Dr. Paley’s Advances
Dr. Paley has developed more than 100 new operative procedures for bone and soft tissue reconstruction of congenital, developmental, and post-traumatic limb disorders. Dr. Paley’s treatment philosophy centers on reconstruction: lengthening and straightening deformed bones and reconstructing congenitally short limbs to avoid amputation, a frequently recommended alternative. Dr. Paley’s advances in the treatment of congenital deformities have given children who would have otherwise lost their legs, excellent function without the need for prosthesis. Furthermore, Dr. Paley has reclassified many of these deformities, with an emphasis on reconstruction treatment rather than amputation.
Dr. Paley has also discovered a new, simple, but accurate method for prediction of limb length discrepancy and height at skeletal maturity. The “multiplier method” has replaced the previous, more complicated methods. The Paley Growth app is available in iTunes.
His method for using a combination of an intramedullary rod and external fixator has shortened the treatment time required with an external fixator while maintaining the accuracy of correction. Dr. Paley is also currently the most experienced surgeon using fully implantable limb lengthening devices.
Most of Dr. Paley’s advances have been in the field of Limb Deformity Correction. His 800-page textbook, “Principles of Deformity Correction” (Springer Verlag, 2002), introduced many new concepts on this subject, most notably, the idea of the Center of Rotation of Angulation (CORA) method. His book has been reprinted 4 times and is considered an orthopedic best seller. These general concepts are the foundation of alignment surgery of the long bones. In addition to these principles, Dr. Paley has developed many specific surgical therapeutics for different uncommon and rare diseases in children and adults for both the upper and lower limbs.
Also known as proximal femoral focal deficiency (PFFD), is the most difficult of all congenital limb length deficiency conditions. In addition to the obvious limb length discrepancy, patients with CFD often have associated bony and soft tissues deformities of the hip and knee. In order to address these deficiencies, Dr. Paley developed the SUPERhip and SUPERknee reconstructions which return the hip and knee to near normal anatomy and function. To date he has performed over 300 SUPERhips and 300 SUPERknees. Dr. Paley also developed a method to lengthen the femur with a special hinge at the hip and knee, to protect these joints during the lengthening. These advances have made limb lengthening a successful treatment option for these patients, allowing them to live normal lives with equal limb length without an amputation.
Fibular hemimelia presents a challenge of foot deformity and deficiency. Dr. Paley developed the SUPERankle procedure to address this problem and prevent recurrence of foot deformity. To date he has performed over 100 SUPERankle procedures. The SUPERankle surgery, combined with serial lengthening procedures, allow equalization of the limb length and correction of the deformity. His methods have been compared to amputation with prosthetic replacement and have shown to give as good or better function (nearly normal) without the need for prosthesis.
Treatment for tibial hemimelia depends on the degree of absence of the tibia. Dr. Paley is one of only two surgeons who have performed the special knee reconstruction where the patella (kneecap) is used to reconstruct the tibia, a patellar arthroplasty. In patients without a patella, Dr. Paley created a new operation to reconstruct the quadriceps, centralize and tether the fibula to the femur, and create a stable knee joint. He has also developed several new methods to reconstruct ankle deformities in these patients. This is followed by lengthening surgery with a specially-designed fixator construct. Despite its rarity (one in one million), Dr. Paley has successfully lengthened over 70 tibial hemimelia patients.
Treatment for radial club hand depends on the degree of absence. Dr. Paley developed a treatment for lengthening the partially absent radius combined with correction of the hand deformity. For complete absent radius, he developed the ulnarization technique, which is the first method that leads to no recurrence of deformity. Dr. Paley will then lengthen the forearm at ages 8 and 12 to normalize forearm length. In patients with no thumb, Dr. Paley will perform a pollicization to restore thumb function. Thrombocytopenia absent radius (TAR) patients with hypoplastic (not fully developed) thumbs can also have thumb reconstruction with tendon transfers and web space widening.
Dr. Paley has developed 4 different strategies of lengthening for different degrees of ulnar deficiency. Most notable is a new method of reconstruction for the complete absence of the ulna. A novel humeral osteotomy stabilizes and reorients the elbow combined with rotational osteotomy with lengthening of the radius.
