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The team of Polish orthopedists and neurosurgeons , trusted by Dr. Dror Paley, is an opportunity for many patients from all over Europe. The Paley Institute provides full care from experienced specialists. They guide patients through the process of recovery and achieve the best possible treatment results.
What sets us apart is the quality, unique knowledge and emotional commitment of the entire team. Paley European Institute's treatment philosophy focuses on a commitment to preserving, reconstructing and restoring limb and joint function.

Surgical treatment - selected procedures

1. indications

Forearm bone lengthening on an external apparatus is indicated mainly in patients with congenital underdevelopment of the radial or ulnar bones (e.g. radial hemimelia), limb length inequality resulting from congenital defects, traumatic conditions or past bone infections that have inhibited normal bone growth. The procedure is also recommended in cases of disproportion of the forearm negatively affecting hand function.

2 Mileage

The procedure is usually performed under general anesthesia. The surgeon cuts through the bones of the forearm (osteotomy) at a precise location. He then attaches an external brace (usually of the Hexapod or monolateral type) using special Kirschner wires or Schanz screws to stabilize the bones. After about 5-7 days, gradual, controlled stretching of the bone begins, usually at a rate of about 0.5-1 mm per day, until the planned length is achieved. The elongation phase is followed by a consolidation phase, during which new bone tissue matures and mineralizes.

3 Advantages

Possibility of precise and controlled bone elongation.
Correction of angular and rotational deformations.
Low invasiveness of the procedure, minimal risk of soft tissue damage.
Wide possibilities for adjusting the rate and length of elongation during treatment.

4 Author's modifications

In centers specializing in the treatment of limb deformities, such as the Paley European Institute, modifications including:

The use of advanced Hexapod-type external cameras that allow simultaneous correction of deformations in three spatial planes.
Modify rehabilitation protocols and post-operative care by rapidly implementing functional physiotherapy, thereby minimizing the risk of contractures and loss of limb function.
The introduction of modern techniques to aid bone regeneration, such as the use of growth factors and biological therapies that accelerate the process of bone consolidation and regeneration.

5. recovery

Recovery is lengthy and depends on the length of the planned lengthening and the age of the patient. The average period of treatment with external braces is about 4-6 months (the period of active lengthening plus bone consolidation). During this time, the patient remains under close medical supervision. A very important part of recovery is intensive physical rehabilitation and occupational therapy, which minimize the risk of complications such as joint contractures, muscle weakness or limitation of limb function. After treatment with external braces, further orthopedic, rehabilitation and follow-up support is often required for a period of several months

Reconstruction of a dislocated radial-arm joint in MHE (Multiple Bone Chondrosarcoma).

1. indications

The procedure of reconstruction of the radial-arm joint in the course of multiple bone osteochondrosis (MHE) is indicated in the situation of painful, chronic dislocation or subluxation of the head of the radial bone. Such dislocation can cause pain, limitation of mobility, aesthetic deformity of the upper limb and progressive elbow dysfunction, which affects the patient's quality of life. Intervention is recommended especially when conservative treatment is ineffective and the changes are progressive in nature.

2 Mileage

The operation is performed under general anesthesia. The procedure begins with surgical access that allows a thorough evaluation of the radial-arm joint and resection of pathological cartilaginous outgrowths, which are the cause of the dislocation. This is followed by a corrective osteotomy of the ulnar and radial bones, restoring the normal anatomy of the joint and allowing repositioning of the radial head. Depending on the degree of ligamentous damage, ligamentous reconstructions using tissue grafts or synthetic materials may also be performed. The procedure is completed by stabilizing the osteotomy with Kirschner wires, screws or bone plates.

3 Advantages

Restoration of joint function: Reconstruction makes it possible to restore the normal anatomy of the radial-arm joint, increase the range of motion and improve the function of the limb.
Pain reduction: Removal of bone outgrowths and repositioning of the head of the radius bone significantly reduce pain.
Prevention of secondary deformities: The treatment avoids further progression of deformity of the upper limb and protects against degenerative changes.

4 Author's modifications

As part of the author's modifications of the operation are used:

Author's procedure program published in the world literature. Based on our experience, we have developed individual criteria for eligibility for surgery and a detailed protocol for its performance. Spatial bending of the elbow bone exceeding 30 degrees is the cutoff point at which surgical intervention should be considered.
Minimally invasive access: Reduce the extent of the surgical incision by using arthroscopic techniques or minimally invasive accesses, which improves healing and reduces the risk of complications.
Biological methods to promote healing: Use of stem cell concentrate or growth factors to accelerate soft tissue regeneration and bone healing.

5. recovery

Immediately after surgery, the patient remains in the hospital for several days. The upper limb is immobilized for about 4-6 weeks, and then intensive rehabilitation is implemented. The rehabilitation program includes exercises to increase range of motion, strengthen muscles and improve joint stability. Full recovery usually takes from 3 to 6 months, with a return to full activity usually possible about 6 months after surgery. During this time, the patient is regularly monitored by the attending physician.

Release of finger syndactyly

1. indications

Finger syndactylia release surgery is indicated in patients with congenital or acquired adhesions of the fingers of the hand or foot, leading to restricted mobility, functional disruption of the limb or causing aesthetic problems. The procedure is particularly recommended when syndactyly impedes the normal development of hand function, such as grasping or precise finger movements, as well as in cases of adhesions that can cause deformities in the growing bones of the fingers.

2 Mileage

The operation involves surgical separation of the joined fingers. The procedure is performed under general anesthesia with a tourniquet to reduce bleeding. The surgeon precisely cuts the skin, soft tissues and membranes connecting the fingers, forming "Z" or "zig-zag" skin flaps that provide adequate wound coverage after separation. For larger skin defects, skin grafts taken from other areas of the body (usually the groin or forearm area) are used. Once the procedure is complete, a protective dressing or specialized cast is placed to secure the fingers in the correct position.

3 Advantages

Improving hand function and finger range of motion.
Better aesthetic results, reducing the visibility of scars due to the technique of proper skin flap formation.
Avoid or reduce the risk of developing secondary bone and joint deformities.
Improve the patient's quality of life and independence, especially important in children during development.

4 Author's modifications

Surgeons may use their own modifications to syndactyly surgery, including microsurgical techniques that allow precise release and protection of the vessels and nerves of the fingers. Some specialists also use biological replacement materials (e.g., skin matrices) that reduce the need for skin grafts, which reduces surgical trauma, speeds healing and improves the cosmetic appearance of the wound.

5. recovery

The recovery period usually lasts from 4 to 8 weeks. During this time, it is important to take proper wound care, change dressings regularly and avoid intense exertion of the limb. Physiotherapy for the hand begins as early as possible after surgery, with the goal of preventing adhesions and improving the range of motion of the fingers. Complete return of function, strength and mobility may require longer rehabilitation, especially with complex adhesions or skin grafts. Regular follow-ups allow assessment of treatment effects and early detection of possible complications.

Here is a general description of the reconstructive procedure used in congenital hip dislocation (CTSb) with simultaneous hip osteotomy, femoral head ligament reconstruction, capsular reconstruction and femoral osteotomy, broken down according to the paragraphs indicated:

1. indications

The procedure is intended for children with congenital dislocation of the hip joint, in whom the acetabulum and femoral head have not developed properly. The indication for surgery is instability or permanent dislocation of the hip that has not been successfully treated conservatively (e.g. with orthoses) or surgically earlier in life. The goal of the operation is to restore centering of the femoral head in the acetabulum and create conditions for normal hip development.

2 Mileage

The procedure is performed under general anesthesia. It consists of several stages:

Open repositioning of the hip joint - the surgeon frees the head of the femur and inserts it into the joint acetabulum.
Reconstruction of the ligament of the head of the femur - the structures that stabilize the joint (known as the obturator ligament) are rebuilt to improve the stability of the hip.
Joint capsule reconstruction - the joint capsule is reduced in size (known as capsulorrhaphy), which increases the stability of the hip.
Hip osteotomy (usually Salter, Dega or Pemberton type) - the acetabulum is repositioned to better cover the femoral head.
Femoral osteotomy (usually shortening and/or realignment) - improves the length and alignment of the femur to avoid excessive stress on the joint.

3 Advantages

Recovery of anatomical alignment of the hip joint.
Prevention of secondary degenerative changes and lameness.
Improving pelvic biomechanics and gait.
Ability to conduct normal physical activity in the future.
Reducing the risk of needing hip replacement at a young age.

4 Author's modifications

Depending on the center's experience and the specific case, modifications are possible:

Use of modern implants (angle plates, bioresorbable sutures and anchors).
Intraoperative vascular and nerve monitoring.
Concurrent tendon lengthening if contracture is present.
Minimally invasive techniques for osteotomies using fluoroscopy.
A proprietary method of stabilizing the obturator ligament to better centralize the head.

5. recovery

The patient remains in a hip-spica plaster dressing for 4-6 weeks.
Once the cast is removed, physiotherapy aimed at improving range of motion and strengthening muscles begins.
Load on the limb is introduced gradually after 6-8 weeks.
It usually takes 6 to 12 months to return to full activity.
Indicated regular radiological checks to monitor the development of the hip joint.

1. indications

Polycystis is a surgical procedure involving the transfer of the index finger in place of the thumb, used in situations of congenital absence of the thumb (aplasia) or when the thumb is underdeveloped (hypoplasia). The operation is indicated especially when the thumb cannot perform its grasping function or when the patient was born completely without a thumb. The goal is to improve the functionality of the hand, especially the ability to grasp with precision and strength.

2 Mileage

Policyzation involves the relocation and proper positioning of the index finger in place of the thumb. During the procedure, the surgeon makes specialized skin and bone incisions, then shortens and rotates the index bone to best restore thumb function. Reconstruction of nerves, blood vessels, muscles and tendons is also carried out to ensure the greatest possible mobility and sensation in the newly formed thumb. The operation requires a high degree of precision and usually takes 2 to 4 hours.

3 Advantages

The main advantage of policyzation is a significant improvement in hand function and the patient's quality of life. This procedure enables precision grasps that would be impossible without a properly functioning thumb. In addition, the cosmetic appearance of the hand is improved, which has a positive effect on the social acceptance and psychological comfort of patients.

4 Author's modifications

Many specialized centers use their own proprietary modifications of the policyzation technique, such as altered skin incision techniques, specific methods of tendon and muscle reconstruction, or additional bone stabilization procedures. One popular proprietary modification is the Buck-Gramcko method, which places great emphasis on optimal alignment of the finger and precise reconstruction of the musculotendinous apparatus for better motor function.

5. recovery

The post-polysis recovery period includes immobilization of the operated hand for about 4-6 weeks to ensure proper healing. Intensive rehabilitation is then implemented, including exercises to improve grip and improve mobility and strength of the new thumb. Full recovery usually takes 3-6 months, depending on the age of the patient and the extent of the surgical work performed. Regular follow-ups with a specialist are essential to monitor the results of treatment.

1. indications

Varus Derotation Osteotomy (VDRO) of the femur is indicated primarily for the treatment of children and adolescents with hip dysplasia, hip instability, hip subluxations and dislocations, often secondary to cerebral palsy (MPD). The procedure is also performed for rotational deformities of the lower limb, disorders of the mechanical axis of the femur, and postural defects resulting from hip malalignment.

