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DROR PALEY PRINCIPLES OF DEFORMITY CORRECTION Springer-Verlag Berlin Heidelberg GmbH DROR PALEY PRINCIPLES OF 0 EFOR M I TV CORRECTION With Editorial Assistance from J. E. Herzenberg With More Than 1,800 Separate Illustrations, Clinical Photographs, and Radiographs i Springer DROR PALEY,MD,FRCSC ISBN 978-3-642-63953-1 ISBN 978-3-642-59373-4 (eBook) DOI 10.1007/978-3-642-59373-4 Director, Rubin Institute for Advanced Orthopedics Sinai Hospital 1st ed. 2002. Corr. 3rd printing 2005 Co-Director, The International Center for Limb Lengthening, Sinai Hospital CIP-data applied for Baltimore, MD Die Deutsche Bibliothek- CIP-Einheitsaufnahme Paley, Dror: Principles of deformity correction 1 Dror Paley.­ Berlin; Heidelberg; New York; Barcelona; Hongkong; Present address: London ; Mailand ; Paris ; Singapur ; Tokio : Springer, 2002 Rubin Institute for Advanced Orthopedics Sinai Hospital This work is subject to copyright. Ali rights are reserved, 2401 West Belvedere Avenue whether the whole or part of the material is concerned, specif­ Baltimore, Maryland 21215-5271, USA ically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any E-mail: [email protected] other way, and storage in data banks. Duplication of this pub­ lication or parts thereof is permitted only under the provisions www.limblengthening.org of the German Copyright Law of September 9, 1965, in its cur­ www.deformitycourse.com rent version, and permission for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under the German Copyright Law. http:/ /www.springer.de © Springer-Verlag Berlin Heidelberg 2002 Originally published by Springer-Verlag Berlin Heidelberg New York in 2002 Softcover reprint of the hardcover 1st edition 2002 The use of general descriptive names, registered names, trade­ marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publishers cannot guarantee the accu­ racy of any information about dosage and application con­ tained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: E. Kirchner, Heidelberg Product management and layout: B. Wieland, Heidelberg Typesetting and production: AM-production, Wiesloch 24/3150-5 4 3 2 1 o Printed on acid-free paper ~----------------------------------------------------... This book is dedicated to the memory of my father, Zvi Paley, who gave so much and asked for so little. Foreword - What is genius? Analyzing complex problems and find­ are technique-centric, this tome is principle-based and ing simple ways to explain them in an understandable will therefore stand the test of time. manner. By this definition, this book is genius. The limb lengthening and deformity reconstruction center created by Drs. Paley and Herzenberg in Balti­ The most dramatic progress in orthopaedic surgery more is not only the clinical laboratory where this defor­ during the last 2 decades has been in the field of defor­ mity correction work was developed and understood mity correction. The treatment of deformities has occu­ but has also become the Mecca for students in this med­ pied and challenged orthopaedic surgeons since Nicho­ ical specialty, with visitors from allover the world trav­ las Andry. So many brilliant people have worked in this eling to learn firsthand from these masters of deformity field. Among them, Friedrich Pauwel and Gavril Ilizarov correction. It is in this manner that I first became ex­ should be individually named. Dr. Ilizarov developed posed to the CORA method of mechanical and anatom­ new methods oflimb lengthening and deformity correc­ ic axis planning. This has resulted in a long-standing col­ tion and sparked the newfound interest and develop­ laboration between our two facilities, centered on our ments in this field today. In Dror Paley, this spark be­ common interest in this subspecialty. We routinely apply came a raging fire. these principles to deformity correction at our center in Dr. Paley inaugurated many innovations in the field Germany. Many of the new deformity correction devic­ of deformity correction. Among them, his nomenclature es that I and others are designing are now based on the deserves special mention. Before his classification based CORA principles. on joint orientation, we had a plethora of confusing Dr. Paley'S deformity correction courses around the terminology and definitions leading to a confusion of world have popularized the planning methods and prin­ language reminiscent of the Tower of Babel. Dr. Paley's ciples espoused in this book. The annual Baltimore Limb nomenclature standardizes the terminology in a man­ Deformity Course is the foundation for this book, work­ ner that requires little memorization. This logically book, and CD. Each of its chapters has been presented as based system has gained international recognition and lectures at this course, and the workbook and multime­ acceptance as the single language of deformity analysis dia CD have been tested by live audiences at these cours­ and correction. This book presents us with these con­ es for many years. cepts. The principles and concepts outlined in this book I am sure this book will become the bible for the under­ were not discovered or understood overnight. They rep­ standing, diagnosis, and treatment of lower limb defor­ resent an evolution of Dr. Paley's ideas from the past mities. 