Dror Paley

Paley Orthopedic and Spine Institute

Background: Congenital synostosis of the knee is a rare condition with limited data on treatment options and outcomes. This study reports clinical findings, treatment approach, and surgical/clinical outcomes for congenital synostosis of the knee. Methods: An institutional review board-approved retrospective review of patients with congenital syn...

Torsional malalignment of the legs is common in children, and those that do not remodel may benefit from surgical correction. Traditionally, this is corrected with an open osteotomy. Guided growth is the gold standard for minimally invasive angular correction and has been investigated for use in torsional deformities. This study presents our prelim...

This study aims to develop multipliers for the spine and sitting height to predict sitting height at maturity. With the aid of longitudinal and cross-sectional clinical databases, we divided the total sitting height, cervical, thoracic, and lumbar lengths at skeletal maturity by these same four factors at each age for each percentile given. A serie...

Background: The treatment of congenital pseudarthrosis of the tibia (CPT) remains a challenge because of the difficulties of achieving and maintaining bone union, as well as complications of joint deformity and limb-length discrepancy. The purpose of this study was to evaluate the efficacy of cross-union of the tibia and fibula in achieving union...

Background Great difficulty and more failures were the descriptions of the treatment of congenital patella dislocation in pediatric patients. This study aims to evaluate the outcomes of patients with congenital patellar dislocations treated with the modified Langenskiöld procedure. Methods The medical records of 16 knees in 11 patients with a diag...

We reviewed 18 limbs in 17 patients who underwent ankle fusion with simultaneous tibial lengthening with a magnetic internal lengthening nail. All patients had preoperative limb length discrepancy (LLD) (mean 4.9cm (2.6-7.6cm)) with ankle deformity. The ankle was fused from medial or lateral approaches using screws/plate constructs placed adjacent...

Background: Great difficulty and more failures were the descriptions of the treatment of congenital patella dislocation in pediatric patients. This study aims to evaluate the outcomes of patients with congenital patellar dislocations treated with the modified Langenskiöld procedure. Methods: The medical records of 16 knees in 11 patients with a dia...

Background: Multiple hereditary exostoses (MHE) is a rare bone disease that results in growth of benign cartilage-capped tumors and a number of skeletal deformities. Forearm deformities are present in up to 60% of patients with MHE, and radial head subluxation or dislocation occurs in 20% to 30%. Radial head subluxation/dislocation results in a sh...

(1) Background: Patients treated with the two previous generations of ulnarization developed a bump related to the ulnar head becoming prominent on the radial side of the hand. To finally remedy this problem, a third generation of ulnarization was developed to keep the ulnar head contained. While still ulnar to the wrist center, the center of the w...

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...

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 f...

There are multiple forms of enchondromatosis with Ollier’s and Maffucci’s being the most prevalent types. Limb length discrepancy is a common problem in patients with Ollier’s and Maffucci’s enchondromatosis. There are multiple reports about lengthening bones in patients with enchondromatosis using external fixators. However, there are no case seri...

Congenital femoral deficiency (CFD) Paley type 1b is characterized by severe bony deformity of the upper femur, extra-articular contractures of the hip, and, delayed ossification of the femoral neck and/or subtrochanteric region. The Systematic Utilitarian Procedure for Extremity Reconstruction of the hip (SUPERhip) procedure for the correction of...

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 treat...

Fibular hemimelia (FH) presents with foot and ankle deformity and leg length discrepancy. Many historic reconstructions have resulted in poor outcomes. This report reviews modern classification and reconstruction methods. The Paley SHORDT procedure (SHortening Osteotomy Realignment Distal Tibia) is designed to correct dynamic valgus deformity. The...

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 aceta...

Limb deformity corrective surgery has exceedingly benefited by the introduction of hexapod systems. Although the principles of deformity correction planning still remain the same as with the Ilizarov system, the corrective phase is made easier thanks to the computer-assisted simultaneous correction of deformity in all space planes. In this chapter,...

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. Classific...

Extensive limb lengthening (ELL) was completed in 75 patients: 66 achondroplasia and 9 hypochondroplasia. The average lengthening was 27cm for achondroplasia (12-40cm) and 17cm for hypochondroplasia (range 10-25cm). There were 48 females and 27 males. Lengthening was done either by 2-segment (14 patients; both tibias and/or both femurs) or by seria...

Success in treatment of congenital pseudarthrosis of the tibia (CPT) is defined as obtaining union without refracture. The success rate of most techniques (rodding, Ilizarov, rodding with Ilizarov, free vascularized fibula, etc) is on average 50%. Recently a new technique has emerged that improves this success rate to as high as 100% in some report...

Background: Congenital femoral deficiency (CFD) is a rare condition that affects the morphology of the hip and surrounding soft tissues. Bony deformity and distorted muscular anatomy are well known, but no studies have described the relationship of the femoral neurovascular (NV) bundle to surgically relevant anatomic landmarks. The authors compare...

