Function, psychological adjustment and quality of life after primary
limb reconstruction in patients with
severe fibular deficiency are both comparable and within
normal limits for a healthy population, according to a recently presented
|AP radiograph of a 14-month-old
boy with FH and fixed equinovalgus foot deformity. This patient has a
three-toed, two-ray foot.
|Images: Dror Paley|
The findings were shared by Dror Paley, MD, FRCSC, at the 2011 Annual
Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in San Diego.
“All previous studies showed that the results of lengthening are
not as good as the function after lengthening reconstruction surgery,”
Paley said. “The consistent finding is that recurrent or residual foot
deformities are the cause of the bad results from lengthening. In this study,
we used a new procedure I developed for fibular hemimelia reconstruction called
the ‘superankle procedure.’”
The procedure, Paley said, includes a combination of soft tissue
releases and supramelleolar and/or subtalar osteotomy combined with a more
proximal lengthening osteotomy.
Use of the technique, Paley said, has resulted in “almost no
recurrent foot deformities,” therefore the results are “functionally
excellent with correction of limb length discrepancy and foot deformity.”
|AP radiograph after 6-cm
lengthening and superankle surgery for foot deformity correction at age 18
months. There is near equalization of limb length.
“This has never been achieved before,” Paley said. “When
you can achieve reliable foot deformity correction with equalization of limb
length, the result is nearly normal lower limb function.”
According to the findings, patients and surgeons need to weigh life-long
prosthetic requirements against increased surgical intervention for limb
reconstruction when treating severe fibular deficiency.
Twenty children who underwent amputation at one center were compared
with 22 children who underwent limb reconstruction at a second center, Paley
reported. Average evaluation age was 9 years, and included psychosocial status,
quality of life characteristics and patient/parent satisfaction surveys, as
well as gait analysis with a timed 25-yard dash.
According to the findings, parents of boys who underwent amputation
perceived a lower quality of life for their child. There were no other reported
differences between the two groups or between the groups and a healthy
population. All patients and parents, the study noted, would select the same
Statistically significant differences in some parameters were identified
between the groups by gait analysis at self-selected walking speed, but no
significant differences in average performance were noted for the timed 25-yard
Paley reported two patients with amputation underwent three additional
surgical procedures. Twenty-two patients who underwent reconstruction
reportedly had an average of 3.4 surgical procedures. Patients required an
average of 2.2 prosthetic adjustments per year and 0.84 prostheses per year,
with an average estimated cost of $8,863 per prosthesis.
|The standing AP radiograph at age
8 years shows the leg length discrepancy before the second lengthening surgery.
“Our study showed no difference in function between the
reconstructed and the prosthetic replacement,” Paley said. “A
Syme’s amputation with prosthetic replacement gives nearly normal function
compared to normal … we only need to show that reconstruction is
comparable to amputation with prosthetic fitting. This study showed that.”
“[The findings have] corroborated my conclusions based on 25 years
of experience and the treatment of more than 500 fibular hemimelia patients via
evidence-based medicine,” he added. “I hope they will convince others
to offer patients the option of reconstruction either by a second opinion to an
expert performing this or by taking the steps to learn the
‘superankle’ procedure and lengthening techniques for fibular
Getting word out about the technique and its positive results is
imperative, Paley said, and could provide patients – and their parents
– with options they might never otherwise have.
“The most important thing is to give parents the options,”
Paley said. “Most centers are only experienced in doing amputation. They
therefore do not even offer the families the option of getting another opinion.
The majority of patients who I see have only had amputation offered to them
before they saw me. Often, they are angry about this. They do not understand
why their orthopedic surgeon was not aware of how good the results of
reconstruction are and why they were not referred for a second opinion.”
Paley added that many surgeons experienced with limb lengthening have no
experience with the superankle procedure. As a consequence, many complications
result from just performing lengthening without prior adequate correction and
stabilization of the foot deformity.
“The treatment becomes worse than the disease,” he said.
“This is why limb lengthening has fallen into disrepute with congenital
femoral deficiency and fibular hemimelia over the past 30 years. It is time for
societies such as [The Pediatric Orthopaedic Society of North America] and the
AAOS to help surgeons get the training needed to offer treatment for these rare
diseases closer to home.” — by Robert Press
For more information:
Paley D, et al. Limb reconstruction or amputation for severe
fibular deficiency: A two-center comparison. Paper 428. Presented at the 2011
Annual Meeting of the American Academy of Orthopaedic Surgeons. Feb. 14-19. San
Disclosure: Dror Paley, MD, FRCSC,
receives royalties from Springer, as well as Smith & Nephew.