09042011

1

Lower Limb Development

Normal and Abnormal

R Ganger MD PhD

Orthopaedic Hospital Vienna ndash Speising (wwwossat)

Department of Pediatric Orthopaedic Surgery (F Grill)

Lower Limb Development

Frontal plane alignment

bull Physiologic variations the range of normal knee angles

changes with age

bull Account for the greatest number of referrals

(including torsional problems) of children to orthopaedists

- Genu varum bow legs

- Genu valgum knock knees

Lower Limb Development

Frontal plane alignment

bull Genu varum bow legs

bull Genu valgum knock knees

09042011

2

Lower Limb Development

Frontal plane alignment

bull Genu varum bow legs

bull Genu valgum knock knees

Newborn 6 months 18 months

30 months 4-6 years

Lower Limb Development

Frontal plane deformities

bull Genu varum or Genu valgum outside normal range (+- 2 SD)

bull Normal or abnormal

- History family trauma infection

- Body height and body proportion

- Other present deformities

- Unilateral or bilateral

- Leg length difference

- Laboratory examination metabolic

Lower Limb Development

Frontal plane deformities

bull Genu varum or Genu valgum outside normal range (+- 2SD)

bull Warnings

- Asymmetrical defromity

- Progression

- Pain

- Leg length difference

09042011

3

Lower Limb Development

Frontal plane alignment

bull Standard imaging AP-long leg standing radiogram

patella pointing straight forward

incorrect correct

Lower Limb Development

Frontal plane alignment

bull The majority of children with bow legs befors age of 2 yrs and

knock knees presenting before 6 yrs will resolve spontaneously

Natural history

bull benign

bull selfcorrecting deformity

Correction devices (twister cables night splints shoe wedges)

are unnecessary

Anual clinical checks are recommended

Lower Limb Development

Frontal plane alignment

bull The minority of children with unilateral deformity progression

leg length discrepancy and pain need further investigation

Pathological genu varum valgum

bull M Blount

bull Rickets VitD - resistent rickets

bull Deformities after infection trauma

tumor

09042011

4

Lower Limb Development

Frontal plane alignment

Goal

bull Physiological deformities are best observed

bull Pathological deformities are treated surgically to achieve

straight legs at same length

Lower Limb Development

Torsional problems

Intoing

bull usually not abnormal

bull developmental variation

bull resolves spontaneously

If the deformity is severe TORSIONAL DEFORMITY

Lower Limb Development

Torsion problems

What conditions cause intoing

bull medial femoral torsion

bull medial tibial torsion

bull forefoot adduction

Each is contributing to the degree of intoeing

09042011

5

Lower Limb Development

Forefoot adduction

Adduction of the forefoot in respect to the hindfoot can cause intoing

Lower Limb Development

Femoral torsion

Definition angular difference between the axis

of the upper femur and that of the knee

Natural history

bull at birth the femoral torsion is 30deg

bull it decreases with growth and averages at 15deg for adults

From HEFTI

Kinderorthopaumldie

Springer-Verlag

Lower Limb Development

Increased femoral antetorsion

bull intoing gait pattern with kneeing in (patella pointing medially)

bull increased medial hip rotation decreased lateral hip rotation

Medial (internal) hip rotation Lateral (external) hip rotation

09042011

6

Lower Limb Development

Tibial torsion

Definition deformity in which the horizontal plane

of the tibia is rotated medially or laterally

Natural history

bull at birth the tibial torsion is 0deg

bull with growth it averages at 15deg - 20deg external rotation

From HEFTI

Kinderorthopaumldie

Springer-Verlag

Lower Limb Development

Increased medial tibial torsion

bull resolve spontaneously in 95 over time

bull often in combination with genua vara

Lower Limb Development

Torsional deformity

Age at presentation is important

bull early infancy usually due to metatarsus adductus

bull toddler age medial tibial torsion

bull early childhood medial femoral torsion

09042011

7

Lower Limb Development

Torsional deformity

Pitfalls of diagnosis avoid overlooking underlying diseases

bull intoeing hip dysplasia mild diplegia or hemiplegia

bull out-toeing SCFE

Lower Limb Development

Femoral and tibial torsion

Imaging

bull Sonography

bull Rotational CT-scan

helpful when operative

correction is planned

Lower Limb Development

Femoral and tibial torsional deformities

Treatment

bull the majority will resolve spontaneously over time

bull devices like twister cables night splints shoe wedges

and inserts are not effective

bull convince the family that observation is the best

09042011

8

Lower Limb Development

Tibial torsional deformities

Medial tibial torsion

bull mostly improves

bull if persistant supramalleolar derotation osteotomy

Lateral tibial torsion

bull increases with growth

bull more often requires operative treatment

Lower Limb Development

Femoral torsional deformities

Medial femoral torsion

bull normally improves

bull no risk of osteoarthritis

bull if persistant and severe rotational femoral osteotomy at the

proximal level in adolescence

Lateral femoral torsion (retrotorsion)

bull risk of osteoarthritis

bull requires operative treatment

Lower Limb Development

Femoral torsional deformities

Rotational femoral osteotomy

plate fixation

09042011

2

Lower Limb Development

Frontal plane alignment

bull Genu varum bow legs

bull Genu valgum knock knees

Newborn 6 months 18 months

30 months 4-6 years

Lower Limb Development

Frontal plane deformities

bull Genu varum or Genu valgum outside normal range (+- 2 SD)

bull Normal or abnormal

- History family trauma infection

- Body height and body proportion

- Other present deformities

- Unilateral or bilateral

- Leg length difference

- Laboratory examination metabolic

Lower Limb Development

Frontal plane deformities

bull Genu varum or Genu valgum outside normal range (+- 2SD)

bull Warnings

- Asymmetrical defromity

- Progression

- Pain

- Leg length difference

09042011

3

Lower Limb Development

Frontal plane alignment

bull Standard imaging AP-long leg standing radiogram

patella pointing straight forward

incorrect correct

Lower Limb Development

Frontal plane alignment

bull The majority of children with bow legs befors age of 2 yrs and

knock knees presenting before 6 yrs will resolve spontaneously

Natural history

bull benign

bull selfcorrecting deformity

Correction devices (twister cables night splints shoe wedges)

are unnecessary

Anual clinical checks are recommended

Lower Limb Development

Frontal plane alignment

bull The minority of children with unilateral deformity progression

leg length discrepancy and pain need further investigation

Pathological genu varum valgum

bull M Blount

bull Rickets VitD - resistent rickets

bull Deformities after infection trauma

tumor

09042011

4

Lower Limb Development

Frontal plane alignment

Goal

bull Physiological deformities are best observed

bull Pathological deformities are treated surgically to achieve

straight legs at same length

Lower Limb Development

Torsional problems

Intoing

bull usually not abnormal

bull developmental variation

bull resolves spontaneously

If the deformity is severe TORSIONAL DEFORMITY

Lower Limb Development

Torsion problems

What conditions cause intoing

bull medial femoral torsion

bull medial tibial torsion

bull forefoot adduction

Each is contributing to the degree of intoeing

09042011

5

Lower Limb Development

Forefoot adduction

Adduction of the forefoot in respect to the hindfoot can cause intoing

Lower Limb Development

Femoral torsion

Definition angular difference between the axis

of the upper femur and that of the knee

Natural history

bull at birth the femoral torsion is 30deg

bull it decreases with growth and averages at 15deg for adults

From HEFTI

Kinderorthopaumldie

Springer-Verlag

Lower Limb Development

Increased femoral antetorsion

bull intoing gait pattern with kneeing in (patella pointing medially)

bull increased medial hip rotation decreased lateral hip rotation

Medial (internal) hip rotation Lateral (external) hip rotation

09042011

6

Lower Limb Development

Tibial torsion

Definition deformity in which the horizontal plane

of the tibia is rotated medially or laterally

Natural history

bull at birth the tibial torsion is 0deg

bull with growth it averages at 15deg - 20deg external rotation

From HEFTI

Kinderorthopaumldie

Springer-Verlag

Lower Limb Development

Increased medial tibial torsion

bull resolve spontaneously in 95 over time

bull often in combination with genua vara

Lower Limb Development

Torsional deformity

Age at presentation is important

bull early infancy usually due to metatarsus adductus

bull toddler age medial tibial torsion

bull early childhood medial femoral torsion

09042011

7

Lower Limb Development

Torsional deformity

Pitfalls of diagnosis avoid overlooking underlying diseases

bull intoeing hip dysplasia mild diplegia or hemiplegia

bull out-toeing SCFE

Lower Limb Development

Femoral and tibial torsion

Imaging

bull Sonography

bull Rotational CT-scan

helpful when operative

correction is planned

Lower Limb Development

Femoral and tibial torsional deformities

Treatment

bull the majority will resolve spontaneously over time

bull devices like twister cables night splints shoe wedges

and inserts are not effective

bull convince the family that observation is the best

09042011

8

Lower Limb Development

Tibial torsional deformities

Medial tibial torsion

bull mostly improves

bull if persistant supramalleolar derotation osteotomy

Lateral tibial torsion

bull increases with growth

bull more often requires operative treatment

Lower Limb Development

Femoral torsional deformities

Medial femoral torsion

bull normally improves

bull no risk of osteoarthritis

bull if persistant and severe rotational femoral osteotomy at the

proximal level in adolescence

Lateral femoral torsion (retrotorsion)