Restoration of sphericity to the femoral head has the best prognosis after Perthes disease, typically accomplished via an osteochondroplasty or femoral head reduction osteotomy (FHRO). Three types of FHRO—Ganz, Paley, and Burian—have been developed due to the different patterns of femoral head deformity necessitating a change in the orientation of...

Unloading of the hip was originally considered important in the treatment of Perthes disease. However, various methods of unloading were unsuccessful in altering the natural history of the disease. This may have been due to the misconception that non-weight bearing and unloading were equivalent. To truly remove the compressive forces from the hip,...

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 diamete...

Since May 2018, 106 patients (187 limb segments) have completed internal lengthening with the Stryde implant. Fifty-seven skeletally mature patients (12 female and 45 male) underwent cosmetic stature lengthening of the femur (41), tibia (4), or combined bilateral femur and tibia (12). Forty-nine other patients (ages 9 to 60 y) with a variety of lim...

Purpose Langenskiöld described a reconstructive soft-tissue procedure for irreducible lateral congenital patellar dislocations. Paley further detailed the technique in the surgical management of congenital femoral deficiency. The aim of this study was to evaluate the outcomes of patients with congenital, chronic and recurrent patellar dislocations...

Stump overgrowth is the most common complication after limb amputation in children. Its morbidity is relatively high, that required frequent revisions of the stump and prosthesis. The incidence of stump overgrowth varies in the literature; depending on different factors. The exact pathogenesis is unclear, many hypotheses have been suggested. The tr...

Legg-Calvé-Perthes Disease (LCPD) remains a challenging hip condition to treat. More than a century after its identification, the etiology of LCPD remains unclear and treatment continues to be controversial. The main goal of treatment is to prevent femoral head deformation. Preservation of femoral head sphericity is known to minimize the risk of pr...

Lower extremity rotational alignment must be quantified in cases of recurrent patellofemoral instability. Femoral and tibial rotation can be measured with both physical examination and radiographic studies. Derotational osteotomies of both the femur and the tibia can be used to correct patients with excessive femoral anteversion and tibial external...

Introduction: Triple pelvic osteotomy (TPO) involves periacetabular osteotomies of the ilium, ischium, and pubis to reorient the acetabulum. This operation is indicated in certain situations for the treatment of developmental dysplasia of the hip, dysplastic neuromuscular hips, and for containment of the femoral head in cases of Legg-Calvé-Perthes...

Background: Fibular hemimelia, a congenital disorder characterized by the partial or complete absence of the fibula, tibial growth inhibition, and foot and ankle deformity and deficiency, is the most common deficiency of long bones. The purpose of the present study of children with congenital fibular hemimelia was to examine the functional and psy...

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 hamart...

Purpose Stump overgrowth is the main problem of limb amputation in children. Many surgical procedures have been developed to overcome the problem, but all have shown inconsistent results. The only surgical procedure that has been successful in preventing overgrowth is capping of the amputated limb with a cartilaginous cap taken from the amputated l...

Fusion of the knee is a singularly difficult operation to accomplish. The indications are usually chronic infection after multiple previous total knee procedures, complicated traumatic injury to the knee leaving no significant surfaces for a replacement procedure, or a tumorous condition. On occasion, there may be an unusual case that is considered...

This chapter was originally published in my book Principles of Deformity Correction in 2002. I was asked to publish this chapter for this new book of my colleagues from Istanbul University. Because of the limited page numbers and images, this time I had to extract some of the topics which are originally mentioned in this chapter. However, you will...

Femoral head reduction osteotomy (FHRO) is the surgical treatment of choice for a misshapen (nonspherical) and enlarged (coxa magna) femoral head in a spherical acetabulum, most often occurring as a sequela of Legg–Calves–Perthes disease, but also arising secondary to skeletal dysplasia and avascular necrosis. Left untreated, the nonspherical femor...

Congenital femoral deficiency (CFD) presents a spectrum of deficiency, deformity and dysplasia of the upper femur, hip joint and acetabulum. The Paley classification divides this spectrum into separate pathoanatomical groups that can be treated using discreetly different operative procedures specific to the pathoanatomy of each type of CFD. The SUP...

Background: Rotational deformities of the femur and tibia are some of the most common orthopedic alignment problems in the lower extremity. In-toeing and out-toeing are common complaints seen by pediatric orthopedic surgeons as well. The idea of guided growth to correct axial rotation deformities in children is appealing. The purpose of this study...

Purpose: We studied 31 individuals whose femur or tibia was elongated with the PRECICE™ intramedullary lengthening nail in a protocol-controlled, multicentric, prospective series. Only skeletally mature individuals were included in the study. Materials and Methods: The protocol entailed 2-year follow-up after consolidation of the regenerate new bon...