2 Mileage

The VDRO procedure involves surgically cutting the femur, most often in its proximal aspect, and correcting the alignment of the limb in two main planes - in the frontal plane (bringing the bone into a staggered, or varus, position) and in the transverse plane (derotating the bone, or reducing abnormal torsion). Once the proper alignment of the femoral bone is made, it is stabilized with metal implants (usually angle plates, screws or specialized pediatric blade-plate systems). The operation is performed under full anesthesia and takes about 1-2 hours.

3 Advantages

Improving stability and coverage of the femoral head by the acetabulum of the hip joint.
Correction of the lower limb axis, improving gait biomechanics.
Reduce the risk of developing hip degeneration in later life.
Significantly improve patient comfort by eliminating pain and improving motor function.

4 Author's modifications

Among the most common proprietary VDRO modifications are:

The use of plate osteosynthesis with adjustable angle and degree of rotation, enabling more precise correction of deformities.
Combine VDRO osteotomy with additional soft tissue procedures (such as adductor lengthening or joint capsule release) to improve functional outcomes.
Use of minimally invasive surgical techniques to reduce soft tissue trauma, reduce the risk of complications and shorten the recovery period.

5. recovery

The recovery period after VDRO surgery usually lasts from 6 to 12 weeks. Initially, the patient benefits from immobilization in the form of a splint, plaster dressing or orthosis, depending on the surgeon's indications. Rehabilitation begins in the first days after surgery, and includes isometric exercises, gradual weight-bearing of the limb and learning to walk properly using crutches or a walker. A full return to physical activity is usually achieved 3-6 months after surgery, depending on the rate of bone healing and the patient's individual predisposition.

1. indications

Femoral support osteotomy is indicated primarily for hip dysplasia, Perthes disease, deformity of the lower limb axis, and for the treatment of degenerative changes resulting from defective mechanics of the hip joint. The main goal of the operation is to correct the abnormal load axis of the limb, improve the coverage of the femoral head and reduce the risk of progression of degenerative changes.

2 Mileage

The procedure is performed under general or subarachnoid anesthesia. The surgeon performs a controlled transection (osteotomy) of the femur at the intertrochanteric level. This is followed by an appropriate correction of the femoral axis, which may include a change in the cervicothoracic angle (varus), rotation or translation of bone fragments to achieve better coverage of the femoral head by the acetabulum. Once the fragments are properly positioned, the bone is stabilized with special plates, screws or intramedullary nails. The operation ends with an X-ray check to confirm the correct positioning of the bone fragments and implants.

3 Advantages

Reduce pain by improving the mechanics of the hip joint.
Inhibiting the progression of degenerative changes.
Improve stability and range of motion of the hip joint.
Delaying or avoiding the need for hip endoprosthesis.
Better coverage of the head of the femur by the acetabulum, providing more favorable distribution of forces loading the joint.

4 Author's modifications

The author's modifications of femoral support osteotomy usually include methods that allow more precise and less invasive correction of bone alignment. Computer-assisted techniques are used here to improve the accuracy of cutting and repositioning bone fragments. Modifications to minimize surgical access (so-called minimally invasive techniques) are also popular, reducing recovery time and the risk of complications.

5. recovery

The recovery period after a proximal femoral osteotomy takes an average of 8-12 weeks. Immediately after the operation, the patient uses elbow crutches, gradually increasing the load on the operated limb as prescribed by the doctor. Rehabilitation includes exercises to strengthen the muscles of the hip girdle, improving range of motion and coordination. Regular X-ray checks are necessary to monitor the healing process. Full return to physical activity depends on the rate of bone healing and the patient's individual circumstances, and usually occurs about 4-6 months after surgery.

1. indications

Extrusion osteotomy of the distal end of the femur is used mainly in patients with flexion deformity of the knee, often resulting from cerebral palsy, arthrogryposis, trauma or other neurological/orthopedic diseases, in which there is a fixed contracture of the knee. Indications include significant functional limitation, difficulty in verticalization and walking, as well as pain due to disruption of the limb's biomechanics.

2 Mileage

The procedure involves surgically cutting the femur near the distal epiphysis, usually over the condyles. After the osteotomy, the bone is placed in a corrective position, eliminating excessive flexion of the knee joint. The bone is then stabilized with special plates and screws or intramedullary nails. During surgery, additional procedures may also be performed to lengthen soft-tissue structures, such as releasing the popliteal tendons or joint capsule, to allow for a full range of correction.

3 Advantages

-Significant improvement in lower limb function and gait biomechanics.
Reducing pain and improving quality of life.
Enabling better patient uprightness and improving stability when walking.
Reduce the risk of secondary joint deformities in the lower limb.

4 Author's modifications

Depending on the surgical center, various modifications to the standard osteotomy technique are possible, such as the use of custom-designed implants (custom-made), the use of modern navigation and computer techniques (osteotomy using 3D technology and computer navigation), and the simultaneous combination of osteotomy with procedures that minimize soft tissue tension, such as selective flexor muscle tenotomy.

5. recovery

The recovery period usually lasts from 6 to 12 weeks. After surgery, the patient initially uses orthopedic equipment (orthoses, crutches) and begins rehabilitation exercises aimed at gradually regaining range of motion and muscle strength. Full weight-bearing of the limb is possible once adequate bone stabilization has been achieved, usually about 8-12 weeks after surgery. Rehabilitation includes lower limb muscle strengthening exercises, manual therapy and gait training. Long-term rehabilitation significantly increases the effectiveness of treatment.

1. indications

The procedure is indicated for patients with chronic or recurrent instability of the patellofemoral joint who have suffered multiple dislocations of the patella or permanent lateral alignment of the patella. Specific indications are:

Abnormal lower limb alignment (especially excessive femoral antegrade),
Femoral block dysplasia,
The high alignment of the patella (patella alta),
Tibial tuberosity malalignment (high TT-TG index),
MPFL ligament failure,
failure of the medial volar muscle (VMO).

The procedure is most often used in young, active patients for whom patellar instability significantly limits daily function and sports activities.

2 Mileage

The operation consists of several key steps performed during a single procedure:

Derotation of the femur (derotation osteotomy):
The femur is cut at the shaft or supracondylar and then rotated in the appropriate direction (usually outward) to correct excessive antegrade and restore the normal alignment of the limb's axis. Stabilization is done with a plate and screws.
VMO advancement (medial displacement of the medial vastus muscle):
The VMO muscle is repositioned and fixed in a new, more medial and distal position to increase its stabilizing effect on the patella.
Tibial Tuberosity Osteotomy (TTO):
The tibial cusp (the attachment site of the patellar ligament) is cut off and displaced (usually medially, sometimes also distally) to correct the alignment of the patella with respect to the block. The cusp is fixed with titanium screws.
The entire procedure is performed under general anesthesia, under radiological control.

3 Advantages

Correcting all causes of instability in a single procedure.
Significant improvement in the biomechanics of the patellofemoral joint.
Reducing the risk of recurrent patellar dislocations.
Improve limb alignment and function of the muscles that stabilize the patella.
Ability to return the patient to physical and sports activities.

4 Author's modifications

In some centers, it is used:

Planning the procedure based on accurate 3D CT scans - which allows precise determination of the derotation angle and osteotomy site,
The use of biological grafts or MPFL ligament augmentation,
Integrated management of the procedure by the orthopedic and physiotherapy team, taking into account the individual risk of recurrence.
In selected cases, navigation systems or personalized bone incisions (PSI) are used.

5. recovery

Hospitalization usually lasts 3-5 days.
For the first 6 weeks, it is mandatory to limit the load on the limb and wear a knee brace within the established range of motion.
After 6 weeks - a follow-up X-ray and a gradual increase in load and range of motion.
Physiotherapy from the first day after surgery - initially passive, then active.
Return to normal gait without crutches: usually 8-10 weeks.
Return to sport: 3-6 months, depending on the severity of the correction and the individual course of rehabilitation.

1. indications

Administration of botulinum toxin (BTX) to the iliac-lumbar muscle through the abdominal shell is mainly indicated for patients with excessive muscle tension (spasticity), especially in the course of cerebral palsy and other neurological conditions. This procedure is used to reduce muscle contracture, improve the range of motion of the hip joint, reduce pain and facilitate the patient's rehabilitation.

2 Mileage

The procedure takes place in an outpatient or hospital setting, usually under ultrasound guidance, which increases the accuracy and safety of the injection. After disinfecting the skin, the doctor makes a needle puncture through the anterior abdominal wall, directing it under ultrasound guidance directly into the iliac-lumbar muscle. An appropriately selected dose of BTX is then administered. The procedure is quick, minimally invasive and generally well tolerated by the patient.

3 Advantages

Significant reduction in muscle tension.
Improving range of motion in the hip joint.
Easier to conduct rehabilitation and physiotherapy.
Short procedure time and low level of invasiveness.
The possibility of repeating the procedure if necessary.

4 Author's modifications

We are one of the few centers in Europe using the method of precise BTX injection into the iliac and lumbar muscles under sedation. Our proprietary program includes the use of a dedicated upright corset to consolidate the effect.

5. recovery

Recovery after the procedure is short. The patient can return to normal activity practically immediately after the procedure. However, it is important to start properly targeted rehabilitation immediately after the injection, the aim of which will be to take full advantage of the effect of reducing muscle tension. The effect of the toxin usually appears after a few days and lasts on average for about 3-6 months, after which the procedure can be repeated.

1. indications

2 Mileage

3 Advantages

Significant reduction in muscle tension.
Improving range of motion in the hip joint.
Easier to conduct rehabilitation and physiotherapy.
Short procedure time and low level of invasiveness.
The possibility of repeating the procedure if necessary.

4 Author's modifications

5. recovery

1. indications

The surgical procedure of releasing the hip-lumbar muscle using the over the brim method is mainly used to treat flexion contracture of the hip joint, resulting from excessive tension or shortening of this muscle. The most common indications are:

Spastic contracture of the iliac-lumbar muscle in cerebral palsy.
Secondary changes in the course of neurological diseases with excessive muscle tension.
Persistent flexion deformities of the hip joint that do not respond to conservative treatment (physiotherapy, drug treatment, botulinum injections).

2 Mileage

The over the brim release operation proceeds as follows:

The patient is laid on his back (supine position).
The surgeon performs surgical access in the groin area, above the anterior edge of the acetabulum of the hip joint.
After dissecting the superficial tissues, the anterior edge of the pelvic bone (brim - or pelvic edge) is exposed.
The iliac-lumbar muscle is identified and then released by partially or completely cutting its tendon at the level of the edge of the pelvic bone (over the brim method).
Once adequate release is achieved and the improvement in hip range of motion is checked, the wound is closed in layers.

The procedure is performed under palpation and visual control, ensuring that the operation is performed precisely with minimal risk of damage to surrounding structures.

3 Advantages

The over the brim method has significant advantages:

Minimally invasive surgical access limits damage to surrounding tissues.
Rapidly achieve significant improvements in hip joint range of motion.
Precise and controlled release of the tendon, which minimizes the risk of neurological and vascular complications.
Reduced treatment time and ability to start rehabilitation quickly.