bull risk of osteoarthritis

bull requires operative treatment

Lower Limb Development

Femoral torsional deformities

Rotational femoral osteotomy

plate fixation

09042011

3

Lower Limb Development

Frontal plane alignment

bull Standard imaging AP-long leg standing radiogram

patella pointing straight forward

incorrect correct

Lower Limb Development

Frontal plane alignment

bull The majority of children with bow legs befors age of 2 yrs and

knock knees presenting before 6 yrs will resolve spontaneously

Natural history

bull benign

bull selfcorrecting deformity

Correction devices (twister cables night splints shoe wedges)

are unnecessary

Anual clinical checks are recommended

Lower Limb Development

Frontal plane alignment

bull The minority of children with unilateral deformity progression

leg length discrepancy and pain need further investigation

Pathological genu varum valgum

bull M Blount

bull Rickets VitD - resistent rickets

bull Deformities after infection trauma

tumor

09042011

4

Lower Limb Development

Frontal plane alignment

Goal

bull Physiological deformities are best observed

bull Pathological deformities are treated surgically to achieve

straight legs at same length

Lower Limb Development

Torsional problems

Intoing

bull usually not abnormal

bull developmental variation

bull resolves spontaneously

If the deformity is severe TORSIONAL DEFORMITY

Lower Limb Development

Torsion problems

What conditions cause intoing

bull medial femoral torsion

bull medial tibial torsion

bull forefoot adduction

Each is contributing to the degree of intoeing

09042011

5

Lower Limb Development

Forefoot adduction

Adduction of the forefoot in respect to the hindfoot can cause intoing

Lower Limb Development

Femoral torsion

Definition angular difference between the axis

of the upper femur and that of the knee

Natural history

bull at birth the femoral torsion is 30deg

bull it decreases with growth and averages at 15deg for adults

From HEFTI

Kinderorthopaumldie

Springer-Verlag

Lower Limb Development

Increased femoral antetorsion

bull intoing gait pattern with kneeing in (patella pointing medially)

bull increased medial hip rotation decreased lateral hip rotation

Medial (internal) hip rotation Lateral (external) hip rotation

09042011

6

Lower Limb Development

Tibial torsion

Definition deformity in which the horizontal plane

of the tibia is rotated medially or laterally

Natural history

bull at birth the tibial torsion is 0deg

bull with growth it averages at 15deg - 20deg external rotation

From HEFTI

Kinderorthopaumldie

Springer-Verlag

Lower Limb Development

Increased medial tibial torsion

bull resolve spontaneously in 95 over time

bull often in combination with genua vara

Lower Limb Development

Torsional deformity

Age at presentation is important

bull early infancy usually due to metatarsus adductus

bull toddler age medial tibial torsion

bull early childhood medial femoral torsion

09042011

7

Lower Limb Development

Torsional deformity

Pitfalls of diagnosis avoid overlooking underlying diseases

bull intoeing hip dysplasia mild diplegia or hemiplegia

bull out-toeing SCFE

Lower Limb Development

Femoral and tibial torsion

Imaging

bull Sonography

bull Rotational CT-scan

helpful when operative

correction is planned

Lower Limb Development

Femoral and tibial torsional deformities

Treatment

bull the majority will resolve spontaneously over time

bull devices like twister cables night splints shoe wedges

and inserts are not effective

bull convince the family that observation is the best

09042011

8

Lower Limb Development

Tibial torsional deformities

Medial tibial torsion

bull mostly improves

bull if persistant supramalleolar derotation osteotomy

Lateral tibial torsion

bull increases with growth

bull more often requires operative treatment

Lower Limb Development

Femoral torsional deformities

Medial femoral torsion

bull normally improves

bull no risk of osteoarthritis

bull if persistant and severe rotational femoral osteotomy at the

proximal level in adolescence

Lateral femoral torsion (retrotorsion)

bull risk of osteoarthritis

bull requires operative treatment

Lower Limb Development

Femoral torsional deformities

Rotational femoral osteotomy

plate fixation

09042011

4

Lower Limb Development

Frontal plane alignment

Goal

bull Physiological deformities are best observed

bull Pathological deformities are treated surgically to achieve

straight legs at same length

Lower Limb Development

Torsional problems

Intoing

bull usually not abnormal

bull developmental variation

bull resolves spontaneously

If the deformity is severe TORSIONAL DEFORMITY

Lower Limb Development

Torsion problems

What conditions cause intoing

bull medial femoral torsion

bull medial tibial torsion

bull forefoot adduction

Each is contributing to the degree of intoeing

09042011

5

Lower Limb Development

Forefoot adduction

Adduction of the forefoot in respect to the hindfoot can cause intoing

Lower Limb Development

Femoral torsion

Definition angular difference between the axis

of the upper femur and that of the knee

Natural history

bull at birth the femoral torsion is 30deg

bull it decreases with growth and averages at 15deg for adults

From HEFTI

Kinderorthopaumldie

Springer-Verlag

Lower Limb Development

Increased femoral antetorsion

bull intoing gait pattern with kneeing in (patella pointing medially)

bull increased medial hip rotation decreased lateral hip rotation

Medial (internal) hip rotation Lateral (external) hip rotation

09042011

6

Lower Limb Development

Tibial torsion

Definition deformity in which the horizontal plane

of the tibia is rotated medially or laterally

Natural history

bull at birth the tibial torsion is 0deg

bull with growth it averages at 15deg - 20deg external rotation

From HEFTI

Kinderorthopaumldie

Springer-Verlag

Lower Limb Development

Increased medial tibial torsion

bull resolve spontaneously in 95 over time

bull often in combination with genua vara

Lower Limb Development

Torsional deformity

Age at presentation is important

bull early infancy usually due to metatarsus adductus

bull toddler age medial tibial torsion

bull early childhood medial femoral torsion

09042011

7

Lower Limb Development

Torsional deformity

Pitfalls of diagnosis avoid overlooking underlying diseases

bull intoeing hip dysplasia mild diplegia or hemiplegia

bull out-toeing SCFE

Lower Limb Development

Femoral and tibial torsion

Imaging

bull Sonography

bull Rotational CT-scan

helpful when operative

correction is planned

Lower Limb Development

Femoral and tibial torsional deformities

Treatment

bull the majority will resolve spontaneously over time

bull devices like twister cables night splints shoe wedges

and inserts are not effective

bull convince the family that observation is the best

09042011

8

Lower Limb Development

Tibial torsional deformities

Medial tibial torsion

bull mostly improves

bull if persistant supramalleolar derotation osteotomy

Lateral tibial torsion

bull increases with growth

bull more often requires operative treatment

Lower Limb Development

Femoral torsional deformities

Medial femoral torsion

bull normally improves

bull no risk of osteoarthritis

bull if persistant and severe rotational femoral osteotomy at the

proximal level in adolescence

Lateral femoral torsion (retrotorsion)

bull risk of osteoarthritis

bull requires operative treatment

Lower Limb Development

Femoral torsional deformities

Rotational femoral osteotomy

plate fixation

09042011

5

Lower Limb Development

Forefoot adduction

Adduction of the forefoot in respect to the hindfoot can cause intoing

Lower Limb Development

Femoral torsion

Definition angular difference between the axis

of the upper femur and that of the knee

Natural history

bull at birth the femoral torsion is 30deg

bull it decreases with growth and averages at 15deg for adults

From HEFTI

Kinderorthopaumldie

Springer-Verlag

Lower Limb Development

Increased femoral antetorsion

bull intoing gait pattern with kneeing in (patella pointing medially)