14 years of clinical work in the field of deformity correc­ tion. Unlike other texts, which come and go because they Wiesbaden, Germany JOACHIM PFEIL Preface - My prediction: this book will become a classic. Brave pathological abnormalities that come under the pur­ words, but I can safely make this statement because this view of the adult and pediatric orthopaedist. book is not about the latest surgical operation or about It has been my privilege and honor to be associated our knowledge of certain pathologies, which is constant- professionally with Dr. Dror Paley for the past 10 years, 1y changing. Rather, this book presents a system of de­ and I probably know him better than anyone else does. I formity analysis that is universal and applicable to any have therefore been in a unique position to observe how past, current, or future surgical osteotomy techniques he developed the CORA method and to contribute as a and hardware. One needs only to think back to medical co-developer, editor, and author. Dr. Paley has an uncan­ school and realize that most of the textbooks that we so ny knack of clearly seeing and understanding ortho­ carefully studied are now "of historic interest only:' paedic deformities. More importantly, he has a unique Grant's Atlas ofAnatomy is perhaps the only book from ability to then process and integrate this information to my medical school days that I still use. I predict that Pa­ make it accessible to the less clairvoyant. We have ley's Principles of Deformity Correction will also have a striven to make this method practical and teachable. It long shelflife. The treatment of skeletal deformity is the is not hard to learn, but it does take some effort and heart of our specialty. Indeed, the very name of our spe­ practice. The method is mercifully low-tech: the only cialty, orthopaedics, was coined by Nicholas Andry in tools required are a pencil, ruler, and goniometer. We 1741 as a word derived from two Greek words, orthos have honed our ability to teach this method during the (meaning straight) and paedis (meaning child) to indi­ past 10 years at our annual Baltimore Limb Deformity cate his goal "to teach the different methods of prevent­ Course, and many of the figures and cases illustrated in ing and correcting deformities of children" (from Mer­ this book have been used in the course. The case studies cer Rang's Anthology of Orthopaedics, 1966). and the artists' diagrams are all derived from our own Since Andry's writings 260 years ago, little progress practices and are representative of deformities that we has been made in understanding, analyzing, and quan­ have treated. In this regard, we are greatly indebted to tifying the types of limb deformities. Rarely do we come our patients for providing us with both typical and atyp­ across an orthopaedic surgeon who is truly an artist (or ical problems to study and illustrate. sculptor). Such an individual does not require accurate Interestingly, the CORA method of deformity analy­ preoperative planning to execute a flawless corrective sis began simply as an attempt to make some sense of the osteotomy. However, for the rest of us journeymen or­ Ilizarov apparatus. As the orthopaedic surgeon who in­ thopaedic surgeons, achieving such beautiful artistic troduced this method in Canada and the USA, Dr. Paley and aesthetic outcomes is elusive. We tend to take a struggled to understand the concept of the Ilizarov wedge here or there, by eyeball estimation, and then hinge, which is what made the Ilizarov fixator so unique rationalize the less than perfect appearance of the final in its ability to correct deformities in a controlled fash­ X-ray. "It's not bad" or "it should remodel:' True, there ion. In his early experience, he observed some of the sec­ have been attempts by notable surgeons, such as Fried­ ondary deformities that arose from mismatching the lo­ rich Pauwels and Maurice Mueller, to be more precise in cation of the hinge and the CORA. In his effort to more our planning. Although we may have received training accurately identify the level for the Ilizarov hinge, he de­ in the precise repositioning of fracture fragments with rived the CORA method of mechanical and anatomic plates and screws and accurate preoperative planning axis planning described in this text.

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