4 Author's modifications

Many surgical teams are making minor proprietary modifications to the over the brim method, such as:

Additional use of intraoperative nerve monitoring (neuromonitoring) to increase the safety of surgery.
Minimally invasive techniques using special surgical instruments that limit the extent of access.
Combining the treatment with selective releases of other hip muscles (e.g., the rectus femoris or adductor muscles) for a more comprehensive functional effect.

5. recovery

Recovery from an over the brim procedure is usually relatively quick:

In the first few days after surgery, passive exercises are indicated, along with gradually introduced active exercises.
Early mobilization of the patient, often as early as the first day after surgery, is key to avoiding complications and speeding up recovery.
Physiotherapy is an essential part of treatment - this includes stretching, strengthening antagonistic muscles and improving gait function.
A full return to pre-surgery activities usually occurs after a few weeks, and the final functional effect is assessed approximately 3-6 months after surgery.

1. indications

Posterior tibialis muscle tendon transfer is primarily used to treat foot deformities, such as clubfoot, hollow foot, or drop foot in the course of neurological paralysis (e.g., cerebral palsy, meningo-spinal hernia, stroke). The main goal of the surgery is to restore proper foot function, improve gait, and increase stability and balance.

2 Mileage

The procedure involves relocating the terminal attachment of the tibialis posterior muscle tendon from its natural location on the inside of the foot to the dorsal surface of the foot or lateral ankle, in order to improve the function of the dorsal flexors of the foot. The surgeon first releases the tendon, then pulls it through a specially prepared channel in the bones of the foot or under the skin and fixes it in its new location with bone anchors or special interference screws. After transfer, the tendon performs its new function, improving gait mechanics and correcting the deformity.

3 Advantages

Effective correction of foot deformities.
Improved gait function - restoration of active dorsiflexion.
Improved patient stability and comfort while walking.
Reducing the need for orthoses.
Prevention of further deformation and overloading of other structures of the lower limb.

4 Author's modifications

Some surgeons use proprietary techniques that involve minimally invasive guidance of the tendon subcutaneously, without performing wide bone canals, which reduces operative time and surgical trauma. Additional procedures to stabilize the ankle joint, such as popliteal arthrodesis and corrective osteotomies, are often used to increase the effectiveness of tendon transfer and improve long-term treatment outcomes.

5. recovery

The recovery period after transfer of the posterior tibialis muscle tendon lasts about 6-12 weeks. Initially, a splint or orthosis is used to immobilize the foot. After about 4-6 weeks, gradual rehabilitation is implemented, including exercises to strengthen muscles, improve range of motion and proprioception. A return to full physical activity is usually possible about 3-6 months after surgery. During recovery, it is important for the patient to systematically cooperate with the rehabilitator and follow the doctor's recommendations.

1 Indications:

Transfer of the tibialis anterior muscle tendon is performed in patients with foot deformity, most commonly in cases of clubfoot, hollow foot or other muscular imbalances that cause excessive supination of the foot. The procedure is recommended for patients in whom conservative treatment has failed or there are recurrences of the deformity after Ponseti treatment.

2 Mileage:

The operation involves moving the attachment of the tibialis anterior muscle tendon from its original location (usually at the medial epicondyle or first metatarsal bone) to a more lateral position, usually at the third epicondyle or base of the third metatarsal bone. The procedure is performed through a small skin incision, the tendon is exposed, then cut and fixed in the new position with special anchors or surgical sutures. Once the new fixation point is established, a plaster dressing is applied to hold the foot in position until it heals.

3 Advantages:

Correction of permanent supination of the foot and restoration of proper muscle balance.
Functional and aesthetic improvement of gait.
Prevention of recurrence of deformity and further complications associated with abnormal foot loading.

4 Author's modifications:

Popular proprietary modifications include:

A minimally invasive technique using small skin incisions, which reduces the risk of complications and speeds up recovery.
Tendon fixation with a bone bridge - an implant-free method that eliminates the need for subsequent removal.
Modifications of the transfer point - individual adjustment of the location of the new attachment depending on the characteristics of the patient's deformity.

5 Recuperation:

The recovery period usually lasts 6-8 weeks. For the first 4-6 weeks, the patient wears a plaster bandage or orthosis, after which he or she begins rehabilitation that includes exercises to strengthen and stretch the muscles of the foot and shin. Return to full physical activity usually occurs about 3-6 months after surgery. Regular follow-up visits and rehabilitation are crucial to the final outcome of treatment.

1. indications

Ankle endoprosthesis is an operation to replace worn joint surfaces with an artificial prosthesis. The procedure is performed mainly in patients with advanced degenerative, post-traumatic and rheumatoid lesions of the ankle joint, in whom conservative treatment (anti-inflammatory drugs, rehabilitation, delivery injections) has ceased to provide pain relief and the function of the joint is significantly impaired.

2 Mileage

The procedure is performed under general or regional anesthesia. The surgeon makes an incision in the anterolateral region of the ankle joint. The damaged articular surfaces of the tibia and ankle bone are then removed in preparation for implantation of prosthetic components. The implants consist of a tibial component, an ankle component and a polyethylene insert to ensure joint mobility. Once the prosthesis is precisely fixed, a stability and mobility test is performed, then the wound is closed in layers and the foot is immobilized in a splint or stabilizer.

3 Advantages

Significant reduction in pain.
Improved range of motion and quality of life.
Preserving the natural biomechanics of the foot, which enables a gait close to the physiological one.
Shorter rehabilitation period compared to arthrodesis (joint stiffening).

4 Author's modifications

Proprietary modifications include the use of custom implants designed based on the patient's CT scan (custom-made implants). In addition, minimally invasive techniques are used to reduce soft tissue damage, as well as specialized methods that spare ligaments and stabilize periarticular structures. These modifications contribute to a faster return to activity for the patient and increase the life of the prosthesis.

5. recovery

After surgery, the patient initially benefits from immobilization and elbow crutches for about 4-6 weeks. Rehabilitation begins very early, in the first days after surgery, initially focusing on isometric exercises and gentle passive movements of the ankle joint. Gradually, strengthening exercises, proprioception exercises and learning to walk properly are implemented. Return to full activity usually occurs after 3-6 months, depending on the progress of rehabilitation and the patient's overall health.

1. indications

Lengthening of the Achilles tendon or the triceps calf muscle with the PERCS (Percutaneous Epiphysiodesis of the Achilles or Gastrocnemius) technique using the Bowman method is primarily used for patients with ankle flexion contracture caused by shortening of the triceps calf muscle.

The most common indications include:

cerebral palsy (MPD)
gait disturbances (e.g., walking on tiptoe)
Neurological syndromes with muscle contracture
idiopathic contractures of the Achilles tendon
Prevention of recurrence of deformities after previous orthopedic surgeries

2 Mileage

The procedure is performed minimally invasively, using a percutaneous technique, usually under general anesthesia.

The Bowman method involves selectively cutting selected fibers of a tendon or muscle stretch, keeping the structure of most of the tendon intact.

In practice, the surgeon makes several small (a few millimeters) incisions around the Achilles tendon or the gastrocnemius and hamstring muscle tendon, precisely lengthening the structure without the need for a full incision.

3 Advantages

- Low invasiveness: no large incisions and minimal scarring
Quick return to activity: often no need for immobilization with a plaster cast
Precision: ability to selectively lengthen one head of the triceps muscle (e.g., only the gastrocnemius)
Safety: low risk of muscle weakness
Treatment often bilateral and simultaneous: what's important in treating children with MPD

4 Author's modifications

In some centers, such as the Paley Institute, the PERCS procedure using the Bowman method may be:

Supported by intraoperative assessment of muscle tone and joint range of motion
Combined with other procedures, such as tibial derotation
performed as part of a larger gait treatment protocol (e.g., "Single Event Multilevel Surgery" - SEMLS)
adapted to the age and height of the patient by varying the depth of the cuts and selecting the structures to be lengthened

The use of serial plastering after ophthalmic treatment perpetuates the effect
Selection of dedicated orthotic supplies

5. recovery

Hospitalization: usually 1 day
Return to activity: depending on indications - immediately after surgery or after a few days
Rehabilitation: key - emphasis on improving gait pattern, stretching and strengthening muscles. Use of serial plastering after surgery
Immobilization: often unnecessary, possibly short-term use of orthoses
Return to school/preschool: usually within a week
Full effect: assessed after 6-12 weeks

1. indications

The procedure is indicated for patients with multilevel deformities of the lower limb, most often of an axial nature (e.g., myelomeningocele, valgus, excessive rotation). It can apply to patients with:

Congenital defects of the skeletal system (e.g., achondroplasia, bone dysplasias),
acquired post-traumatic deformities or after orthopedic treatment,
Deformities secondary to neurological diseases (such as cerebral palsy).

The goal of the procedure is to simultaneously correct abnormalities in the femur and tibia, thereby restoring the normal axis of the limb, improving gait function and reducing secondary pain and degenerative conditions.

2 Mileage

The procedure takes place under general anesthesia and includes:

Correction planning based on imaging studies (X-ray, 3D CT, EOS),
Performing osteotomies (cutting the bones) in the planned locations - most often in the distal femur and proximal tibia,
Angular, rotational or length correction,
Stabilization of the fractures with plates, screws or using an external stabilizer (e.g., Taylor Spatial Frame), performing the procedure in a simultaneous manner, which means correction of both bones during one operation.

3 Advantages

Simultaneous multilevel correction avoids multiple surgeries,
Reducing the total treatment and rehabilitation time,
Better functional and biomechanical results (full correction of limb axis and rotation),
The ability to precisely plan the correction using 3D technology,
Improving the patient's quality of life and independence.

4 Author's modifications

In modern centers, such as the Paley European Institute, modifications are used to increase the effectiveness and safety of the procedure:

Osteotomy planning using 3D models and virtual simulations,
The use of mini-invasive surgical techniques (MIS),
The use of modern low-profile implants,
Simultaneous treatment of concurrent problems (e.g., patellar instability, contractures),
Use of rapid mobilization protocols after surgery.

5. recovery

The hospital stay usually lasts 3-7 days,
Early mobilization of the limb with the help of a physiotherapist (often as early as day 1),
Load the limb gradually, depending on the type of stabilization,
Bone fusion time is about 8-12 weeks,
Full rehabilitation can take from 3 to 6 months,
The effects of the treatment last long term, provided that the recommendations are followed

1. indications

Triple arthrodesis of the foot (triplex arthrodesis) is a surgical procedure involving the fusion of three joints of the butt-foot:

The subtalar joint (ankle-foot joint),
ankle-ankle joint,
heel and ankle joint.

The indications for this treatment are primarily:

Advanced deformities of the foot (for example, in the course of cerebral palsy, neuromuscular diseases, post-traumatic deformities),
Rearfoot instability,
Chronic pain and reduced function that do not respond to conservative treatment,
Post-inflammatory deformities or after tumor resection,
degeneration within these three joints.

2 Mileage

The procedure is performed under general or subarachnoid anesthesia. Surgical access allows all three joints to be reached.

After opening, the surgeon removes the articular surfaces and corrects the axis of the foot, bracing it in a functional alignment. Anastomosis is achieved with screws, sometimes aided by plates or other implants.

If necessary, simultaneous correction of heel valgus or hallux valgus, bone shortening or tendon transfers, such as the posterior tibial tendon, are performed.

3 Advantages

Stabilization and improvement of the foot axis,
Elimination of pain associated with failed joints,
Improving the foot's weight-bearing capacity and gait,
Possibility of simultaneous correction of complex deformations,
Good and predictable results in patients with refractory deformities.