bull increased medial hip rotation decreased lateral hip rotation

Medial (internal) hip rotation Lateral (external) hip rotation

09042011

6

Lower Limb Development

Tibial torsion

Definition deformity in which the horizontal plane

of the tibia is rotated medially or laterally

Natural history

bull at birth the tibial torsion is 0deg

bull with growth it averages at 15deg - 20deg external rotation

From HEFTI

Kinderorthopaumldie

Springer-Verlag

Lower Limb Development

Increased medial tibial torsion

bull resolve spontaneously in 95 over time

bull often in combination with genua vara

Lower Limb Development

Torsional deformity

Age at presentation is important

bull early infancy usually due to metatarsus adductus

bull toddler age medial tibial torsion

bull early childhood medial femoral torsion

09042011

7

Lower Limb Development

Torsional deformity

Pitfalls of diagnosis avoid overlooking underlying diseases

bull intoeing hip dysplasia mild diplegia or hemiplegia

bull out-toeing SCFE

Lower Limb Development

Femoral and tibial torsion

Imaging

bull Sonography

bull Rotational CT-scan

helpful when operative

correction is planned

Lower Limb Development

Femoral and tibial torsional deformities

Treatment

bull the majority will resolve spontaneously over time

bull devices like twister cables night splints shoe wedges

and inserts are not effective

bull convince the family that observation is the best

09042011

8

Lower Limb Development

Tibial torsional deformities

Medial tibial torsion

bull mostly improves

bull if persistant supramalleolar derotation osteotomy

Lateral tibial torsion

bull increases with growth

bull more often requires operative treatment

Lower Limb Development

Femoral torsional deformities

Medial femoral torsion

bull normally improves

bull no risk of osteoarthritis

bull if persistant and severe rotational femoral osteotomy at the

proximal level in adolescence

Lateral femoral torsion (retrotorsion)

bull risk of osteoarthritis

bull requires operative treatment

Lower Limb Development

Femoral torsional deformities

Rotational femoral osteotomy

plate fixation

09042011

6

Lower Limb Development

Tibial torsion

Definition deformity in which the horizontal plane

of the tibia is rotated medially or laterally

Natural history

bull at birth the tibial torsion is 0deg

bull with growth it averages at 15deg - 20deg external rotation

From HEFTI

Kinderorthopaumldie

Springer-Verlag

Lower Limb Development

Increased medial tibial torsion

bull resolve spontaneously in 95 over time

bull often in combination with genua vara

Lower Limb Development

Torsional deformity

Age at presentation is important

bull early infancy usually due to metatarsus adductus

bull toddler age medial tibial torsion

bull early childhood medial femoral torsion

09042011

7

Lower Limb Development

Torsional deformity

Pitfalls of diagnosis avoid overlooking underlying diseases

bull intoeing hip dysplasia mild diplegia or hemiplegia

bull out-toeing SCFE

Lower Limb Development

Femoral and tibial torsion

Imaging

bull Sonography

bull Rotational CT-scan

helpful when operative

correction is planned

Lower Limb Development

Femoral and tibial torsional deformities

Treatment

bull the majority will resolve spontaneously over time

bull devices like twister cables night splints shoe wedges

and inserts are not effective

bull convince the family that observation is the best

09042011

8

Lower Limb Development

Tibial torsional deformities

Medial tibial torsion

bull mostly improves

bull if persistant supramalleolar derotation osteotomy

Lateral tibial torsion

bull increases with growth

bull more often requires operative treatment

Lower Limb Development

Femoral torsional deformities

Medial femoral torsion

bull normally improves

bull no risk of osteoarthritis

bull if persistant and severe rotational femoral osteotomy at the

proximal level in adolescence

Lateral femoral torsion (retrotorsion)

bull risk of osteoarthritis

bull requires operative treatment

Lower Limb Development

Femoral torsional deformities

Rotational femoral osteotomy

plate fixation

09042011

7

Lower Limb Development

Torsional deformity

Pitfalls of diagnosis avoid overlooking underlying diseases

bull intoeing hip dysplasia mild diplegia or hemiplegia

bull out-toeing SCFE

Lower Limb Development

Femoral and tibial torsion

Imaging

bull Sonography

bull Rotational CT-scan

helpful when operative

correction is planned

Lower Limb Development

Femoral and tibial torsional deformities

Treatment

bull the majority will resolve spontaneously over time

bull devices like twister cables night splints shoe wedges

and inserts are not effective

bull convince the family that observation is the best

09042011

8

Lower Limb Development

Tibial torsional deformities

Medial tibial torsion

bull mostly improves

bull if persistant supramalleolar derotation osteotomy

Lateral tibial torsion

bull increases with growth

bull more often requires operative treatment

Lower Limb Development

Femoral torsional deformities

Medial femoral torsion

bull normally improves

bull no risk of osteoarthritis

bull if persistant and severe rotational femoral osteotomy at the

proximal level in adolescence

Lateral femoral torsion (retrotorsion)

bull risk of osteoarthritis

bull requires operative treatment

Lower Limb Development

Femoral torsional deformities

Rotational femoral osteotomy

plate fixation

09042011

8

Lower Limb Development

Tibial torsional deformities

Medial tibial torsion

bull mostly improves

bull if persistant supramalleolar derotation osteotomy

Lateral tibial torsion

bull increases with growth

bull more often requires operative treatment

Lower Limb Development

Femoral torsional deformities

Medial femoral torsion

bull normally improves

bull no risk of osteoarthritis

bull if persistant and severe rotational femoral osteotomy at the

proximal level in adolescence

Lateral femoral torsion (retrotorsion)

bull risk of osteoarthritis

bull requires operative treatment

Lower Limb Development

Femoral torsional deformities

Rotational femoral osteotomy

plate fixation

09042011

9

Lower Limb Development

Torsional Malalignment Syndrom

Combination of medial femoral torsion and lateral tibial torsion

bull foot progression angle is normal but the knee

is rotated medially

bull patients complain of patellofemoral knee pain

bull double osteotomy may be required in severe cases

Lower Limb Development

Torsional Malalignment Syndrom

Combination of medial femoral torsion and lateral tibial torsion

Lower Limb Development

Torsional Malalignment Syndrom

Combination of medial femoral torsion and lateral tibial torsion

09042011

10

Lower Limb Development

Leg Length Difference ndash LLD

Structural LLD

bull may occur at any site in the limb or pelvis

the height of the foot and pelvis should be included

in calculating the total discrepancy

Functional LLD

bull shorter

- adduction contracture of the hip

- flexion contracture of the knee

bull longer

- abduction contracture of the hip

- foot equinus

Lower Limb Development

Leg Length Difference ndash LLD

Idiopathic LLD lt 1cm

bull can be found up to 30

LLD gt 2 cm

bull after trauma

bull congenital (CFD FH TH)

bull metabolic (rickets Vit-D-resitent rickets)

bull after infection or radiation

bull neurological (polio cerebral palsyhellip)

bull osteodysplastic disorders syndromas

(M Ollier Klippel-Trenaunay)

Lower Limb Development

Leg Length Difference ndash LLD

LLD gt 2 cm

bull effect on gait depends on the magnitude

compensation by flexing the knee on the long side

standing in ankle equinus on the shortened side

bull functional scoliosis because of

pelvis inequality

bull sometimes back-pain

bull causal relationship between LLD and

osteoarthritis has not been shown

09042011

11

Lower Limb Development

Leg Length Difference ndash LLD

Clinical examination

bull LLD is best assessed

by progressively elevating

the short side with plates

until the pelvis is at

the same level

Lower Limb Development

Leg Length Difference ndash LLD

Clinical examination

bull measuring tape

not accurate enough

Lower Limb Development

Leg Length Difference ndash LLD

Clinical examination

bull note a difference

in femoral or tibial length

09042011

12

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull AP-view standing radiograph

of the pelvis

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull AP-view standing radiograph

