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Limb reconstruction or amputation provide similar function and quality of life to healthy population
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Function, psychological adjustment and quality of life after primary amputation or limb reconstruction in patients with severe fibular deficiency are both comparable and within normal limits for a healthy population, according to a recently presented study.
The findings were shared by Dror Paley, MD, FRCSC, at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in San Diego.
“All previous studies showed that the results of lengthening are not as good as the function after lengthening reconstruction surgery,” Paley told Orthopedics Today. “The consistent finding is that recurrent or residual foot deformities are the cause of the bad results from lengthening. In this study, we used a new procedure I developed for fibular hemimelia reconstruction called the ‘superankle procedure.’”
The procedure, Paley said, includes a combination of soft tissue releases and supramelleolar and/or subtalar osteotomy combined with a more proximal lengthening osteotomy.
Use of the technique, Paley noted, has resulted in “almost no recurrent foot deformities,” therefore the results are “functionally excellent with correction of limb length discrepancy and foot deformity.”
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AP and lateral radiographs of a 14-month-old boy with FH and fixed equinovalgus foot deformity. This patient has a three-toed, two-ray foot. Images: Paley D |
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“This has never been achieved before,” Paley said. “When you can achieve reliable foot deformity correction with equalization of limb length, the result is nearly normal lower limb function.”
Life-long requirements
According to the findings, patients and surgeons need to weigh life-long prosthetic requirements against increased surgical intervention for limb reconstruction when treating severe fibular deficiency.
Twenty children who underwent amputation at one center were compared with 22 children who underwent limb reconstruction at a second center, Paley reported. Average evaluation age was 9 years, and included psychosocial status, quality of life characteristics and patient/parent satisfaction surveys, as well as gait analysis with a timed 25-yard dash.
According to the findings, parents of boys who underwent amputation perceived a lower quality of life for their child. There were no other reported differences between the two groups or between the groups and a healthy population. All patients and parents, the study noted, would select the same treatment.
Statistically significant differences in some parameters were identified between the groups by gait analysis at self-selected walking speed, but no significant differences in average performance were noted for the timed 25-yard dash.
Paley reported two patients with amputation underwent three additional surgical procedures. Twenty-two patients who underwent reconstruction reportedly had an average of 3.4 surgical procedures. Patients required an average of 2.2 prosthetic adjustments per year and 0.84 prostheses per year, with an average estimated cost of $8,863 per prosthesis.
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“Our study showed no difference in function between the reconstructed and the prosthetic replacement,” Paley said. “A Syme’s amputation with prosthetic replacement gives nearly normal function compared to normal … we only need to show that reconstruction is comparable to amputation with prosthetic fitting. This study showed that.”
“[The findings have] corroborated my conclusions based on 25 years of experience and the treatment of more than 500 fibular hemimelia patients via evidence-based medicine,” he added. “I hope they will convince others to offer patients the option of reconstruction either by a second opinion to an expert performing this or by taking the steps to learn the ‘superankle’ procedure and lengthening techniques for fibular hemimelia.”
Providing another option
Getting word out about the technique and its positive results is imperative, Paley said, and could provide patients – and their parents – with options they might never otherwise have.
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“The most important thing is to give parents the options,” Paley said. “Most centers are only experienced in doing amputation. They therefore do not even offer the families the option of getting another opinion. The majority of patients who I see have only had amputation offered to them before they saw me. Often, they are angry about this. They do not understand why their orthopedic surgeon was not aware of how good the results of reconstruction are and why they were not referred for a second opinion.”
Paley added that many surgeons experienced with limb lengthening have no experience with the superankle procedure. As a consequence, many complications result from just performing lengthening without prior adequate correction and stabilization of the foot deformity.
“The treatment becomes worse than the disease,” he said. “This is why limb lengthening has fallen into disrepute with congenital femoral deficiency and fibular hemimelia over the past 30 years. It is time for societies such as [The Pediatric Orthopaedic Society of North America] and the AAOS to help surgeons get the training needed to offer treatment for these rare diseases closer to home.” – by Robert Press
Reference:
- Paley D, et al. Limb reconstruction or amputation for severe fibular deficiency: A two-center comparison. Paper 428. Presented at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons. Feb. 14-19. San Diego.
- Dror Paley, MD, FRCSC, can be reached at 901 45th Street, Kimmel Building, West Palm Beach, FL 33407. 877- 765-4637; e-mail: dpaley@lengthening.us.
- Disclosure: Paley receives royalties from Springer, as well as Smith & Nephew.