4 Author's modifications

In specialized centers, such as the Paley European Institute, the procedure is often supplemented with:

Precise planning of axes in three planes (often using 3D X-ray or tomography),
Use of minimally invasive access techniques with less soft tissue damage,
Autogenous or allogeneic bone grafts to fill defects,
Intraoperative position tracking with C-arms and navigation.

5. recovery

After the procedure, the patient stays in a plaster dressing or orthosis for 6-8 weeks, without putting any weight on the operated limb.
Then gradual weight-bearing and rehabilitation - especially in gait pattern and muscle strength.
Complete return to full activity can take 3 to 6 months, depending on the patient's age and comorbidities.
In some cases, early orthotic supplies (such as orthotics or orthoses) are used to stabilize the foot after healing.

1. indications

Minimally invasive correction of the hallux valgus toe is recommended for patients with a forefoot deformity involving lateral deviation of the toe and medial displacement of the first metatarsal bone. Indications are:

Pain when walking or wearing shoes,
Increased abrasion and inflammation in the area of the tuberosity of the first metatarsal bone,
Progression of the deformity despite conservative treatment,
The desire to avoid a classic open procedure with extensive tissue interference.

2 Mileage

The procedure is performed under local or subarachnoid anesthesia. Through incisions of several millimeters, specialized tools (cutters, osteotomes) are inserted under X-ray guidance:

- An osteotomy (cutting) of the metatarsal bones is performed in a precisely designated place,
- Bone fragments are repositioned to restore the toe's axis,
- Stabilization is done with small implants (usually screws),
- Soft tissues, such as the joint capsule or tendons, can be further corrected without extensive transection.
The whole process usually takes 30-60 minutes, and the patient can leave the hospital the same day.

3 Advantages

Minimal incisions - better aesthetic effect and less risk of infection,
Shorter recovery time and less pain after surgery,
Faster return to daily activities,
Preservation of natural soft tissue structures,
Precision of correction through intraoperative X-ray inspection.

4 Author's modifications

In some centers, it is used:

modified osteotomy angles tailored to the degree of deformity,
The use of bioresorbable implants that do not require removal,
A combination of minimally invasive techniques and mini-arthroscopy of the metatarsophalangeal joint,
Individualized treatment planning based on three-dimensional images of the foot (e.g., from CBCT scans).

5. recovery

Partial-load walking is usually possible from the first day in a special Barouk shoe.
The stitches are removed after 2 weeks.
Full loading and return to athletic/classic shoes usually occurs after 4-6 weeks.
Exercises to improve joint mobility and muscle strength are introduced gradually under the supervision of a physiotherapist.
Full return to sports - after about 3 months.

1. indications

Reconstruction surgery according to Dunn is indicated in patients with slipped capital femoral epiphysis (SCFE), especially in cases with a high degree of displacement or in acute, unstable forms of slipping. The goal of the operation is anatomical positioning of the femoral head, while minimizing the risk of vascular damage that threatens necrosis of the femoral head.

2 Mileage

The procedure is carried out under general anesthesia. The operation according to Dunn (often modified by Ganz - by surgical dislocation of the hip joint) consists of:

Surgical dislocation of the hip joint in a way that is safe for the femoral head,
Total repositioning of the displacement of the femoral epiphysis to its anatomical position,
Stabilization of the femoral head with screws,
Preservation of retinacular vessels through careful mobilization and protection of the femoral neck.

The procedure requires a high degree of precision and operator experience, due to the proximity of the vessels that feed the femoral head.

3 Advantages

The greatest advantage of the Dunn technique is the ability to achieve full anatomical repositioning of the femoral epiphysis, which minimizes the risk of secondary deformities (e.g. CAM-type FAI). This method also allows direct evaluation and protection of vascular structures, which significantly reduces the risk of necrosis of the femoral head, which is high with classical attempts at closed repositioning. In addition - the operation makes it possible to treat both exfoliation and accompanying morphological conflicts in a single session.

4 Author's modifications

Some centers use a modification of the Dunn procedure according to Ganz, using a course of anterolateral access and modern tools for intraoperative assessment of head vascularization (e.g. ICG fluorescence). Some teams also use resorbable screws instead of titanium ones, and support themselves with 3D navigation and nerve monitoring.

5. recovery

After surgery, the patient remains in the hospital for several days, and then undergoes a staged return to weight-bearing of the limb (usually 6-12 weeks of weight-bearing). Rehabilitation includes range of motion and muscle strength exercises, under the supervision of a physiotherapist. A full return to physical activity is usually possible after a few months, but monitored

1. indications

Hip reconstruction according to Morsher (also known as Morsher osteotomy) is mainly used in children and young adults with:

- Hip dysplasia (congenital or developmental),
- Instability or subluxation of the joint,
- Abnormal coverage of the femoral head by the acetabulum,
- Some cases of cerebral palsy in which improvement of hip biomechanics is required.

The goal of the operation is to increase the coverage of the femoral head by the pelvic acetabulum, which reduces the risk of further deformity and the development of secondary osteoarthritis.

2 Mileage

The treatment consists of:

- Performing a pelvic osteotomy (usually in the hip bone),
- Tilting a section of the acetabulum so that it better encompasses the femoral head,
- Displacement of the bone fragment in a new position and stabilization (e.g., with bone grafts and screws),
- often performed at the same time as other corrective procedures (e.g., femoral osteotomy) if there is significant deformity of the femoral neck or other accompanying pathologies.

The procedure requires precise radiological planning and surgical experience, as it interferes with the anatomy of the acetabulum.

3 Advantages

- Improved coverage of the femoral head, which reduces the risk of dislocation or subluxation,
- Improved biomechanics of the hip, resulting in better function and less pain,
- Slowing or preventing the development of degenerative changes,
- The possibility of avoiding hip replacement at a young age.

4 Author's modifications

In some centers, the Morsher technique is sometimes modified by:

The use of modern stabilization systems (such as anatomical plates),
The use of intraoperative navigation or 3D planning,
Combining with minimally invasive techniques to reduce healing time,
Individualization of the osteotomy angle based on accurate analysis of CT scans.

5. recovery

After the operation, the patient usually stays several days in the hospital,
It is recommended to avoid putting weight on the limb for the first 6-8 weeks (the time depends on the stability of the anastomosis),
Rehabilitation is then implemented to regain range of motion and muscle strength,
Full recovery usually takes 3-6 months, although it may take longer to return to sports,
follow-up X-rays are taken regularly to assess osteotomy healing and joint position.

1. indications

San Diego pelvic osteotomy is an orthopedic procedure performed mainly in children with hip dysplasia and in patients with cerebral palsy who have hip instability and a tendency to subluxation or dislocation. The procedure is particularly useful in cases where a classic Dega or Pemberton osteotomy does not provide sufficient coverage of the femoral head, especially in the posterolateral plane.

2 Mileage

The procedure involves an incomplete osteotomy through the iliac plate, starting near the anterior inferior iliac spine and arcing posteriorly, but not passing through the acetabular growth zone. Unlike the classic Dega osteotomy, the direction and extent of the incision in the San Diego technique allows controlled modeling of the acetabular coverage in different directions (anterior, lateral or posterior).

Bone wedges (often from the patient's hip bone plate) are placed at the osteotomy site to correct and stabilize the position of the acetabulum without the need for metal stabilization.

3 Advantages

The possibility of fine-tuning the direction of correction to a specific type of acetabular deformity.
The procedure spares the growth cartilage, which is especially important in younger children.
Stable correction without the need for metal implants.
Good results in cases of secondary acetabular dysplasia in cerebral palsy.
Shorter hospitalization and recovery time compared to osteotomies requiring plates.

4 Author's modifications

Some centers use modification of the direction of osteotomy depending on the type and direction of hip instability. In cases of severe posterior instability (such as in cerebral palsy), the osteotomy is performed more posteriorly to improve the posterior portion of the acetabular coverage. Often, an individual bone wedge shape is also selected for more precise correction.

5. recovery

After a San Diego osteotomy, immobilization in a cast is usually not used, which is one of the advantages of this technique. The child can begin rehabilitation relatively early, and verticalization and weight-bearing of the limb depend on the degree of correction and the operator's decision. In many cases, walking (with assistance) is possible after a few weeks.

Full recovery usually takes several months and includes:

Hip joint range of motion exercises,
Strengthening the muscles of the hip girdle,
gait learning and motor re-education.

The speed of return to activity depends on the child's general condition, the presence of other deformities and associated diseases (such as cerebral palsy)

1. indications

Hip endoprosthesis, or surgical implantation of an artificial hip joint, is indicated for:

Advanced osteoarthritis of the hip (primary or secondary),
rheumatoid arthritis,
Sterile necrosis of the femoral head,
Post-traumatic complications (e.g., after femoral neck fractures),
Hip dysplasia,
Metabolic diseases of the joint (such as Paget's disease),
severe pain, reduced mobility and decreased quality of life that do not respond to conservative treatment.

2 Mileage

The procedure is performed under subarachnoid or general anesthesia. Basic stages of the operation:

Surgical access to the joint (usually posterior, lateral or anterior).
Removal of the damaged components of the joint - the femoral head and the acetabulum of the joint.
Preparation of the bone for implantation of the endoprosthesis components.
Implanting the artificial acetabulum and stem with the head of the prosthesis - they can be cemented or cementless.
Checking the stability and range of motion of the new joint.
Wound closure and drain placement (if necessary).

3 Advantages

Effective abolition of hip pain.
Significant improvement in range of motion and function of the limb.
Restoring independence and comfort in life.
Durability of the endoprosthesis - up to 15-25 years for modern implants.
Ability to mobilize quickly after surgery (depending on technique and implant).

4 Author's modifications

In some centers, it is used:

Minimally invasive access techniques (e.g., anterior access without muscle cutting) that reduce postoperative pain and speed up recovery.
Computer navigation or robotics to increase the precision of component embedding.
Personalization of implants - selection of an endoprosthesis based on the patient's individual anatomy (e.g., using 3D printing).
The use of modern materials, such as ceramic and antibacterial coatings.

5. recovery

Hospitalization usually lasts 3-5 days.
Rehabilitation begins as early as day 1-2 after surgery - the patient gets up and learns to walk with the help of crutches.
Loading of the limb depends on the type of endoprosthesis - cemented ones allow full loading earlier than uncemented ones.
Return to independent functioning usually occurs within 4-8 weeks.
Full recovery and return to physical activity can take up to six months.
Further rehabilitation, learning to walk properly and exercises to strengthen the hip muscles are essential.

1. indications

Total Knee Arthroplasty (TKA) is performed on patients with advanced degenerative changes in the knee joint that cause severe pain, limited mobility and a decreased quality of life. The most common cause is osteoarthritis (osteoarthrosis), but indications can also include rheumatoid arthritis, deformities of the knee axis (valgus, patellar), avulsion necrosis of the femoral condyles and traumatic injuries.

2 Mileage

The procedure is performed under subarachnoid or general anesthesia. During the operation, the surgeon removes the damaged articular surfaces of the femur, tibia and patella, and then implants a prosthesis consisting of metal and polyethylene components. The components can be fixed with bone cement or cementless (depending on the patient's age, bone quality and the operating team's preference). The operation usually takes between 1.5 and 2 hours. After surgery, early mobilization and rehabilitation begins.