of the pelvis

bull the short side should be

supported on a lift

to eliminate compensatory

mechanisms that could

affect measurement

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Orthoradiogram

09042011

13

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Orthoradiogram

- for calculation

of femoral and tibial length

- does not adress

foot height or

pelvic inequality

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Teleradiogram

- film-focus distance

305cm

- metal ball

diameter 25mm

at the level

of the bone

for calibration

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Teleradiogram

09042011

14

Lower Limb Development

Prediction of LLD

Calculation discrepancy at maturity

bull LLD at the end of growth

bull Strategy of correction

- lift lengthening shortening epiphysiodesis

bull Timing of epiphysiodesis

Lower Limb Development

Prediction of LLD

Calculation discrepancy at maturity

bull Problems

- different methods based on the bone age

- not accurate enough during period of puberty

- different formulas are based on the same patients data

Lower Limb Development

Determination of the bone age

bull according to Greulich and Pyle

- details from AP-hand radiogram

- specific for boys and girls

- data from children

born between 1917 and 1942

bull according to Tanner and Whitehouse

- AP-hand radiogram

- 20 different details

- time consuming

09042011

15

Lower Limb Development

Determination of percentile group

bull bone age

bull body height

bull Anderson charts

Lower Limb Development

Prediction of LLD

Growth remaining charts ndash Green amp Anderson

bull determination

of bone age and

height percentile

bull identification

of remaining growth

on the diagram

bull specific for

boys and girls

Lower Limb Development

Prediction of LLD

Moseley straigth-line graph

bull graphic method based on

the Anderson data

bull 3-4 evaluations of actual

LLD are necessary

to predict final LLD

at maturity

09042011

16

Lower Limb Development

Prediction of LLD

Multiplier method according to Paley

bull biological age and

age-specific multipliers

are used

bull specific

for boys and girls

Lower Limb Development

Prediction of LLD

Multiplier method according to Paley

Height at maturity =

actual height x

multiplier

LLD at maturity

actual LLD x

multiplier

Lower Limb Development

LLD conservative treatment

Insole

bull 05 ndash 1 cm

Shoe lift

bull 1 ndash 5 cm

bull avoid instability

Orthopedic shoes

bull 5 ndash 10 cm

Orthoprothetic device

bull more than 10 cm

09042011

17

Lower Limb Development

LLD conservative treatment

Insole

bull 05 ndash 1 cm

Shoe lift

bull 1 ndash 5 cm

bull avoid instability

Orthopedic shoes

bull 5 ndash 10 cm

Orthoprothetic device

bull more than 10 cm

Lower Limb Development

Algorithm for management of LLD

From STAHELI Fundamentals of Pediatric Orthopedics

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

09042011

18

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Anatomical axis

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

versus

bull Anatomical axis

Femur

difference of 6deg

Tibia

same

Lower Limb Development

Normal lower limb alignment

Sagittal plane

09042011

19

Lower Limb Development

Lower limb malalignment

Deformity analysis

Frontal plane

bull Varus valgus translation

Sagittal plane

bull Antecurvation recurvation translation

Axial plane

bull Rotation lengthening or shortening

Lower Limb Development

Malalignment test acc to Paley and Herzenberg

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral deformity

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Tibial deformity

09042011

20

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral and tibial

deformity

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

09042011

21

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program Deformity 4deg

Correction 85deg

With Auto Alignment

MAD 7mm med

Individual Alignment

MAD 1mm med

09042011

22

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

09042011

23

Lower Limb Development

LLD procedures for lengthening and axial correction

Different devices

Lower Limb Development

LLD procedures for lengthening and axial correction

Different indications for different devices

bull Etiology of the disease (congenital metabolic posttraumatic

postinfectionhellip)

bull Type of deformity (unilevel multilevel leg length difference)

bull Bony maturation (open closed growth plates)

bull Training and skill of the surgeon

bull Availibility of the system (costshellip)

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixators

bull Orthofix ndash fixator (Orthofix company)

bull Dynafix ndash fixator (Biomet company)

bull Fixation with screws

(diameter of 5 or 6 mm)

Best indications

bull Diaphyseal and distal femoral deformities

bull Distal femoral lengthening procedures

09042011

24

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

102000 42001 42002 1 y after removal

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

Gavril A Ilizarov

Each frame is a special custom made construct

for a given deformity

09042011

25

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

10

Lower Limb Development

Leg Length Difference ndash LLD

Structural LLD

bull may occur at any site in the limb or pelvis

the height of the foot and pelvis should be included

in calculating the total discrepancy

Functional LLD

bull shorter

- adduction contracture of the hip

- flexion contracture of the knee

bull longer

- abduction contracture of the hip

- foot equinus

Lower Limb Development

Leg Length Difference ndash LLD

Idiopathic LLD lt 1cm

bull can be found up to 30

LLD gt 2 cm

bull after trauma

bull congenital (CFD FH TH)

bull metabolic (rickets Vit-D-resitent rickets)

bull after infection or radiation

bull neurological (polio cerebral palsyhellip)

bull osteodysplastic disorders syndromas

(M Ollier Klippel-Trenaunay)

Lower Limb Development

Leg Length Difference ndash LLD

LLD gt 2 cm

bull effect on gait depends on the magnitude

compensation by flexing the knee on the long side

standing in ankle equinus on the shortened side

bull functional scoliosis because of

pelvis inequality

bull sometimes back-pain

bull causal relationship between LLD and

osteoarthritis has not been shown

09042011

11

Lower Limb Development

Leg Length Difference ndash LLD

Clinical examination

bull LLD is best assessed

by progressively elevating

the short side with plates

until the pelvis is at

the same level

Lower Limb Development

Leg Length Difference ndash LLD

Clinical examination

bull measuring tape

not accurate enough

Lower Limb Development

Leg Length Difference ndash LLD

Clinical examination

bull note a difference

in femoral or tibial length

09042011

12

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull AP-view standing radiograph

of the pelvis

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull AP-view standing radiograph

of the pelvis

bull the short side should be

supported on a lift

to eliminate compensatory

mechanisms that could

affect measurement

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Orthoradiogram

09042011

13

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Orthoradiogram

- for calculation

of femoral and tibial length

- does not adress

foot height or

pelvic inequality

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Teleradiogram

- film-focus distance

305cm

- metal ball

diameter 25mm

at the level

of the bone

for calibration

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Teleradiogram

09042011

14

Lower Limb Development

Prediction of LLD

Calculation discrepancy at maturity

bull LLD at the end of growth

bull Strategy of correction

- lift lengthening shortening epiphysiodesis

bull Timing of epiphysiodesis

Lower Limb Development

Prediction of LLD

Calculation discrepancy at maturity

bull Problems

- different methods based on the bone age

- not accurate enough during period of puberty

- different formulas are based on the same patients data

Lower Limb Development

Determination of the bone age

bull according to Greulich and Pyle

- details from AP-hand radiogram

- specific for boys and girls

- data from children

born between 1917 and 1942

bull according to Tanner and Whitehouse

- AP-hand radiogram

- 20 different details

- time consuming

09042011

15

Lower Limb Development

Determination of percentile group

bull bone age

bull body height

bull Anderson charts

Lower Limb Development

Prediction of LLD

Growth remaining charts ndash Green amp Anderson

bull determination

of bone age and

height percentile

bull identification

of remaining growth

on the diagram

bull specific for

boys and girls

Lower Limb Development

Prediction of LLD

Moseley straigth-line graph

bull graphic method based on

the Anderson data

bull 3-4 evaluations of actual

LLD are necessary

to predict final LLD

at maturity

09042011

16

Lower Limb Development

Prediction of LLD

Multiplier method according to Paley

bull biological age and

age-specific multipliers

are used

bull specific

for boys and girls

Lower Limb Development

Prediction of LLD

Multiplier method according to Paley

Height at maturity =

actual height x

multiplier

LLD at maturity

actual LLD x

multiplier

Lower Limb Development

LLD conservative treatment

Insole

bull 05 ndash 1 cm

Shoe lift

bull 1 ndash 5 cm

bull avoid instability

Orthopedic shoes

bull 5 ndash 10 cm

Orthoprothetic device

bull more than 10 cm

09042011

17

Lower Limb Development

LLD conservative treatment

Insole

bull 05 ndash 1 cm

Shoe lift

bull 1 ndash 5 cm

bull avoid instability

Orthopedic shoes

bull 5 ndash 10 cm

Orthoprothetic device

bull more than 10 cm

Lower Limb Development

Algorithm for management of LLD

From STAHELI Fundamentals of Pediatric Orthopedics

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

09042011

18

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Anatomical axis

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

versus

bull Anatomical axis

Femur

difference of 6deg

Tibia

same

Lower Limb Development

Normal lower limb alignment

Sagittal plane

09042011

19

Lower Limb Development

Lower limb malalignment

Deformity analysis

Frontal plane

bull Varus valgus translation

Sagittal plane

bull Antecurvation recurvation translation

Axial plane

bull Rotation lengthening or shortening

Lower Limb Development

Malalignment test acc to Paley and Herzenberg

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral deformity

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Tibial deformity

09042011

20

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral and tibial

deformity

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

09042011

21

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program Deformity 4deg

Correction 85deg

With Auto Alignment

MAD 7mm med

Individual Alignment

MAD 1mm med

09042011

22

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

09042011

23

Lower Limb Development

LLD procedures for lengthening and axial correction

Different devices

Lower Limb Development

LLD procedures for lengthening and axial correction

Different indications for different devices

bull Etiology of the disease (congenital metabolic posttraumatic

postinfectionhellip)

bull Type of deformity (unilevel multilevel leg length difference)

bull Bony maturation (open closed growth plates)

bull Training and skill of the surgeon

bull Availibility of the system (costshellip)

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixators

bull Orthofix ndash fixator (Orthofix company)

bull Dynafix ndash fixator (Biomet company)

bull Fixation with screws

(diameter of 5 or 6 mm)

