent fractures and failure to achieve union. A large variety of surgical procedures have been attempted for the treatment of fractured cases of CPT with an average rate of union without refracture of only 50%. Intentional cross-union between the tibia and fibula has been reported to improve these results to 100% union with no refractures. This is a retrospective study of 39 cases of CPT in 36 patients treated by the Paley cross-union protocol with internal fixation, bone grafting, zoledronic acid infusion and bone morphogenic protein 2 (BMP2) insertion. All 39 cases of CPT united at the tibia and developed a cross-union to the fibula. Two patients had a persistent fibular pseudarthrosis, one that was later treated at the time of planned rod exchange and one that has remained asymptomatic. There were few postoperative complications. There were no refractures during the up to 7-year follow-up ...
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Extramedullary implantable limb lengthening (EMILL) uses an implantable nail attached to the bone like and internal-external fixator. Cantilever forces can be neutralized by inserting a small diameter solid rod as a guide inside the... more
Extramedullary implantable limb lengthening (EMILL) uses an implantable nail attached to the bone like and internal-external fixator. Cantilever forces can be neutralized by inserting a small diameter solid rod as a guide inside the medullary canal. EMILL expands the indications for internal limb lengthening to younger children with smaller diameter and length bones and to bones with impassable medullary canals. One must follow the same principles as with external fixation lengthening including prevention of joint subluxation and contracture by preparatory surgery (eg, pelvic osteotomy), soft tissue releases, temporary arthrodesis, and bracing. Lengthening should be restricted to amounts no >5 cm to avoid complications. A retrospective review of EMILL cases performed at the authors’ institution since 2015 was performed. Thirteen patients underwent 14 EMILL procedures; 10 femurs and 4 tibias. Twelve of 13 patients lengthened to within 5 mm of their preoperative goal. There were no...
Rotationplasty is a reconstructive option for severe congenital femoral deficiency (CFD). The senior author (D.P.) developed five new rotationplasty techniques for use in CFD based on the Paley classification, including the Paley–Brown... more
Rotationplasty is a reconstructive option for severe congenital femoral deficiency (CFD). The senior author (D.P.) developed five new rotationplasty techniques for use in CFD based on the Paley classification, including the Paley–Brown (fusion femur to pelvis), Paley (fusion femur to femoral head), Paley–Winkelman (insertion tibial condyle to acetabulum), PaleySUPERhip–Van Nes (hip osteotomy with knee fusion) and PaleySling–Van Nes (hip reconstruction with knee fusion revision) rotationplasty techniques. The purpose of this study is to retrospectively evaluate the complications, radiographic outcomes and need for secondary surgery in 19 rotationplasty cases performed by the senior author (D.P.) for severe CFD from 2009 to 2019. Rotationplasty comprised only 2% of the authors treated CFD cases during this period. Average age at surgery was 8.6 years old. Average follow-up was 3.3 years. Sixteen concomitant procedures were performed including temporary arthrodesis, tibial osteotomy an...
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Extensive limb lengthening (ELL) was completed in 75 patients: 66 achondroplasia and 9 hypochondroplasia. The average lengthening was 27 cm for achondroplasia (12–40 cm) and 17 cm for hypochondroplasia (range 10–25 cm). There were 48... more
Extensive limb lengthening (ELL) was completed in 75 patients: 66 achondroplasia and 9 hypochondroplasia. The average lengthening was 27 cm for achondroplasia (12–40 cm) and 17 cm for hypochondroplasia (range 10–25 cm). There were 48 females and 27 males. Lengthening was done either by 2-segment (14 patients; both tibias and/or both femurs) or by 4-segment lengthenings (64 patients; both femurs and tibias at the same time). Most patients also had bilateral humeral lengthening. Patients had 2 or 3 lower limb lengthenings and one humeral lengthening. Lengthenings were either juvenile-onset (31), adolescent-onset (38) or adult-onset (6). The average age at final follow-up was 26 years old (range 17–43 years). There were few permanent sequelae of complications. The most serious was one paraparesis. All patients returned to activities of normal living and only one was made worse by the surgery (paraparesis). This is the first study to show that ELL can lead to an increase of height into ...