3 Advantages

Effective pain reduction and improved knee function
Significant improvement in quality of life and independence
Correction of limb axis deformities
Enabling a return to daily activity and, in some cases, low-impact sports activities on the joint

4 Author's modifications

In specialized centers, modifications to the surgical technique are possible, such as:

Use of computer navigation or robotics to precisely position implants
Minimally invasive surgical approaches to reduce soft tissue trauma
Individually designed prostheses based on 3D imaging
Modifications of components according to deformity or instability of the knee

5. recovery

Early rehabilitation begins as early as the first day after surgery - it includes verticalization, learning to walk with assistance and range-of-motion exercises. The hospital stay usually lasts 3-5 days. Full recovery takes 6-12 weeks, depending on the patient's age, overall health and commitment to the rehabilitation process. In most cases, it is possible to return to daily activities within 2-3 months.

1. indications

Debridement of bone infections (osteomyelitis) is used for:

Chronic or acute bone infections,
The presence of necrotic bone fragments (sequesters),
lack of response to antibiotic therapy,
Bone fistulas or periosteal abscesses,
Postoperative infections of orthopedic implants,
Osteoarthritis in the course of diabetic foot.

2 Mileage

The procedure is performed under general or regional anesthesia and includes:

A skin incision over the focus of infection,
Removal of necrotic, infected and purulent tissues,
resection of bone fragments affected by necrosis (sequestrectomy),
Thorough rinsing of the wound (e.g., pulsing with antiseptic solutions),
Collection of material for microbiological examination,
In the case of implants - their removal or revision,
If necessary - filling the bone defect (for example, with antibiotic cement),
Primary or secondary wound closure (sometimes with VAC).

3 Advantages

Removing the source of infection and reducing the bacterial load,
Improving tissue healing,
Ability to accurately select targeted antibiotic therapy,
Reduce the risk of generalized infection (e.g., sepsis),
The possibility of preserving the limb and avoiding amputation.

4 Author's modifications

In some centers, it is used:

modern vacuum-assisted wound flushing systems (VAC Instill),
Local administration of antibiotics in the form of gentamicin beads (Stimulan) or cement (Cerament)
Endoscopic debridement techniques (minimally invasive),
Combining the procedure with biological therapy (e.g., growth factors or cell transplants),
Cooperation with the chronic wound care team.

5. recovery

Hospitalization usually lasts from a few days to two weeks,
Intravenous or oral antibiotic therapy for 4-6 weeks (sometimes longer),
Avoid putting weight on the operated limb (temporary weight relief or immobilization),
Regular laboratory and imaging checks (CRP, ESR, X-ray, MRI),
Rehabilitation and treatment of comorbidities (such as diabetes),
In some cases, further stages of surgical treatment are needed.

1. indications

Paley femoral rotoplasty is a reconstructive procedure used mainly in children with extensive defects of the lower limb, such as:

Severe congenital hypoplasia of the femur (CFD - Congenital Femoral Deficiency),
Complex deformities of the limb with loss of knee function,
Previous failure of reconstruction or irreversible damage to the knee joint,
Tumors of the femur that require resection (such as osteosarcoma).
The goal of the procedure is to enable the patient to walk functionally with the prosthesis, while keeping his own foot and ankle joint as the "knee" joint of the prosthetic limb.

2 Mileage

During the operation:

The femur is cut (osteotomy) and then rotated 180 degrees.
With this rotation, the ankle joint takes over the function of the knee, and the foot takes over the function of the thigh stump.
Muscles, vessels and nerves are lengthened or moved as appropriate to maintain their function despite the limb's change in position.
The distal part of the lower limb (shin and foot) is positioned inversely (toes pointing backward), which allows the ankle joint to function properly in the prosthesis.
The operation is performed with the utmost precision to ensure stability, proper rotation and minimize neurological complications.

3 Advantages

Limb preservation - Unlike amputation, rotoplasty allows you to use your own foot as a flexor joint.
Improved sensation and proprioception - the foot retains innervation, which improves control of the prosthesis.
Improved gait performance - patients often achieve high functional capacity.
Ability to adapt the prosthesis to the child's height - thigh prostheses are easier to fit than complex orthoses with other reconstructive methods.

Durability of the effect - the method gives good functional results for many years, including in adulthood.

4 Author's modifications

Dr. Dr. Paley developed his version of rotoplasty, taking into account:

Precise planning of limb length reconstruction using lengthening techniques,
The use of internal lengtheners (PRECICE, STRYDE) after rotoplasty to achieve equal limb length,
Optimizing limb axis and rotation to ensure the best possible gait biomechanics,
Minimizing the risk of neurological complications with advanced nerve and vascular preparation techniques.

5. recovery

After surgery, the patient usually remains in the hospital for 1-2 weeks, and then is referred to rehabilitation.The bone healing process takes about 6-12 weeks, depending on age and the techniques used.Physiotherapy focuses on maintaining range of motion, strengthening muscles and learning to walk with the new prosthesis.Adjustment and learning to use the prosthesis takes place over several months.Full functionality is usually achieved after 6-12 months, with the ability to participate in physical activities.

1. indications

The Pemberton osteotomy is mainly used to treat hip dysplasia in children, usually between the ages of 18 months and 8 years. It can also be used in cases of hip instability, subluxation, and as part of the treatment of some forms of cerebral palsy or neurological syndromes affecting the development of the hip acetabulum.

2 Mileage

The Pemberton osteotomy involves a pelvic incision within the iliac bone (ilium), while maintaining the integrity of the posterior and inferior edges of the acetabulum. This incision allows the acetabulum to be tilted and deepened to better cover the femoral head. A bone wedge, often autologous (e.g., from the hip plate), is inserted into the osteotomy slot to maintain the new alignment. The operation is usually performed from an anterolateral access and does not require cutting the hip joint.

3 Advantages

Increase coverage of the femoral head without opening the joint.
The procedure can be performed without the risk of damaging the triradiate cartilage (Y growth cartilage), making it safe in younger children.
The lasting effect of stabilizing the hip joint.

Less risk of instability than with classic Salter osteotomies.

4 Author's modifications

In some centers, modifications are used to include:

Using special implants instead of bone grafts,
Performing the procedure in conjunction with a femoral osteotomy if increased antetorsion or valgus thigh is found,

5. recovery

After a San Diego osteotomy, immobilization in a cast is usually not used, which is one of the advantages of this technique. The child can start rehabilitation relatively early, and verticalization and weight-bearing of the limb depend on the degree of correction and the operator's decision. In many cases, walking (with assistance) is possible after a few weeks.

Full recovery usually takes several months and includes:

Hip joint range of motion exercises,
Strengthening the muscles of the hip girdle,
gait learning and motor re-education.
The speed of return to activity depends on the child's overall condition, the presence of other deformities and associated diseases (such as cerebral palsy).

1. indications

Hip endoprosthesis, or surgical implantation of an artificial hip joint, is indicated for:

-advanced osteoarthritis of the hip (primary or secondary),
rheumatoid arthritis,
Sterile necrosis of the femoral head,
Post-traumatic complications (e.g., after femoral neck fractures),
Hip dysplasia,
Metabolic diseases of the joint (such as Paget's disease),

severe pain, reduced mobility and decreased quality of life that do not respond to conservative treatment.

2 Mileage

The procedure is performed under subarachnoid or general anesthesia. Basic stages of the operation:

Surgical access to the joint (usually posterior, lateral or anterior).
Removal of damaged joint components - the head of the femur and the acetabulum of the joint.
Bone preparation for implantation of endoprosthesis components.
Implanting an artificial acetabulum and stem with the head of the prosthesis - they can be cemented or cementless.
Checking the stability and range of motion of the new joint.
Closure of the wound and placement of a drain (if necessary).

3 Advantages

Effective abolition of hip pain.
Significant improvement in range of motion and function of the limb.
Restoring independence and comfort in life.
Durability of the endoprosthesis - up to 15-25 years for modern implants.
Ability to mobilize quickly after surgery (depending on technique and implant).

4 Author's modifications

In some centers, it is used:
Minimally invasive access techniques (e.g., anterior access without muscle cutting) that reduce postoperative pain and speed up recovery.
Computer navigation or robotics to increase the precision of component embedding.
Personalization of implants - selection of an endoprosthesis based on the patient's individual anatomy (e.g., using 3D printing).
The use of modern materials, such as ceramic and antibacterial coatings.

5. recovery

Hospitalization usually lasts 3-5 days.
Rehabilitation begins as early as day 1-2 after surgery - the patient gets up and learns to walk with the help of crutches.
Loading of the limb depends on the type of endoprosthesis - cemented ones allow full loading earlier than uncemented ones.
Return to independent functioning usually occurs within 4-8 weeks.
Full recovery and return to physical activity can take up to six months.
Further rehabilitation, learning to walk properly and exercises to strengthen the hip muscles are essential.

1. indications

2 Mileage

3 Advantages

Effective pain reduction and improved knee function
Significant improvement in quality of life and independence
Correction of limb axis deformities

4 Author's modifications

In specialized centers, modifications to the surgical technique are possible, such as:

Use of computer navigation or robotics to precisely position implants
Minimally invasive surgical approaches to reduce soft tissue trauma
Individually designed prostheses based on 3D imaging

Modifications of components according to deformity or instability of the knee

5. recovery

1. indications

Single-compartment endoprosthesis (a.k.a. partial, single-compartment or unilateral) of the knee joint is a surgical procedure to replace only one of the three parts of the knee joint - usually the medial compartment. The indication for surgery is advanced degenerative changes limited to only one compartment, with preserved ligament function and no instability of the joint. A typical patient is a person with knee pain ineffectively treated conservatively (rehabilitation, pharmacotherapy), with reduced function and quality of life, but without multi-compartment joint disease.

2 Mileage

The procedure is usually performed under subarachnoid or general anesthesia. The surgeon makes a small incision on the side of the affected compartment, gaining access to the damaged structures. The affected articular surfaces of the femur and tibia in the affected compartment are removed, and then properly fitted endoprosthesis (metal-polyethylene) components are implanted. The rest of the joint, including healthy ligaments and other compartments, remains intact. The procedure usually takes 60-90 minutes.

3 Advantages

Smaller incision and less interference with the joint than a total endoprosthesis
Shorter operation time and less blood loss
Faster recovery and return to daily activities
More natural feeling of the joint - preserving its own ligaments and some structures

Lower risk of complications (e.g. infection, thrombosis) compared to total endoprosthesis

4 Author's modifications

Some centers or operators use modifications to the surgical technique, such as the use of surgical robots (robotic endoprosthesis), minimally invasive techniques with smaller incisions and precise implant placement. In addition, it is possible to use modern implants tailored individually to the patient's anatomy based on 3D imaging.

5. recovery

The patient usually gets up and starts walking with the help of a physiotherapist as early as the first day after the procedure. Hospitalization lasts 2 to 3 days. Rehabilitation lasts several weeks and focuses on regaining full mobility of the joint, strengthening muscles and learning to walk properly. Full return to activity usually takes 6-12 weeks. In many patients, it is possible to return to light sports, such as cycling, swimming and hiking.