Best indications

bull Diaphyseal and distal femoral deformities

bull Distal femoral lengthening procedures

09042011

24

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

102000 42001 42002 1 y after removal

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

Gavril A Ilizarov

Each frame is a special custom made construct

for a given deformity

09042011

25

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

11

Lower Limb Development

Leg Length Difference ndash LLD

Clinical examination

bull LLD is best assessed

by progressively elevating

the short side with plates

until the pelvis is at

the same level

Lower Limb Development

Leg Length Difference ndash LLD

Clinical examination

bull measuring tape

not accurate enough

Lower Limb Development

Leg Length Difference ndash LLD

Clinical examination

bull note a difference

in femoral or tibial length

09042011

12

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull AP-view standing radiograph

of the pelvis

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull AP-view standing radiograph

of the pelvis

bull the short side should be

supported on a lift

to eliminate compensatory

mechanisms that could

affect measurement

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Orthoradiogram

09042011

13

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Orthoradiogram

- for calculation

of femoral and tibial length

- does not adress

foot height or

pelvic inequality

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Teleradiogram

- film-focus distance

305cm

- metal ball

diameter 25mm

at the level

of the bone

for calibration

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Teleradiogram

09042011

14

Lower Limb Development

Prediction of LLD

Calculation discrepancy at maturity

bull LLD at the end of growth

bull Strategy of correction

- lift lengthening shortening epiphysiodesis

bull Timing of epiphysiodesis

Lower Limb Development

Prediction of LLD

Calculation discrepancy at maturity

bull Problems

- different methods based on the bone age

- not accurate enough during period of puberty

- different formulas are based on the same patients data

Lower Limb Development

Determination of the bone age

bull according to Greulich and Pyle

- details from AP-hand radiogram

- specific for boys and girls

- data from children

born between 1917 and 1942

bull according to Tanner and Whitehouse

- AP-hand radiogram

- 20 different details

- time consuming

09042011

15

Lower Limb Development

Determination of percentile group

bull bone age

bull body height

bull Anderson charts

Lower Limb Development

Prediction of LLD

Growth remaining charts ndash Green amp Anderson

bull determination

of bone age and

height percentile

bull identification

of remaining growth

on the diagram

bull specific for

boys and girls

Lower Limb Development

Prediction of LLD

Moseley straigth-line graph

bull graphic method based on

the Anderson data

bull 3-4 evaluations of actual

LLD are necessary

to predict final LLD

at maturity

09042011

16

Lower Limb Development

Prediction of LLD

Multiplier method according to Paley

bull biological age and

age-specific multipliers

are used

bull specific

for boys and girls

Lower Limb Development

Prediction of LLD

Multiplier method according to Paley

Height at maturity =

actual height x

multiplier

LLD at maturity

actual LLD x

multiplier

Lower Limb Development

LLD conservative treatment

Insole

bull 05 ndash 1 cm

Shoe lift

bull 1 ndash 5 cm

bull avoid instability

Orthopedic shoes

bull 5 ndash 10 cm

Orthoprothetic device

bull more than 10 cm

09042011

17

Lower Limb Development

LLD conservative treatment

Insole

bull 05 ndash 1 cm

Shoe lift

bull 1 ndash 5 cm

bull avoid instability

Orthopedic shoes

bull 5 ndash 10 cm

Orthoprothetic device

bull more than 10 cm

Lower Limb Development

Algorithm for management of LLD

From STAHELI Fundamentals of Pediatric Orthopedics

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

09042011

18

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Anatomical axis

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

versus

bull Anatomical axis

Femur

difference of 6deg

Tibia

same

Lower Limb Development

Normal lower limb alignment

Sagittal plane

09042011

19

Lower Limb Development

Lower limb malalignment

Deformity analysis

Frontal plane

bull Varus valgus translation

Sagittal plane

bull Antecurvation recurvation translation

Axial plane

bull Rotation lengthening or shortening

Lower Limb Development

Malalignment test acc to Paley and Herzenberg

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral deformity

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Tibial deformity

09042011

20

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral and tibial

deformity

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

09042011

21

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program Deformity 4deg

Correction 85deg

With Auto Alignment

MAD 7mm med

Individual Alignment

MAD 1mm med

09042011

22

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

09042011

23

Lower Limb Development

LLD procedures for lengthening and axial correction

Different devices

Lower Limb Development

LLD procedures for lengthening and axial correction

Different indications for different devices

bull Etiology of the disease (congenital metabolic posttraumatic

postinfectionhellip)

bull Type of deformity (unilevel multilevel leg length difference)

bull Bony maturation (open closed growth plates)

bull Training and skill of the surgeon

bull Availibility of the system (costshellip)

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixators

bull Orthofix ndash fixator (Orthofix company)

bull Dynafix ndash fixator (Biomet company)

bull Fixation with screws

(diameter of 5 or 6 mm)

Best indications

bull Diaphyseal and distal femoral deformities

bull Distal femoral lengthening procedures

09042011

24

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

102000 42001 42002 1 y after removal

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

Gavril A Ilizarov

Each frame is a special custom made construct

for a given deformity

09042011

25

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

12

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull AP-view standing radiograph

of the pelvis

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull AP-view standing radiograph

of the pelvis

bull the short side should be

supported on a lift

to eliminate compensatory

mechanisms that could

affect measurement

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Orthoradiogram

09042011

13

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Orthoradiogram

- for calculation

of femoral and tibial length

- does not adress

foot height or

pelvic inequality

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Teleradiogram

- film-focus distance

305cm

- metal ball

diameter 25mm

at the level

of the bone

for calibration

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Teleradiogram

09042011

14

Lower Limb Development

Prediction of LLD

Calculation discrepancy at maturity

bull LLD at the end of growth

bull Strategy of correction

- lift lengthening shortening epiphysiodesis

bull Timing of epiphysiodesis

Lower Limb Development

Prediction of LLD

Calculation discrepancy at maturity

bull Problems

- different methods based on the bone age

- not accurate enough during period of puberty

- different formulas are based on the same patients data

Lower Limb Development

Determination of the bone age

bull according to Greulich and Pyle

- details from AP-hand radiogram

- specific for boys and girls

- data from children

born between 1917 and 1942

bull according to Tanner and Whitehouse

- AP-hand radiogram

- 20 different details

- time consuming

09042011

15

Lower Limb Development

Determination of percentile group

bull bone age

bull body height

bull Anderson charts

Lower Limb Development

Prediction of LLD

Growth remaining charts ndash Green amp Anderson

bull determination

of bone age and

height percentile

bull identification

of remaining growth

on the diagram

bull specific for

boys and girls

Lower Limb Development

Prediction of LLD

Moseley straigth-line graph

bull graphic method based on

the Anderson data

bull 3-4 evaluations of actual

LLD are necessary

to predict final LLD

at maturity

09042011

16

Lower Limb Development

Prediction of LLD

Multiplier method according to Paley

bull biological age and

age-specific multipliers

are used

bull specific

for boys and girls

Lower Limb Development

Prediction of LLD

Multiplier method according to Paley

Height at maturity =

actual height x

multiplier

LLD at maturity

actual LLD x

multiplier

Lower Limb Development

LLD conservative treatment

Insole

bull 05 ndash 1 cm

Shoe lift

bull 1 ndash 5 cm

bull avoid instability

Orthopedic shoes

bull 5 ndash 10 cm

Orthoprothetic device

bull more than 10 cm

09042011

17

Lower Limb Development

LLD conservative treatment

Insole

bull 05 ndash 1 cm

Shoe lift

bull 1 ndash 5 cm

bull avoid instability

Orthopedic shoes

bull 5 ndash 10 cm

Orthoprothetic device

bull more than 10 cm

Lower Limb Development

Algorithm for management of LLD

From STAHELI Fundamentals of Pediatric Orthopedics

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

09042011

18

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Anatomical axis

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

versus

bull Anatomical axis

Femur

difference of 6deg

Tibia

same

Lower Limb Development

Normal lower limb alignment

Sagittal plane

09042011

19

Lower Limb Development

Lower limb malalignment

Deformity analysis

Frontal plane

bull Varus valgus translation

Sagittal plane

bull Antecurvation recurvation translation

Axial plane

bull Rotation lengthening or shortening

Lower Limb Development

Malalignment test acc to Paley and Herzenberg

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral deformity

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Tibial deformity

09042011

20

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral and tibial

deformity

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

09042011

21

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program Deformity 4deg

Correction 85deg

With Auto Alignment

MAD 7mm med

Individual Alignment

MAD 1mm med

09042011

22

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

09042011

23

Lower Limb Development

LLD procedures for lengthening and axial correction

Different devices

Lower Limb Development

LLD procedures for lengthening and axial correction

Different indications for different devices

bull Etiology of the disease (congenital metabolic posttraumatic

postinfectionhellip)

bull Type of deformity (unilevel multilevel leg length difference)

bull Bony maturation (open closed growth plates)

bull Training and skill of the surgeon

bull Availibility of the system (costshellip)