Introduction: This study compared bone transport to acute shortening/lengthening in a series of infected tibial segmental defects for infected tibial non-union. Methods: In a retrospective comparative study 42 patients treated for infected tibial non-union with segmental bone loss measuring between 3 and 10cm were included. Group A was treated w...

Recurrent deformity from centralization and radialization led to the development in 1999 of a new technique by the author called ulnarization. This method is performed through a volar approach in a vascular and physeal sparing fashion. It biomechanically balances the muscle forces on the wrist by dorsally transferring the flexor carpi ulnaris (FCU)...

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 an...

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 classi...

Background and purpose — Femoral lengthening may result in decrease in knee range of motion (ROM) and quadriceps and hamstring muscle weakness. We evaluated preoperative and postoperative knee ROM, hamstring muscle strength, and quadriceps muscle strength in a diverse group of patients undergoing femoral lengthening. We hypothesized that lengthenin...

Background: 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. Methods: We assessed for hip stability in 69 children (91 femoral le...

Reconstruction of the Charcot foot is challenging with a relatively high rate of complications. Many different techniques are available to surgically manage foot and ankle Charcot deformities. This chapter highlights the static and dynamic advantages of external fixation for the correction of the diabetic neuropathic foot and ankle. Adherence to th...

Objectives: The 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. Methods: In this matched case study, 16 adult patients underwent 19 tibial lengthening over nails (LON) procedures. For the matched case group, 17 patients who...

Tibial hemimelia is a rare congenital deficiency that involves a spectrum of deformity of the tibia, ranging from mild shortening to total absence of the tibia. This chapter is a comprehensive review of the management principles of children born with tibial hemimelia as well as the senior author’s experience with the treatment of multiple types. Th...

Congenital femoral deficiency (CFD), also known as proximal femoral focal deficiency, is a rare birth defect that can affect the hip, femur, and knee. The spectrum of deformity can range from mild shortening to a proximal or distal deficiency, or even complete absence of the femur. This chapter is a comprehensive review of CFD, including the histor...

Background: The peroneal nerve is often stretched during limb lengthening and deformity correction. If the nerve becomes entrapped under the peroneal muscle fascia and/or anterior intermuscular septum, decompression is indicated to treat nerve compromise. Purpose: The purpose of this study was to quantify peroneal nerve tension after varus osteotom...

Introduction: Femoral fracture after lengthening of congenital femoral deficiency (CFD) is a common complication with a high incidence, up to 50%. The purpose of this study is to determine whether prophylactic intramedullary Rush rodding after lengthening for CFD is an effective method to prevent femoral fracture and to assess any complications th...

The treatment of congenital pseudarthrosis of the tibia (CPT) is challenging with variable results. Refracture, need for multiple operations, persistent nonunion, and residual limb length discrepancy are common. This chapter describes a comprehensive new treatment strategy with proven results of 100 % union and no refractures.

Congenital femoral deficiency (CFD) is a spectrum of severity of femoral deficiency and deformity. Deficiency implies a lack of integrity, stability, and mobility of the hip and knee joints. Deformity refers to bone malorientation, bone malrotation, and soft tissue contractures of the hip and knee. Both deficiencies and deformities are present at b...

Fibular hemimelia (FH) is the most common lower extremity congenital longitudinal deficiency. It is associated with a constellation of deformities including foot ray deficiencies, coalitions, ankle and hindfoot joint malorientation, diaphyseal deformity, and limb length discrepancy. Severe rigid and intractable equinovalgus deformity of the foot in...

Previous methods of treatment of radial club hand (RCH) have resulted in recurrent deformity and growth arrest of the distal ulna in a very high percent of cases. Ulnarization (procedure developed by Paley in 1999) is the first treatment of RCH to demonstrate no recurrence or growth arrest. Through a volar approach, the entire carpus is acutely tra...

Multiple hereditary exostoses (MHE) produces characteristic deformities of the forearm leading to problems at the wrist and elbow. Understanding the patho-anatomy allows one to correct all these deformities in a single or staged fashion. Two complementary cases, both in skeletally immature patients, are presented side by side to illustrate the scop...

Management of Perthes disease remains controversial despite extensive literature exploring this subject. Obtaining and maintaining hip range of motion are the only principles of treatment that are universally agreed upon. Containment of the femoral head within the acetabulum is thought to have a beneficial role, especially in patients with more tha...

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 patient...

Stature lengthening for short stature, often referred to as cosmetic stature lengthening, is controversial. Previous methods and devices have been fraught with high complications rates. The PRECICE intramedullary lengthening nail offers a superior alternative for these patients due to its minimal incision technique, remote controlled gradual distra...