1. indications

Debridement of bone infections (osteomyelitis) is used for:

Chronic or acute bone infections,
The presence of necrotic bone fragments (sequesters),
lack of response to antibiotic therapy,
Bone fistulas or periosteal abscesses,
Postoperative infections of orthopedic implants,

Osteoarthritis in the course of diabetic foot.

2 Mileage

The procedure is performed under general or regional anesthesia and includes:

A skin incision over the focus of infection,
Removal of necrotic, infected and purulent tissues,
resection of bone fragments affected by necrosis (sequestrectomy),
Thorough rinsing of the wound (e.g., pulsing with antiseptic solutions),
Collection of material for microbiological examination,
In the case of implants - their removal or revision,
If necessary - filling the bone defect (for example, with antibiotic cement),
Primary or secondary wound closure (sometimes with VAC).

3 Advantages

Removing the source of infection and reducing the bacterial load,
Improving tissue healing,
Ability to accurately select targeted antibiotic therapy,
Reduce the risk of generalized infection (e.g., sepsis),
The possibility of preserving the limb and avoiding amputation.

4 Author's modifications

In some centers, it is used:

modern vacuum-assisted wound flushing systems (VAC Instill),
Local administration of antibiotics in the form of gentamicin beads (Stimulan) or cement (Cerament)
Endoscopic debridement techniques (minimally invasive),
Combining the procedure with biological therapy (e.g., growth factors or cell transplants),
Cooperation with the chronic wound care team.

5. recovery

Hospitalization usually lasts from a few days to two weeks,
Intravenous or oral antibiotic therapy for 4-6 weeks (sometimes longer),
Avoid putting weight on the operated limb (temporary weight relief or immobilization),
Regular laboratory and imaging checks (CRP, ESR, X-ray, MRI),
Rehabilitation and treatment of comorbidities (such as diabetes),
In some cases, further stages of surgical treatment are needed.

1. indications

Paley femoral rotoplasty is a reconstructive procedure used mainly in children with extensive defects of the lower limb, such as:

Severe congenital hypoplasia of the femur (CFD - Congenital Femoral Deficiency),
Complex deformities of the limb with loss of knee function,
Previous failure of reconstruction or irreversible damage to the knee joint,
Tumors of the femur that require resection (such as osteosarcoma).
The goal of the procedure is to enable the patient to walk functionally with the prosthesis, while keeping his own foot and ankle joint as the "knee" joint of the prosthetic limb.

2 Mileage

During the operation:

The femur is cut (osteotomy) and then rotated 180 degrees.
With this rotation, the ankle joint takes over the function of the knee, and the foot takes over the function of the thigh stump.
Muscles, vessels and nerves are lengthened or moved as appropriate to maintain their function despite the limb's change in position.
The distal part of the lower limb (shin and foot) is positioned inversely (toes pointing backward), which allows the ankle joint to function properly in the prosthesis.
The operation is performed with the utmost precision to ensure stability, proper rotation and minimize neurological complications.

3 Advantages

Limb preservation - Unlike amputation, rotoplasty allows you to use your own foot as a flexor joint.
Improved sensation and proprioception - the foot retains innervation, which improves control of the prosthesis.
Improved gait performance - patients often achieve high functional capacity.
Ability to adapt the prosthesis to the child's height - thigh prostheses are easier to fit than complex orthoses with other reconstructive methods.

Durability of the effect - the method gives good functional results for many years, including in adulthood.

4 Author's modifications

Dr. Dr. Paley developed his version of rotoplasty, taking into account:

Precise planning of limb length reconstruction using lengthening techniques,
The use of internal lengtheners (PRECICE, STRYDE) after rotoplasty to achieve equal limb length,
Optimizing limb axis and rotation to ensure the best possible gait biomechanics,

Minimizing the risk of neurological complications with advanced nerve and vascular preparation techniques.

5. recovery

After the operation, the patient usually remains in the hospital for 1-2 weeks, and is then referred for rehabilitation.
The bone healing process takes about 6-12 weeks, depending on age and the techniques used.
Physiotherapy focuses on maintaining range of motion, strengthening muscles and learning to walk with the new prosthesis.
Adjustment and learning to use the prosthesis takes place over several months.
Full functionality is usually achieved after 6-12 months, with the ability to participate in physical activities.

1. indications

2 Mileage

3 Advantages

Increase coverage of the femoral head without opening the joint.
The procedure can be performed without the risk of damaging the triradiate cartilage (Y growth cartilage), making it safe in younger children.
The lasting effect of stabilizing the hip joint.
Less risk of instability than with classic Salter osteotomies.

4 Author's modifications

In some centers, modifications are used to include:

Using special implants instead of bone grafts,
Performing the procedure in conjunction with a femoral osteotomy if increased antetorsion or valgus thigh is found,
using intraoperative navigation or fluoroscopy for precise acetabular positioning.

5. recovery

Full recovery usually takes several months and includes:

Hip joint range of motion exercises,
Strengthening the muscles of the hip girdle,
gait learning and motor re-education.
The speed of return to activity depends on the child's overall condition, the presence of other deformities and associated diseases (such as cerebral palsy).

1. indications

Triple pelvic osteotomy (TPO) is a procedure used to treat hip dysplasia, mainly in children and young adults whose articular cartilage is still well preserved. The main goal of the operation is to improve the coverage of the femoral head by the acetabulum in order to reduce overload, delay wear and tear on the joint and prevent the development of early osteoarthritis of the hip.

2 Mileage

The procedure involves making three cuts in the pelvic bones: the hip, pubic and ischial bones, allowing the acetabulum of the hip joint to be displaced and properly aligned.

Once the pelvic fragment is displaced, it is stabilized with plates and screws. The procedure is usually performed from anterior access and requires precise radiological planning. Intraoperative navigation or fluoroscopy is often used to ensure proper positioning of the acetabulum.

3 Advantages

Improves hip biomechanics by increasing coverage of the femoral head.
It relieves pressure on the acetabulum and reduces the risk of early arthrosis.
It preserves one's own joint (it is a conservative procedure, unlike endoprosthesis).
It can significantly improve function and reduce pain in young patients.

4 Author's modifications

In selected centers, TPO modifications are used, consisting, for example, of:

Minimally invasive accesses, reducing the extent of the procedure and shortening recovery time.
Use of 3D printing for preoperative planning and preparation of cuts.Combination of TPO with hip arthroscopy for co-morbidities
Pathologies (e.g., casing damage, FAI).
In younger children, it is possible to adapt the technique to the anatomy of developmental age.

5. recovery

After the procedure, the patient most often:

For the first 6 weeks, he moves with limited weight bearing on the limb, with the help of crutches.
Rehabilitation focuses on regaining range of motion, strengthening hip muscles and learning to walk properly.
Full loading is usually possible after 8-10 weeks.
Return to sports and activity usually occurs after about 4-6 months, depending on age and the condition of the joint before surgery.

1. indications

Surgery with ascending MAGEC or MARVEL rods is indicated in children with Early Onset Scoliosis (EOS), a curvature of the spine diagnosed before the age of 10. The procedure is recommended in cases of progressive spinal deformity that cannot be stopped with conservative treatment (such as a corset). The main goal is to control the curvature and at the same time allow further growth of the spine and thorax, which is crucial for the child's lung development and overall health.

2 Mileage

The procedure involves the surgical insertion of special rods - the MAGEC or MARVEL system - on both sides of the spine.

MAGEC: rods with an internal magnetic mechanism that allows non-surgical, ambulatory lengthening with a special external device.
MARVEL: a system with a more rigid design that can be adjusted mechanically in the treatment room, usually under anesthesia, but also allows for partial rotational correction of the spine.
During the first procedure, the surgeon stabilizes the rods on healthy segments of the spine with screws or hooks. Correction of the deformity is carried out carefully to avoid overloading the tissues and nervous system.

3 Advantages

They make it possible to control scoliosis without having to repeat open surgeries every few months (especially MAGEC).
They allow further growth of the spine and development of the lungs.
Reduce the risk of spinal stiffness in adulthood compared to classic spinal fusion in early adulthood.The MARVEL system, with its additional rotation correction options, can be beneficial in patients with more complex three-dimensional deformities.

4 Author's modifications

Advanced centers use modified implantation techniques, including:

Unilateral rod placement in patients with less curvature,
The use of growth guides only on selected segments (so-called "skip constructs"),
Combining MAGEC with MARVEL components in exceptional cases to optimize correction. At the Paley European Institute, the priority is to maximize protection of growth function and individualize deformity dynamics - which can influence the choice of system and patient management strategy.

5. recovery

After surgery, the child usually spends several days in the hospital. It takes about 2-4 weeks to return to daily activities. With MAGEC, outpatient rod extensions are scheduled every 2-4 months - without the need for anesthesia.

For the MARVEL system, periodic modifications are usually necessary, but attempts are increasingly being made to minimize their number.
Final spinal fusion may be considered after growth is complete, usually in the teenage years

1. indications

Rhizotomy (most commonly: selective dorsal rhizotomy - SDR) is a neurosurgical procedure used to treat muscle spasticity, mainly in children with cerebral palsy (MPD), especially in the form of spastic diplegia.

The purpose of the surgery is to reduce excessive muscle tension that makes it difficult to walk, sit or perform daily activities. It is also indicated in cases where spasticity leads to pain, joint deformity or impedes movement therapy.

2 Mileage

During the procedure, the neurosurgeon cuts selected (selectively) sensory nerve root fibers coming out of the spinal cord (usually in the lumbar L1-S2 region).

The operation is performed under general anesthesia, and the decision to cut specific fibers is made based on an intraoperative assessment of the muscle response to electrical stimulation. This ensures that only those fibers responsible for pathological muscle tension are removed, without affecting sensation or motor function.

3 Advantages

Significant reduction in leg spasticity
Facilitate gait learning and improve gait quality
Reduce pain and risk of orthopedic deformities
Possibility of cancelling or reducing doses of antispastic drugs
Facilitating the delivery of effective physiotherapy

4 Author's modifications

Some centers, such as the Paley Institute, modify the classic procedure by:

More accurate patient selection (e.g., with the help of gait analysis and brain MRI),
Use of additional intraoperative technologies (e.g., neuromonitoring with more advanced algorithms),
Integration of the procedure into a broader treatment program (e.g., rhizotomy as a step preceding or accompanying limb lengthening or deformity correction).

5. recovery

Rehabilitation after rhizotomy is intensive and long-term.

Immediately after the procedure, the patient is often immobilized for several days.
In the following weeks, physiotherapy begins, which lasts up to 6-12 months.
Rehabilitation focuses on learning movement control, building muscle strength, and improving balance and gait. The effects of the treatment are lasting, but require the involvement of the entire treatment team and the family.

1. indications

The procedure is used primarily for children with cerebral palsy (MPD) and other neurological conditions that cause spasticity. Indications include muscle contractures that limit range of motion, limb deformities, gait abnormalities and soreness resulting from excessive muscle tension. The goal is to improve function, facilitate verticalization, gait and reduce pain and the risk of further deformities.