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixators

bull Orthofix ndash fixator (Orthofix company)

bull Dynafix ndash fixator (Biomet company)

bull Fixation with screws

(diameter of 5 or 6 mm)

Best indications

bull Diaphyseal and distal femoral deformities

bull Distal femoral lengthening procedures

09042011

24

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

102000 42001 42002 1 y after removal

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

Gavril A Ilizarov

Each frame is a special custom made construct

for a given deformity

09042011

25

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

13

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Orthoradiogram

- for calculation

of femoral and tibial length

- does not adress

foot height or

pelvic inequality

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Teleradiogram

- film-focus distance

305cm

- metal ball

diameter 25mm

at the level

of the bone

for calibration

Lower Limb Development

Leg Length Difference ndash LLD

Imaging methods

bull Teleradiogram

09042011

14

Lower Limb Development

Prediction of LLD

Calculation discrepancy at maturity

bull LLD at the end of growth

bull Strategy of correction

- lift lengthening shortening epiphysiodesis

bull Timing of epiphysiodesis

Lower Limb Development

Prediction of LLD

Calculation discrepancy at maturity

bull Problems

- different methods based on the bone age

- not accurate enough during period of puberty

- different formulas are based on the same patients data

Lower Limb Development

Determination of the bone age

bull according to Greulich and Pyle

- details from AP-hand radiogram

- specific for boys and girls

- data from children

born between 1917 and 1942

bull according to Tanner and Whitehouse

- AP-hand radiogram

- 20 different details

- time consuming

09042011

15

Lower Limb Development

Determination of percentile group

bull bone age

bull body height

bull Anderson charts

Lower Limb Development

Prediction of LLD

Growth remaining charts ndash Green amp Anderson

bull determination

of bone age and

height percentile

bull identification

of remaining growth

on the diagram

bull specific for

boys and girls

Lower Limb Development

Prediction of LLD

Moseley straigth-line graph

bull graphic method based on

the Anderson data

bull 3-4 evaluations of actual

LLD are necessary

to predict final LLD

at maturity

09042011

16

Lower Limb Development

Prediction of LLD

Multiplier method according to Paley

bull biological age and

age-specific multipliers

are used

bull specific

for boys and girls

Lower Limb Development

Prediction of LLD

Multiplier method according to Paley

Height at maturity =

actual height x

multiplier

LLD at maturity

actual LLD x

multiplier

Lower Limb Development

LLD conservative treatment

Insole

bull 05 ndash 1 cm

Shoe lift

bull 1 ndash 5 cm

bull avoid instability

Orthopedic shoes

bull 5 ndash 10 cm

Orthoprothetic device

bull more than 10 cm

09042011

17

Lower Limb Development

LLD conservative treatment

Insole

bull 05 ndash 1 cm

Shoe lift

bull 1 ndash 5 cm

bull avoid instability

Orthopedic shoes

bull 5 ndash 10 cm

Orthoprothetic device

bull more than 10 cm

Lower Limb Development

Algorithm for management of LLD

From STAHELI Fundamentals of Pediatric Orthopedics

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

09042011

18

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Anatomical axis

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

versus

bull Anatomical axis

Femur

difference of 6deg

Tibia

same

Lower Limb Development

Normal lower limb alignment

Sagittal plane

09042011

19

Lower Limb Development

Lower limb malalignment

Deformity analysis

Frontal plane

bull Varus valgus translation

Sagittal plane

bull Antecurvation recurvation translation

Axial plane

bull Rotation lengthening or shortening

Lower Limb Development

Malalignment test acc to Paley and Herzenberg

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral deformity

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Tibial deformity

09042011

20

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral and tibial

deformity

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

09042011

21

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program Deformity 4deg

Correction 85deg

With Auto Alignment

MAD 7mm med

Individual Alignment

MAD 1mm med

09042011

22

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

09042011

23

Lower Limb Development

LLD procedures for lengthening and axial correction

Different devices

Lower Limb Development

LLD procedures for lengthening and axial correction

Different indications for different devices

bull Etiology of the disease (congenital metabolic posttraumatic

postinfectionhellip)

bull Type of deformity (unilevel multilevel leg length difference)

bull Bony maturation (open closed growth plates)

bull Training and skill of the surgeon

bull Availibility of the system (costshellip)

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixators

bull Orthofix ndash fixator (Orthofix company)

bull Dynafix ndash fixator (Biomet company)

bull Fixation with screws

(diameter of 5 or 6 mm)

Best indications

bull Diaphyseal and distal femoral deformities

bull Distal femoral lengthening procedures

09042011

24

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

102000 42001 42002 1 y after removal

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

Gavril A Ilizarov

Each frame is a special custom made construct

for a given deformity

09042011

25

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

14

Lower Limb Development

Prediction of LLD

Calculation discrepancy at maturity

bull LLD at the end of growth

bull Strategy of correction

- lift lengthening shortening epiphysiodesis

bull Timing of epiphysiodesis

Lower Limb Development

Prediction of LLD

Calculation discrepancy at maturity

bull Problems

- different methods based on the bone age

- not accurate enough during period of puberty

- different formulas are based on the same patients data

Lower Limb Development

Determination of the bone age

bull according to Greulich and Pyle

- details from AP-hand radiogram

- specific for boys and girls

- data from children

born between 1917 and 1942

bull according to Tanner and Whitehouse

- AP-hand radiogram

- 20 different details

- time consuming

09042011

15

Lower Limb Development

Determination of percentile group

bull bone age

bull body height

bull Anderson charts

Lower Limb Development

Prediction of LLD

Growth remaining charts ndash Green amp Anderson

bull determination

of bone age and

height percentile

bull identification

of remaining growth

on the diagram

bull specific for

boys and girls

Lower Limb Development

Prediction of LLD

Moseley straigth-line graph

bull graphic method based on

the Anderson data

bull 3-4 evaluations of actual

LLD are necessary

to predict final LLD

at maturity

09042011

16

Lower Limb Development

Prediction of LLD

Multiplier method according to Paley

bull biological age and

age-specific multipliers

are used

bull specific

for boys and girls

Lower Limb Development

Prediction of LLD

Multiplier method according to Paley

Height at maturity =

actual height x

multiplier

LLD at maturity

actual LLD x

multiplier

Lower Limb Development

LLD conservative treatment

Insole

bull 05 ndash 1 cm

Shoe lift

bull 1 ndash 5 cm

bull avoid instability

Orthopedic shoes

bull 5 ndash 10 cm

Orthoprothetic device

bull more than 10 cm

09042011

17

Lower Limb Development

LLD conservative treatment

Insole

bull 05 ndash 1 cm

Shoe lift

bull 1 ndash 5 cm

bull avoid instability

Orthopedic shoes

bull 5 ndash 10 cm

Orthoprothetic device

bull more than 10 cm

Lower Limb Development

Algorithm for management of LLD

From STAHELI Fundamentals of Pediatric Orthopedics

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

09042011

18

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Anatomical axis

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

versus

bull Anatomical axis

Femur

difference of 6deg

Tibia

same

Lower Limb Development

Normal lower limb alignment

Sagittal plane

09042011

19

Lower Limb Development

Lower limb malalignment

Deformity analysis

Frontal plane

bull Varus valgus translation

Sagittal plane

bull Antecurvation recurvation translation

Axial plane

bull Rotation lengthening or shortening

Lower Limb Development

Malalignment test acc to Paley and Herzenberg

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral deformity

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Tibial deformity

09042011

20

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral and tibial

deformity

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

09042011

21

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program Deformity 4deg

Correction 85deg

With Auto Alignment

MAD 7mm med

Individual Alignment

MAD 1mm med

09042011

22

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

09042011

23

Lower Limb Development

LLD procedures for lengthening and axial correction

Different devices

Lower Limb Development

LLD procedures for lengthening and axial correction

Different indications for different devices

bull Etiology of the disease (congenital metabolic posttraumatic

postinfectionhellip)

bull Type of deformity (unilevel multilevel leg length difference)

bull Bony maturation (open closed growth plates)

bull Training and skill of the surgeon

bull Availibility of the system (costshellip)

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixators

bull Orthofix ndash fixator (Orthofix company)

bull Dynafix ndash fixator (Biomet company)

bull Fixation with screws

(diameter of 5 or 6 mm)