Treatment of congenital femoral deficiency is a complex, multistage protocol and a variety of strategies have been devised to address joint instability, limb length inequality, and deformities. Despite being an important part of the algorithmic approach to the overall treatment of patients with congenital femoral deficiency, a reproducible, safe, a...

The development of knee flexion contractures is among the most common problems and complications associated with lengthening the femur with an internal device or external fixator. Conservative treatment strategies include physical therapy, serial casting, and low-load prolonged stretching with commercially available splinting systems. The authors d...

Purpose: Outcome assessment after double level tibial lengthening in patients with dwarfism. Methods: Fourteen patients with dwarfism were analyzed after bilateral simultaneous double level tibial lengthening. Results: Average age was 15.1 years. Average lengthening was 13.5 cm. The two levels were lengthened by an average of 7.5 cm proximally...

Congenital femoral deficiency (CFD) is a spectrum of severity of femoral deficiency and deformity. Deficiency implies a lack of integrity, stability, and mobility of the hip and knee joints. Deformity refers to bone malorientation, bone malrotation, and soft tissue contractures of the hip and knee. Both deficiencies and deformities are present at b...

Congenital femoral deficiency (CFD) is a spectrum of severity of femoral deficiency and deformity. Deficiency implies a lack of integrity, stability, and mobility of the hip and knee joints. Deformity refers to bone malorientation, bone malrotation, and soft tissue contractures of the hip and knee. Both deficiencies and deformities are present at b...

Tibial hemimelia (TH) often appears as a shortened leg with knee and ankle deformity. Most often, there are a varus deformity and knee flexion contracture, though multidirectional instability may also be present due to a lack of collateral ligaments. A patella and quadriceps mechanism may be present or absent and may have limited function if presen...

Perthes disease often leads to a nonspherical-shaped femoral head. Coxa magna with coxa breva and an elliptical or saddle-shaped femoral head lead to limitation of motion and pain from femuro-acetabular impingement (FAI) and lack of congruity. The Ganz femoral head reduction osteotomy (FHRO) can be used to reduce the femoral head size and restore s...

The treatment of congenital pseudarthrosis of the tibia (CPT) is challenging with variable results. Refracture, need for multiple operations, persistent nonunion, and residual limb length discrepancy are common. This chapter describes a comprehensive new treatment strategy with proven results of 100 % union and no refractures.

Fibular hemimelia (FH) is the most common lower extremity congenital longitudinal deficiency. It is associated with a constellation of deformities including foot ray deficiencies, coalitions, ankle and hindfoot joint malorientation, diaphyseal deformity, and limb length discrepancy. Severe rigid and intractable equinovalgus deformity of the foot in...

The PRECICE(®) Intramedullary Limb Lengthening System (Ellipse Technologies Inc., CA, USA) is a remotely controlled, magnetically driven, implantable limb lengthening intramedullary nail system. It has both CE mark and US FDA clearance for its first- (2011) and second-generation (2013) implants. It is indicated for the treatment of limb length disc...

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 generall...

Congenital femoral deficiency (CFD) is a spectrum of severity of femoral deficiency, deformity, and discrepancy. Deficiency implies a lack of integrity, stability, and mobility of the hip and knee joints. Deformity refers to bony malorientation, malrotation, and soft tissue contractures of the hip and knee. Both deficiencies and deformities are pre...

Congenital femoral deficiency (CFD) is a spectrum of severity of femoral deficiency and deformity. Deficiency implies a lack of integrity, stability, and mobility of the hip and knee joints. Deformity refers to bone malorientation, bone malrotation, and soft tissue contractures of the hip and knee. Both deficiencies and deformities are present at b...

Tibial hemimelia (TH) often appears as a shortened leg with knee and ankle deformity. Most often, there are a varus deformity and knee flexion contracture, though multidirectional instability may also be present due to a lack of collateral ligaments. A patella and quadriceps mechanism may be present or absent and may have limited function if presen...

Congenital femoral deficiency (CFD) is a spectrum of severity of femoral deficiency and deformity. Deficiency implies a lack of integrity, stability, and mobility of the hip and knee joints. Deformity refers to bone malorientation, bone malrotation, and soft tissue contractures of the hip and knee. Both deficiencies and deformities are present at b...

Perthes disease often leads to a nonspherical-shaped femoral head. Coxa magna with coxa breva and an elliptical or saddle-shaped femoral head lead to limitation of motion and pain from femuro-acetabular impingement (FAI) and lack of congruity. The Ganz femoral head reduction osteotomy (FHRO) can be used to reduce the femoral head size and restore s...

Congenital femoral deficiency (CFD) is a spectrum of severity of femoral deficiency and deformity. Deficiency implies a lack of integrity, stability, and mobility of the hip and knee joints. Deformity refers to bone malorientation, bone malrotation, and soft tissue contractures of the hip and knee. Both deficiencies and deformities are present at b...