2 Mileage

The treatment combines three techniques:

BTX-A (botulinum type A) is administered multi-level, to selected muscle groups in different locations of the lower extremities - depending on the pattern of spasticity. It causes a temporary weakening of the overactive muscle.
SPML (Selective Percutaneous Myofascial Lengthening) is a technique of microdissecting fascia and muscles through small skin incisions, performed immediately after botulinum administration. It aims to relax contracted structures.
PERCS (Percutaneous Muscle/Tendon Lengthening) involves percutaneous lengthening of tendons - most commonly the Achilles tendon, thigh adductors, or sciatic and knee muscles - through small incisions, without opening the tissues.
The procedure is performed under general anesthesia or sedation, usually as a one-day procedure.

3 Advantages

Minimally invasive in nature - quick return to activity.
Possibility of simultaneous correction of multiple levels (e.g. hip, knee, ankle).
Better control of spasticity with a combination of botulinum and soft surgery.
Improving a child's range of motion and comfort without the need for classic, extensive orthopedic surgery.
The treatment can be repeated as the patient grows and needs.

4 Author's modifications

Depending on the center and the experience of the surgical team, modifications may include:

The use of ultrasound to precisely administer BTX-A,
Selection of SPML/PERCS techniques depending on current muscle tension and strength,
combining with additional procedures like point fibrotomy or fascial release,
Individual planning of treatment sequences according to the functional goals of the patient and his treatment team.
Use of an upright corset to consolidate the correction and improve the long-term outcome.

5. recovery

Rehabilitation begins almost immediately after surgery. The first few days may require the use of an upright orthosis, and then intensive physiotherapy is implemented, aimed at maintaining the achieved range of motion, re-educating gait and strengthening new movement patterns. The child usually returns to daily activities within a few days, and the full effects of the procedure are assessed after a few weeks. Turnaround protocols at specialized rehabilitation centers are also often used.

1. indications

SEMLS surgery is mainly used for children with cerebral palsy (MPD) and patients with other neurological disorders that cause spasticity and deformities of the musculoskeletal system. The main indications are:

Lower limb spasticity limiting gait function,
Muscle contractures (e.g., hip-lumbar muscle, Achilles tendon),
Skeletal deformities resulting from disorders of muscle tone (e.g., pelvic anteversion, tendon shortening),
Asymmetries and compensations affecting gait biomechanics,

previous failure of conservative treatment (physiotherapy, orthoses, botulinum toxin).

2 Mileage

SEMLS is a procedure that simultaneously involves multiple structures - muscles, tendons and/or bones - most often in both lower extremities. Treatments are performed in a single surgical session and may include, but are not limited to:

Extension of tendons (e.g., Achilles tendon, sciatic-shin muscle),
Bone osteotomies (e.g., femur, tibia),
muscle and tendon transfers,
Joint stabilizations (e.g., patelloplasties),
release of contractures and soft tissue reconstructions. The whole process is preceded by a 3D gait analysis, which helps to precisely plan the extent of correction.

3 Advantages

Comprehensiveness - many problems corrected during one treatment,
Reduced treatment time compared to staggered single surgeries,
Improved gait biomechanics - improving gait function, posture and quality of life,
Less risk of compensation - due to correction of multiple levels simultaneously,
Less stress for the child and family - one anesthesia, one rehabilitation process.

4 Author's modifications

Depending on the center and surgical team, modifications may include:

The use of modern minimally invasive techniques,
accurate planning based on three-dimensional gait analysis (gait lab),
Integration with intraoperative navigation systems,
Use of individualized orthoses and improvement protocols as early as the planning stage,
The use of modern implants that reduce healing time and allow for faster verticalization.

5. recovery

The recovery process after SEMLS is intensive, but yields significant functional improvements. Includes:

Postoperative hospitalization (usually 3-7 days),
Immobilization or orthosis for several weeks,
Gradual verticalization and learning to walk with a physical therapist,
Individually tailored rehabilitation program (often 6-12 months),
Control gait tests and orthopedic consultations.

1. indications

SPML is mainly used for children with cerebral palsy (MPD), dystonia or other neurological conditions leading to increased muscle tone (spasticity).

Indications for the procedure are muscle contractures that make walking, sitting, independence difficult or lead to limb deformity. The tendons and fascias of the ischiofemoral muscles, thigh adductors, gastrocnemius calf muscle or ankle flexors are most commonly affected.

2 Mileage

The SPML procedure is performed using a minimally invasive technique. Through small skin incisions of a few millimeters, the surgeon uses special tools to cut the fascia and/or muscle in selected areas, lengthening it and reducing tension.

The procedure is performed under general anesthesia and usually takes between 30 and 90 minutes, depending on the number of muscles undergoing intervention.

3 Advantages

Minimally invasive - no large wounds, low risk of complications, fast recovery
Minimal blood loss - bloodless or minimal blood loss procedure
No plastering - no immobilization required in most cases
Shorter hospital stay - children usually go home within 24 hours
Rapid improvement in function - children can get back to rehabilitation and learning to walk faster

4 Author's modifications

At centers such as the Paley European Institute, the SPML procedure can be combined with other techniques - such as intraoperative neuromonitoring, dynamic range-of-motion assessment or botulinum therapy. The team can also customize the incision sites and extent of lengthening, tailoring the procedure to a given patient's tension pattern.

5. recovery

The child can return to rehabilitation as soon as a few days after surgery. Intensive physiotherapy is often recommended for the first few weeks to maintain and develop the new range of motion. Improvements in function - such as walking - are usually noticeable within a few weeks.

Full return to activity depends on previous functional status and commitment to rehabilitation, but SPML significantly shortens this time compared to conventional surgery.

1. indications

Lengthening of the lower leg bones (tibia and/or fibula) using a Hexapod-type external apparatus is used for treatment:

Congenital or acquired shortening of the lower extremities,
Axial deformities (valgus, patellar, displacement in the sagittal plane),
The consequences of previous fractures, infections or developmental diseases (such as achondroplasia),
complications after removal of bone tumors. The method is also used in planned limb lengthening in cases of low stature.

2 Mileage

The procedure involves cutting the bone (osteotomy) in a controlled manner, followed by the installation of an external six-axis brace (Hexapod - usually of the Taylor Spatial Frame or Orthex type).

The apparatus consists of rings or half-rings connected by six telescopic rods (struts) that allow multidirectional movements.

A few days after surgery, the lengthening process begins - the patient (or parent) adjusts the length of the struts daily according to a plan developed by the doctor. The entire lengthening process usually takes a few weeks, followed by a period of consolidation in which the newly formed bone tissue matures and hardens. The total time to wear the braces can be several months.

3 Advantages

Precision: Hexapod enables accurate corrections in multiple planes simultaneously.
Safety: dynamic control allows for real-time adjustment of correction to clinical conditions.
Flexibility: the ability to adjust not only the length but also the alignment of the limb in the process.
No large surgical incisions: a minimally invasive method compared to traditional osteotomies with plates or intramedullary nails.

4 Author's modifications

At Paley European Institute, we use:

Precise planning using specialized software (e.g., Orthex Planner, TSF software),
A combination of lengthening with simultaneous correction of bone torsion or foot rotation,
individualized rehabilitation and pharmacological protocols,
Monitoring of healing with follow-up X-rays and remote consultations (e.g., via the Operio app). In some cases, we use additional
biological support (e.g., cell transplants, PRP) to accelerate bone regeneration.

5. recovery

The recovery process includes:

Daily care of wire/pin insertion sites,
Regular radiological checks (every 2-4 weeks),
Intensive rehabilitation during and after wearing the brace,
learning to walk with the help of crutches, and then gradually relieving the limb. Once the brace is removed, further physiotherapy and a period of adaptation are required, lasting
usually from several to several weeks. Full return to activity depends on the age of the patient, the extent of the lengthening and the rate of healing.

1. indications

Reconstruction of the flat-ankle foot using the Evans method is mainly used in children and adolescents with:

Idiopathic flat-foot (usually flexible),
deformity secondary to cerebral palsy, neurological syndromes or genetic syndromes,
pain and functional limitation caused by axis disruption and abnormal biomechanics of the foot,
lack of improvement after conservative treatment (orthoses, physiotherapy).

2 Mileage

Evans' procedure involves osteotomy of the anterolateral part of the heel bone (close to its joint with the scaphoid bone), with simultaneous implantation of a bone wedge (autogenous or allogenic bone graft or synthetic implant).

The goal of the osteotomy is to lengthen the lateral pillar of the foot to correct forefoot adduction and rearfoot valgus. If necessary, the procedure is combined with:

Extension of the Achilles tendon or mm. calf,
arthrodesis,
Posterior tibial tendon plication (if inoperable),
tendon transplantation (e.g., TP → Navicular).

3 Advantages

Anatomical correction of foot axis and function,
Good functional and aesthetic results,
The possibility of performing the procedure at an early age (even from about 8 years old),
Effective correction of deformities in patients with flexible flatfoot,
relatively low risk of recurrence compared to less invasive methods.

4 Author's modifications

Modifications of the classic Evans technique are used in clinical practice:

Use of off-the-shelf titanium-ceramic implants instead of bone grafts (e.g., BioPro® wedge),
Performing the procedure under intraoperative navigation or 3D X-ray guidance,
combination with modern arthrodesis (metatarsal-ankle implant),
Mini-invasive and reconstructive techniques using intramedullary nails for heel stabilization.

5. recovery

Immobilization in a plaster bandage or orthosis for about 6 weeks without putting weight on the limb,
Gradually increase the load after radiological control (usually from the 7th week),
Return to full physical activity possible after about 3-6 months,
Rehabilitation to regain muscle strength and flexibility (individually tailored program),
Regular checks to monitor growth and any risk of recurrence of the deformity.

1. indications

Ulnarization is a surgical procedure used mainly in patients with congenital hypoplasia of the radius bone (known as radial club hand, or radial hemimelia). This condition causes shortening and/or absence of the radial bone, resulting in deformity and deviation of the hand toward the radial side. Surgery is indicated when the deformity is significant and causes problems with limb function, limits range of motion and affects the appearance and development of the hand.

2 Mileage

Ulnarization involves surgically moving the wrist to the ulnar side and stabilizing it on the ulnar bone. During the operation:

Contracted soft tissue structures on the radial side are released.
The hand is moved and positioned more centrally over the elbow bone.
Stabilization is carried out using Kirschner wires (K-wires), plates or screws.
If necessary, soft tissue plication is performed to improve the range of motion and appearance of the limb.
The procedure is often performed on young children, aged 1-3 years, to allow further development of the hand in a more functional setting.

3 Advantages

Improving limb axis and wrist alignment.
Increasing the functionality of the hand, especially the grip.
Reduce visible deformity.
Improving conditions for further growth and development of the hands.
The possibility of performing the procedure in early childhood.

4 Author's modifications

At Our Center we perform the third generation of the modified ulnarization method

5. recovery

After surgery, the limb is immobilized in a plaster dressing or orthosis for several weeks. Once the stabilization is removed, physiotherapy is implemented:

The goal is to restore range of motion and learn to use the hand in a new setting.
Regular radiological checks monitor the growth and development of the limb.
Sometimes further corrective treatments are needed during adolescence.

1. indications

CPT X-Union is an orthopedic procedure used to treat delayed union and lack of bone fusion (non-union) after fractures or surgeries. The procedure is indicated when standard treatment has failed to achieve proper bone fusion, despite the passage of adequate time. Long bones such as the femur, tibia and humerus are most commonly affected.