Best indications

bull Diaphyseal and distal femoral deformities

bull Distal femoral lengthening procedures

09042011

24

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

102000 42001 42002 1 y after removal

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

Gavril A Ilizarov

Each frame is a special custom made construct

for a given deformity

09042011

25

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

15

Lower Limb Development

Determination of percentile group

bull bone age

bull body height

bull Anderson charts

Lower Limb Development

Prediction of LLD

Growth remaining charts ndash Green amp Anderson

bull determination

of bone age and

height percentile

bull identification

of remaining growth

on the diagram

bull specific for

boys and girls

Lower Limb Development

Prediction of LLD

Moseley straigth-line graph

bull graphic method based on

the Anderson data

bull 3-4 evaluations of actual

LLD are necessary

to predict final LLD

at maturity

09042011

16

Lower Limb Development

Prediction of LLD

Multiplier method according to Paley

bull biological age and

age-specific multipliers

are used

bull specific

for boys and girls

Lower Limb Development

Prediction of LLD

Multiplier method according to Paley

Height at maturity =

actual height x

multiplier

LLD at maturity

actual LLD x

multiplier

Lower Limb Development

LLD conservative treatment

Insole

bull 05 ndash 1 cm

Shoe lift

bull 1 ndash 5 cm

bull avoid instability

Orthopedic shoes

bull 5 ndash 10 cm

Orthoprothetic device

bull more than 10 cm

09042011

17

Lower Limb Development

LLD conservative treatment

Insole

bull 05 ndash 1 cm

Shoe lift

bull 1 ndash 5 cm

bull avoid instability

Orthopedic shoes

bull 5 ndash 10 cm

Orthoprothetic device

bull more than 10 cm

Lower Limb Development

Algorithm for management of LLD

From STAHELI Fundamentals of Pediatric Orthopedics

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

09042011

18

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Anatomical axis

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

versus

bull Anatomical axis

Femur

difference of 6deg

Tibia

same

Lower Limb Development

Normal lower limb alignment

Sagittal plane

09042011

19

Lower Limb Development

Lower limb malalignment

Deformity analysis

Frontal plane

bull Varus valgus translation

Sagittal plane

bull Antecurvation recurvation translation

Axial plane

bull Rotation lengthening or shortening

Lower Limb Development

Malalignment test acc to Paley and Herzenberg

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral deformity

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Tibial deformity

09042011

20

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral and tibial

deformity

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

09042011

21

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program Deformity 4deg

Correction 85deg

With Auto Alignment

MAD 7mm med

Individual Alignment

MAD 1mm med

09042011

22

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

09042011

23

Lower Limb Development

LLD procedures for lengthening and axial correction

Different devices

Lower Limb Development

LLD procedures for lengthening and axial correction

Different indications for different devices

bull Etiology of the disease (congenital metabolic posttraumatic

postinfectionhellip)

bull Type of deformity (unilevel multilevel leg length difference)

bull Bony maturation (open closed growth plates)

bull Training and skill of the surgeon

bull Availibility of the system (costshellip)

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixators

bull Orthofix ndash fixator (Orthofix company)

bull Dynafix ndash fixator (Biomet company)

bull Fixation with screws

(diameter of 5 or 6 mm)

Best indications

bull Diaphyseal and distal femoral deformities

bull Distal femoral lengthening procedures

09042011

24

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

102000 42001 42002 1 y after removal

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

Gavril A Ilizarov

Each frame is a special custom made construct

for a given deformity

09042011

25

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

16

Lower Limb Development

Prediction of LLD

Multiplier method according to Paley

bull biological age and

age-specific multipliers

are used

bull specific

for boys and girls

Lower Limb Development

Prediction of LLD

Multiplier method according to Paley

Height at maturity =

actual height x

multiplier

LLD at maturity

actual LLD x

multiplier

Lower Limb Development

LLD conservative treatment

Insole

bull 05 ndash 1 cm

Shoe lift

bull 1 ndash 5 cm

bull avoid instability

Orthopedic shoes

bull 5 ndash 10 cm

Orthoprothetic device

bull more than 10 cm

09042011

17

Lower Limb Development

LLD conservative treatment

Insole

bull 05 ndash 1 cm

Shoe lift

bull 1 ndash 5 cm

bull avoid instability

Orthopedic shoes

bull 5 ndash 10 cm

Orthoprothetic device

bull more than 10 cm

Lower Limb Development

Algorithm for management of LLD

From STAHELI Fundamentals of Pediatric Orthopedics

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

09042011

18

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Anatomical axis

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

versus

bull Anatomical axis

Femur

difference of 6deg

Tibia

same

Lower Limb Development

Normal lower limb alignment

Sagittal plane

09042011

19

Lower Limb Development

Lower limb malalignment

Deformity analysis

Frontal plane

bull Varus valgus translation

Sagittal plane

bull Antecurvation recurvation translation

Axial plane

bull Rotation lengthening or shortening

Lower Limb Development

Malalignment test acc to Paley and Herzenberg

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral deformity

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Tibial deformity

09042011

20

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral and tibial

deformity

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

09042011

21

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program Deformity 4deg

Correction 85deg

With Auto Alignment

MAD 7mm med

Individual Alignment

MAD 1mm med

09042011

22

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

09042011

23

Lower Limb Development

LLD procedures for lengthening and axial correction

Different devices

Lower Limb Development

LLD procedures for lengthening and axial correction

Different indications for different devices

bull Etiology of the disease (congenital metabolic posttraumatic

postinfectionhellip)

bull Type of deformity (unilevel multilevel leg length difference)

bull Bony maturation (open closed growth plates)

bull Training and skill of the surgeon

bull Availibility of the system (costshellip)

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixators

bull Orthofix ndash fixator (Orthofix company)

bull Dynafix ndash fixator (Biomet company)

bull Fixation with screws

(diameter of 5 or 6 mm)

Best indications

bull Diaphyseal and distal femoral deformities

bull Distal femoral lengthening procedures

09042011

24

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

102000 42001 42002 1 y after removal

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

Gavril A Ilizarov

Each frame is a special custom made construct

for a given deformity

09042011

25

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

17

Lower Limb Development

LLD conservative treatment

Insole

bull 05 ndash 1 cm

Shoe lift

bull 1 ndash 5 cm

bull avoid instability

Orthopedic shoes

bull 5 ndash 10 cm

Orthoprothetic device

bull more than 10 cm

Lower Limb Development

Algorithm for management of LLD

From STAHELI Fundamentals of Pediatric Orthopedics

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

09042011

18

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Anatomical axis

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

versus

bull Anatomical axis

Femur

difference of 6deg

Tibia

same

Lower Limb Development

Normal lower limb alignment

Sagittal plane

09042011

19

Lower Limb Development

Lower limb malalignment

Deformity analysis

Frontal plane

bull Varus valgus translation

Sagittal plane

bull Antecurvation recurvation translation

Axial plane

bull Rotation lengthening or shortening

Lower Limb Development

Malalignment test acc to Paley and Herzenberg

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral deformity

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Tibial deformity

09042011

20

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral and tibial

deformity

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

09042011

21

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program Deformity 4deg

Correction 85deg

With Auto Alignment

MAD 7mm med

Individual Alignment

MAD 1mm med

09042011

22

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

09042011

23

Lower Limb Development

LLD procedures for lengthening and axial correction

Different devices

Lower Limb Development

LLD procedures for lengthening and axial correction

Different indications for different devices

bull Etiology of the disease (congenital metabolic posttraumatic

postinfectionhellip)

bull Type of deformity (unilevel multilevel leg length difference)

bull Bony maturation (open closed growth plates)

bull Training and skill of the surgeon

bull Availibility of the system (costshellip)

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixators

bull Orthofix ndash fixator (Orthofix company)

bull Dynafix ndash fixator (Biomet company)

bull Fixation with screws

(diameter of 5 or 6 mm)

Best indications

bull Diaphyseal and distal femoral deformities

bull Distal femoral lengthening procedures

09042011

24

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

102000 42001 42002 1 y after removal

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

Gavril A Ilizarov

Each frame is a special custom made construct

for a given deformity

09042011

25

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

18

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Anatomical axis

Lower Limb Development

Normal lower limb alignment

Frontal plane

bull Mechanical axis

versus

bull Anatomical axis

Femur

difference of 6deg

Tibia

same

Lower Limb Development

Normal lower limb alignment

Sagittal plane

09042011

19

Lower Limb Development

Lower limb malalignment

Deformity analysis

Frontal plane

bull Varus valgus translation

Sagittal plane

bull Antecurvation recurvation translation

Axial plane

bull Rotation lengthening or shortening

Lower Limb Development

Malalignment test acc to Paley and Herzenberg

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral deformity

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Tibial deformity

09042011

20

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral and tibial

deformity

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

09042011

21

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program Deformity 4deg

Correction 85deg

With Auto Alignment

MAD 7mm med

Individual Alignment

MAD 1mm med

09042011

22

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

09042011

23

Lower Limb Development

LLD procedures for lengthening and axial correction

Different devices

Lower Limb Development

LLD procedures for lengthening and axial correction

Different indications for different devices

bull Etiology of the disease (congenital metabolic posttraumatic

postinfectionhellip)

bull Type of deformity (unilevel multilevel leg length difference)

bull Bony maturation (open closed growth plates)

bull Training and skill of the surgeon

bull Availibility of the system (costshellip)