Dr. Paley developed a special intra-articular osteotomy with distal radio-ulnar joint reconstruction for Madelung’s deformity. This reduces the bothersome bump of the ulnar head and restores the anatomy of the wrist joint to a more normal position.
Dr. Paley developed and published a new method for treatment of this rare, debilitating condition. This includes open reduction of the pseudarthrosis site, resection of the periosteal tissues and replacement with a periosteal graft, autogenous bone grafting, insertion of bone morphogenic protein (BMP), intramedullary stabilization combined with external fixation, and postoperative infusion of bisphosphonate (zolidronic acid) to inhibit bone resorption. This “shotgun” technique has led to union in an unprecedented 100% of all cases with zero refractures.
Dr. Paley recognized that the pathologic tissue is the fascia and therefore performs a subtotal fasciotomy combined with shortening of the femur, capsulotomy, and relengthening. This method has been very successful at preserving the knee joint.
Dr. Paley developed a 5-step method to remove the exostoses in the upper extremity, correct the distal radius deformity, widen the interosseous membrane, lengthen the ulna, and reduce the radial head. This is the first method that consistently improves the forearm rotation and shape and eliminates the bump of the dislocated radial head. In the lower extremity, Dr. Paley uses a combination of guided growth with hemiepiphysiodesis (8-plate) and osteotomy. Dr. Paley was one of the first to recommend routine nerve decompression with osteotomy to avoid nerve injury. He has also used safe surgical dislocation of the hip combined with a hip osteotomy to treat MHE.
Dr. Paley’s method of extensive, simultaneous limb lengthening of both femurs and both tibias allows an increase in height of between 12 and 16 inches. Its biggest advantage is that it reduces the total external fixation time while permitting correction of limb-trunk disproportion, rhizomelic disproportion, and simultaneous correction of deformities. Final heights of over 5 feet tall are typical with these methods, which have proven to be safe, predictable, and reproducible.
Extensive limb lengthening is also possible for other dysplasias, including spondyloepiphyseal dysplasia, pseudoachondroplasia, diastrophic dwarfism, and chondrometaphyseal dysplasia. These require a different approach where we treat one side at a time and span joints to prevent pressure.
Dr. Paley developed hip distraction for Perthes disease in 1988. This method avoids osteotomy and burns no bridges, with a 95% success rate irrespective of age of onset. It is one of the only methods applicable to older children. Dr. Paley was also the first surgeon to adopt Dr. Nuno Lopes’s technique of drilling the femoral head and neck, a method that promotes rapid revascularization of the femoral head in early Perthes disease cases. Dr. Paley was also the first surgeon to apply the Ganz method of femoral head reduction osteotomy to reduce and reshape the femoral head size for older children that are symptomatic from the deformed femoral head.
Melorheostosis is one of the rarest diseases. Since 1988, Dr. Paley recognized that open surgery leads to more scarring and worsening of joint contractures. He began using gradual distraction for these contractures which results in less stiffness.
Dr. Paley has pioneered and improved on methods to preserve joints with arthritis. In many patients, he is able to delay or prevent the need for joint replacement arthroplasty by specialized realignment techniques and joint distraction techniques. This is especially applicable to the hip, knee, and ankle. In the knee and ankle, he developed new intra-articular osteotomies to normalize deformed joint surfaces.
Dr. Paley developed the lengthening over nail (LON) method in 1990 and switched to internal lengthening first with the Albizzia nail in 1994, and then the ISKD in 2001. After many years of working with these internal nails, Dr. Paley served as a consultant with Ellipse Technologies to develop a new internal lengthening device: the PRECICE.
The PRECICE brought many advantages to internal lengthening, most notably exact rate control and the ability to lengthen in reverse (shortening). Dr. Paley was the first surgeon to use the PRECICE nail in 2011. Since then, he has worked with Ellipse to develop a second generation device, the PRECICE 2, which Dr. Paley first used in 2013. The PRECICE 2 is stronger than the original PRECICE, can lengthen longer, and has a smaller diameter, allowing it to be used in younger patients. The PRECICE heralds in a new era for limb lengthening; it can be implanted with minimal incision surgery and can perform lengthening by a remotely controlled mechanism without rate control problems. The safety factor for this device is excellent. The rate control eliminates most of the complications present in earlier internal lengthening devices. The Paley Institute was the first center to implant the PRECICE device in the United States.
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