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Tibial hemimelia is a rare congenital lower limb deficiency presenting with a wide spectrum of associated congenital anomalies, deficiencies and duplications. Reconstructive options have been limited, and the gold standard for treatment... more
Tibial hemimelia is a rare congenital lower limb deficiency presenting with a wide spectrum of associated congenital anomalies, deficiencies and duplications. Reconstructive options have been limited, and the gold standard for treatment has remained amputation with prosthetic fitting. There is now a better understanding of the genetics, etiology and pathoanatomy of tibial hemimelia. Armed with this knowledge, I present here a new classification to guide treatment and prognosis and then discuss new treatment strategies and techniques for limb reconstruction based on this new classification scheme.
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Fibular hemimelia presents with foot deformity and leg length discrepancy. Previous classifications have focused on the degree of fibular deficiency rather than the type of foot deformity. Published methods of surgical reconstruction have... more
Fibular hemimelia presents with foot deformity and leg length discrepancy. Previous classifications have focused on the degree of fibular deficiency rather than the type of foot deformity. Published methods of surgical reconstruction have often failed due to residual or recurrent foot deformity. The purpose of this report is to introduce new classification and reconstruction methods. The Paley SHORDT procedure is used to stabilize the ankle when there is a hypoplastic distal fibula with a dynamic valgus deformity. It involves shortening and realignment of the distal tibia relative to the fibula. In contrast, the Paley SUPERankle procedure is used when there is a fixed equinovalgus foot deformity. The SUPERankle uses a supramalleolar shortening-realignment osteotomy and/or subtalar osteotomies with anlage resection. Due to the bony instead of soft tissue correction of deformity, residual or recurrent deformity is prevented. Weakening of gastro-soleus and peroneal muscles is avoided b...
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Congenital femoral deficiency (CFD) is one of the most challenging and complex conditions for limb lengthening. We focused on the problem of hip instability during femoral lengthening because subluxation and dislocation are potentially... more
Congenital femoral deficiency (CFD) is one of the most challenging and complex conditions for limb lengthening. We focused on the problem of hip instability during femoral lengthening because subluxation and dislocation are potentially catastrophic for hip function. We assessed for hip stability in 69 children (91 femoral lengthenings) who had CFD Paley type 1a (43 children) and 1b (26 children). The mean age at first lengthening was 6.4 years. Hip subluxation/dislocation occurred during 14 (15 %) of 91 lengthenings. Thirty-three pelvic osteotomies were performed before lengthening in an attempt to stabilize hips. Thirteen patients (type 1a, eight; type 1b, five) had acetabular dysplasia at initiation of lengthening. One of the eight with type 1a experienced mild femoral head subluxation; four of the five with type 1b experienced three dislocations and one subluxation. Eight patients (type 1b) experienced hip instability although they had pelvic osteotomies. Proximal femoral lengthening was a significant factor for hip subluxation. Patients with hip subluxation more likely underwent monolateral fixation and the original superhip procedure. Age ±six years was not a contributing factor for hip instability. Important risk factors for hip instability during femoral lengthening are severity of CFD, residual acetabular dysplasia, and proximal femoral lengthening. We recommend routine performance of pelvic osteotomy for patients with Paley type 1b CFD and distal lengthening. Therapeutic Level IV.
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Limb lengthening is still a major procedure with potentially serious complications. It does not, however, deserve the reputation it gained over the last few years. With a proper understanding of the biology, biomechanics, and strategies... more
Limb lengthening is still a major procedure with potentially serious complications. It does not, however, deserve the reputation it gained over the last few years. With a proper understanding of the biology, biomechanics, and strategies of lengthening, excellent results can be consistently obtained with relatively few complications.