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixators

bull Orthofix ndash fixator (Orthofix company)

bull Dynafix ndash fixator (Biomet company)

bull Fixation with screws

(diameter of 5 or 6 mm)

Best indications

bull Diaphyseal and distal femoral deformities

bull Distal femoral lengthening procedures

09042011

24

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

102000 42001 42002 1 y after removal

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

Gavril A Ilizarov

Each frame is a special custom made construct

for a given deformity

09042011

25

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

19

Lower Limb Development

Lower limb malalignment

Deformity analysis

Frontal plane

bull Varus valgus translation

Sagittal plane

bull Antecurvation recurvation translation

Axial plane

bull Rotation lengthening or shortening

Lower Limb Development

Malalignment test acc to Paley and Herzenberg

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral deformity

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Tibial deformity

09042011

20

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral and tibial

deformity

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

09042011

21

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program Deformity 4deg

Correction 85deg

With Auto Alignment

MAD 7mm med

Individual Alignment

MAD 1mm med

09042011

22

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

09042011

23

Lower Limb Development

LLD procedures for lengthening and axial correction

Different devices

Lower Limb Development

LLD procedures for lengthening and axial correction

Different indications for different devices

bull Etiology of the disease (congenital metabolic posttraumatic

postinfectionhellip)

bull Type of deformity (unilevel multilevel leg length difference)

bull Bony maturation (open closed growth plates)

bull Training and skill of the surgeon

bull Availibility of the system (costshellip)

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixators

bull Orthofix ndash fixator (Orthofix company)

bull Dynafix ndash fixator (Biomet company)

bull Fixation with screws

(diameter of 5 or 6 mm)

Best indications

bull Diaphyseal and distal femoral deformities

bull Distal femoral lengthening procedures

09042011

24

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

102000 42001 42002 1 y after removal

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

Gavril A Ilizarov

Each frame is a special custom made construct

for a given deformity

09042011

25

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

20

Lower Limb Development

Malalignment test

bull Identify the source(s)

of the

mechanical axis

deviation

Femoral and tibial

deformity

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

09042011

21

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program Deformity 4deg

Correction 85deg

With Auto Alignment

MAD 7mm med

Individual Alignment

MAD 1mm med

09042011

22

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

09042011

23

Lower Limb Development

LLD procedures for lengthening and axial correction

Different devices

Lower Limb Development

LLD procedures for lengthening and axial correction

Different indications for different devices

bull Etiology of the disease (congenital metabolic posttraumatic

postinfectionhellip)

bull Type of deformity (unilevel multilevel leg length difference)

bull Bony maturation (open closed growth plates)

bull Training and skill of the surgeon

bull Availibility of the system (costshellip)

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixators

bull Orthofix ndash fixator (Orthofix company)

bull Dynafix ndash fixator (Biomet company)

bull Fixation with screws

(diameter of 5 or 6 mm)

Best indications

bull Diaphyseal and distal femoral deformities

bull Distal femoral lengthening procedures

09042011

24

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

102000 42001 42002 1 y after removal

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

Gavril A Ilizarov

Each frame is a special custom made construct

for a given deformity

09042011

25

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

21

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program Deformity 4deg

Correction 85deg

With Auto Alignment

MAD 7mm med

Individual Alignment

MAD 1mm med

09042011

22

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

09042011

23

Lower Limb Development

LLD procedures for lengthening and axial correction

Different devices

Lower Limb Development

LLD procedures for lengthening and axial correction

Different indications for different devices

bull Etiology of the disease (congenital metabolic posttraumatic

postinfectionhellip)

bull Type of deformity (unilevel multilevel leg length difference)

bull Bony maturation (open closed growth plates)

bull Training and skill of the surgeon

bull Availibility of the system (costshellip)

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixators

bull Orthofix ndash fixator (Orthofix company)

bull Dynafix ndash fixator (Biomet company)

bull Fixation with screws

(diameter of 5 or 6 mm)

Best indications

bull Diaphyseal and distal femoral deformities

bull Distal femoral lengthening procedures

09042011

24

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

102000 42001 42002 1 y after removal

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

Gavril A Ilizarov

Each frame is a special custom made construct

for a given deformity

09042011

25

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

22

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

Lower Limb Development

Tibial mechanical axis planning

Frontal plane

bull Digital planning

with

TraumaCad

program

09042011

23

Lower Limb Development

LLD procedures for lengthening and axial correction

Different devices

Lower Limb Development

LLD procedures for lengthening and axial correction

Different indications for different devices

bull Etiology of the disease (congenital metabolic posttraumatic

postinfectionhellip)

bull Type of deformity (unilevel multilevel leg length difference)

bull Bony maturation (open closed growth plates)

bull Training and skill of the surgeon

bull Availibility of the system (costshellip)

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixators

bull Orthofix ndash fixator (Orthofix company)

bull Dynafix ndash fixator (Biomet company)

bull Fixation with screws

(diameter of 5 or 6 mm)

Best indications

bull Diaphyseal and distal femoral deformities

bull Distal femoral lengthening procedures

09042011

24

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

102000 42001 42002 1 y after removal

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

Gavril A Ilizarov

Each frame is a special custom made construct

for a given deformity

09042011

25

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

23

Lower Limb Development

LLD procedures for lengthening and axial correction

Different devices

Lower Limb Development

LLD procedures for lengthening and axial correction

Different indications for different devices

bull Etiology of the disease (congenital metabolic posttraumatic

postinfectionhellip)

bull Type of deformity (unilevel multilevel leg length difference)

bull Bony maturation (open closed growth plates)

bull Training and skill of the surgeon

bull Availibility of the system (costshellip)

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixators

bull Orthofix ndash fixator (Orthofix company)

bull Dynafix ndash fixator (Biomet company)

bull Fixation with screws

(diameter of 5 or 6 mm)

Best indications

bull Diaphyseal and distal femoral deformities

bull Distal femoral lengthening procedures

09042011

24

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

102000 42001 42002 1 y after removal

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

Gavril A Ilizarov

Each frame is a special custom made construct

for a given deformity

09042011

25

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

24

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

Lower Limb Development

LLD procedures for lengthening and axial correction

Unilateral fixator

Posttraumatic LLD left femur ndash 36cm no axial deformity Dynafix 82000

102000 42001 42002 1 y after removal

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

Gavril A Ilizarov

Each frame is a special custom made construct

for a given deformity

09042011

25

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

25

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Traditional

Ilizarov fixator

AE 10y VitD-resistant rickets multiapical and multidirectional deformity

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

26

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

Charles J Taylor

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Circular external fixation system

bull Gradual correction by use of 6 telescopic struts

(HEXAPOD ndash system)

bull Combination with a webbased software ndash program

Angulation deformity Angulation-translation deformity

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Login-site

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

27

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Define deformity

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull Web-based

software

Prescription

site

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor Spatial Frame

bull multiapical planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

28

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

29

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

LJ Achondroplasia correction against varus and lengthening of 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm

Lower Limb Development

LLD procedures for lengthening and axial correction

Taylor

Spatial Frame

bull multiapical

planning

Bilateral bilevel correction lengthening 6 cm final result

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

30

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Power Supply

Transmitter

Receiver

Skin

Subcutaneous

TissueBone

Distraction-Nail

(Motor Gear)

Fitbonereg

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

Black prauml-OP

Green post-OP

Red post lengthening

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

MM born 1979

LLD femur ndash 3 cm

62007

retrograde

femoral nail

FITBONE

82007 112007

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

31

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

62007 72007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

SM born 1988

LLD tibia ndash 32 cm

62007

tibia nail

FITBONE

112007

Lower Limb Development

LLD procedures for lengthening and axial correction

Intramedullary lengthening nail ndash FITBONEreg

Indications

bull closed growth plates

bull adequate intramedullary diameter

(FITBONE minimum 12 mm)

bull lengthening procedures with moderate deformities

bull uniapical deformities

09042011

32

Thank you for your attention

09042011

32

Thank you for your attention