2 Mileage

The CPT X-Union procedure involves stimulating the biological bone environment to bring about fusion. The key elements are:

Exposure of the site of non-adhesion
Clearing the pseudarthrosis joint of fibrous and necrotic tissues
Collection and administration of autologous bone graft (e.g., from the hip plate)
Mechanical stabilization of the fracture site - usually with a plate, nail or intramedullary anastomosis The procedure is performed under general anesthesia.

3 Advantages

Restoration of bone continuity and full function of the limb
Increase mechanical stability of the fracture site
Highly effective in cases refractory to conservative treatment
Ability to simultaneously improve limb axis with abnormal fusion

4 Author's modifications

Specialized pediatric orthopedic centers, such as the Paley European Institute, use advanced X-Union support techniques, including:

Biological support of adhesion (e.g., BMP - Bone Morphogenetic Proteins).
Microsurgical techniques to preserve blood supply to grafts
Use of hybrid external-internal stabilization (e.g. fixator + plate)
Integration with previous or concurrent reconstructive procedures

5. recovery

Hospitalization usually lasts several days
Load on the limb depending on the type of stabilization - often partial for 6-8 weeks
Regular radiological checks to assess the progress of adhesion
Individually tailored rehabilitation, often started as early as the first week after surgery
Full healing can take 3 to 6 months, depending on the location and extent of the procedure

1. indications

The SUPERknee (Systematic Utilitarian Procedure for Extremity Reconstruction of the knee) procedure is designed for patients with severe deformities of the knee joint, especially in the course of congenital and acquired diseases, such as:

Hypoplasia of the femur (such as in CFD - Proximal Femoral Focal Deficiency),
Instability of the knee due to the absence of ligaments or their significant insufficiency,
Axial deformities of the knee (valgus, scaphoid),
growth abnormalities or extensive post-traumatic changes. The need for knee stability prior to lower limb lengthening may also be an indication.

2 Mileage

The treatment is complex and multi-stage. It can include:

Reconstruction of cruciate ligaments (ACL, PCL) with autografts or allografts,
Correction of the mechanical axis of the limb (femoral, tibial osteotomies),
Stabilization with an external camera (e.g., Taylor Spatial Frame),
Soft tissue plasticity to improve function and range of motion,
Treatment of accompanying deformities, such as limb shortening or rotation.
All items are precisely planned based on imaging studies and individual patient needs.

3 Advantages

Comprehensiveness - one treatment can correct multiple pathologies simultaneously.
Stability - restores the support function of the knee, which is crucial before lengthening the limb.
Individualization - the procedure is tailored to the patient's specific anatomy and needs.
Amputation avoidance - allows treatment of patients who are referred for prosthetics at other centers.

4 Author's modifications

The Paley European Institute center uses modifications developed by Dr. Paley and team:

Combining ligamentous reconstruction with axial correction and lengthening plan,
The use of hybrid anastomosis and external stabilization,
Optimizing incision and surgical access for minimized scarring and faster mobilization.

5. recovery

The healing and rehabilitation process depends on the scope of the procedure, but usually includes:

6-12 weeks of protection of the limb (stress relief, stabilization),
Intensive physiotherapy from the first days after surgery,
Follow-up x-rays and orthopedic evaluations every few weeks,
full rehabilitation often lasting several months, especially if further limb lengthening is planned.

1. indications

The SUPERhip (Systematic Utilitarian Procedure for Extremity Reconstruction - hip) procedure was developed by Dr. Dr. Paley to treat severe hip deformity and instability in children with congenital and acquired lower extremity defects.

Indications include:

- Hip deformities in the course of femoral underdevelopment (e.g., Proximal Femoral Focal Deficiency - PFFD, Congenital Femoral Deficiency - CFD),
- Hip joint instability with absence of the head or acetabulum,
- Deformities of the hip joint in the course of rare syndromes (e.g. TAR, FFU, fibular hemimelia),
- complex cases where conventional reconstructive techniques are insufficient.

2 Mileage

SUPERhip is a comprehensive, multi-step reconstructive treatment that includes:

- Hip acetabular reconstruction (often using bone grafts),
- Correction of proximal femoral deformity, including neck osteotomy and stabilization,
- Stabilization of the joint through proper alignment and fusion of the femoral and pelvic structures,
- Often simultaneous SUPERknee procedure if knee instability is present.

3 Advantages

- allows the child's own hip to be preserved, which is important for long-term development,
- allows anatomical reconstruction, even in very difficult cases,
- Improves limb stability, length and function,
- Reduces the need for amputations or prostheses,
- is part of a comprehensive approach to limb lengthening and alignment (in conjunction with SUPERknee and other procedures).

4 Author's modifications

Dr. Paley and his team have made numerous modifications to classic orthopedic techniques:

- Using specially profiled bone grafts from the hip bone to reconstruct the acetabulum,
- Proprietary tools and implants to facilitate the correction of femoral neck and shaft deformities,
- Combining the procedure with SUPERknee treatments and planned limb lengthening in a single treatment protocol,
- Detailed planning based on 3D imaging studies and individual surgical splints.

5. recovery

- After the procedure, the patient stays in the hospital for several days, where pain control and initial rehabilitation are carried out.
- If an external appliance is used, recovery includes regular adjustments and pin care.
- The patient undergoes intensive rehabilitation - both in outpatient and inpatient settings - aimed at regaining range of motion, strengthening muscles and learning to walk.
- It may take several months to return to full function, but the end result often means a significant improvement in quality of life.

1. indications

The SUPERankle (Systematic Utilization of Precise Exposure and Reduction of the ankle) procedure is used primarily for patients with deformities of the ankle joint and adjacent bony structures, most commonly in the course of conditions such as:

Fibular hemimelia (absence or underdevelopment of the fibula)
Tibial hemimelia (absence or underdevelopment of the tibia)
Rotational and/or axial deformities of the ankle joint
Failure of the ankle joint after previous surgeries or congenital defects

The goal of the operation is to stabilize and center the ankle joint, improve gait function and prepare the patient for possible limb lengthening.

2 Mileage

The procedure is usually performed under general anesthesia. Key steps:

Accurate exposure of the bony structures of the ankle joint (ankle, tibia, fibula)
Bone alignment correction - including tibial and ankle osteotomies
Joint stabilization with SUPERankle plate or specialized implants
If necessary - simultaneous correction of the foot (e.g., reconstruction of the subtalar joint, arthrodesis, tendon transfer).

The procedure allows anatomical reconstruction of the ankle joint with restoration of normal biomechanics.

3 Advantages

Preserve or improve the function of the ankle joint
Preparation for limb lengthening without destabilizing the joint
Reducing the risk of instability, valgus or spondylolisthesis of the joint
Reduce pain and improve gait quality
Durable functional effects, even with large deformations

4 Author's modifications

At the Paley European Institute, SUPERankle is sometimes combined with:

Correction of foot deformities within the same operation (e.g. forefoot adduction, heel deformities)
Simultaneous insertion of an external device (e.g. PRECICE, Hexapod for planned limb lengthening
Use of special intraoperative 3D imaging methods for precise joint alignment

5. recovery

Hospitalization: 3-5 days
Immobilization in a plaster dressing or orthosis: 6-8 weeks
Gradual loading of the limb after bone fusion is achieved
Rehabilitation aimed at restoring mobility, strength and muscle balance
Return to full activity: usually after 4-6 months

1. indications

Femoral derotation (femoral derotational osteotomy) is performed in patients with abnormal alignment of the femoral axis of rotation - most often with excessive antetorsion (inward twisting) or, less commonly, retrotorsion (outward twisting).

Indications for the procedure include:

Pigeon gait (in-toeing) in children and adolescents that does not resolve on its own,
Rotational deformities after fractures,
Post-traumatic deformities or post-traumatic hip joint lesions,
Secondary changes after neurological conditions (e.g., cerebral palsy),
Worsening instability or pain in the knee and hip associated with abnormal alignment.

2 Mileage

The procedure is usually performed under general anesthesia. It consists of:

incision of the skin and reaching the shaft of the femur (usually in the proximal or distal part),
Cut (osteotomy) of the femur,
Turning the bone fragment in the correct direction (inward or outward) to restore the correct angle of torsion,
Stabilizing the bone with a plate with screws or an intramedullary rod (depending on the location of the osteotomy). The procedure can be performed unilaterally or bilaterally - depending on the needs.

3 Advantages

Restoring proper alignment of the lower limb,
Improving gait biomechanics,
Reduction of pain in the hip, knee or lumbar joint,
Reduce the risk of secondary overload and degenerative changes,
Improving gait and posture aesthetics.

4 Author's modifications

Many centers use modifications of the procedure:

Minimally invasive technique using intramedullary rods (e.g., at the Paley Institute: the Precice Stryde or Nail to Nail rod),
The procedure is combined with other corrections - such as knee valgus correction or foot procedures,
Use of assistive planning technologies (e.g., 3D planning, navigation),
Ability to correct in more than one plane (e.g., rotation + valgus/spine angle).

5. recovery

The patient usually remains in the hospital for 2-5 days,
Initially, it is necessary to move around on crutches,
Loading of the operated limb depends on the type of stabilization - usually partial for 4-6 weeks,
Rehabilitation includes exercising range of motion, strength and learning the correct gait pattern,
Return to full activity usually possible after 3-6 months.

1. indications

Tibial derotation is performed in patients who have pathological tibial alignment - most commonly inward torsion (known as internal torsion) or, less commonly, outward torsion. Indications for the procedure are:

Permanent deformation of the lower limb axis affecting gait (e.g., pigeon walking, stumbling),
No improvement despite the passage of time and conservative treatment,
complaints of pain or secondary strain changes in the knees, hips or feet,

Cosmetic and functional difference relative to the other limb.

2 Mileage

The procedure involves cutting the tibia (sometimes also the fibula) to correct the angle of the torsion. Stages of surgery:

Making a skin incision and exposing the bone,
Cutting the shaft of the tibia (osteotomy),
Rotation of bone fragments relative to each other to the correct alignment,
Stabilization of the new alignment with a plate and screws (or external anastomosis, such as in an Ilizarov apparatus),
Checking the axis of the limb and closing the wound in layers.

3 Advantages

Significant improvement in limb alignment and gait biomechanics,
Reducing pain and the risk of overload joint damage,
Improving the appearance of the limb and the psychological comfort of the patient,
Prevention of secondary deformities and degenerative changes.

4 Author's modifications

Depending on the experience and preference of the operating team, different techniques can be used:

Osteotomy using computer navigation or 3D planning,
Simultaneous correction of other deformities (e.g., knee valgus),
The use of minimally invasive cuts.
Minimally invasive approach without osteotomy of the fibula

5. recovery

For the first few weeks, the patient moves with limb relief and assistance (crutches, orthoses).
Bone healing usually takes 6-8 weeks - during this time the load is gradually increased.
Rehabilitation focuses on regaining full range of motion, muscle strength and learning to walk properly.
Full return to activity takes about 3-6 months, depending on age and type of stabilization.

1. indications

Bilateral hip instability reconstruction is mainly performed in children with congenital or acquired hip instability. The most common indications are:

hip dysplasia (DDH),
Post-traumatic instability,
Instability secondary to neurological diseases (such as MPD),
Lack of satisfactory effect of conservative treatment (Pavlik suspenders, harnesses, orthoses),
Previous failures of surgical treatment.
The decision to operate is based on clinical examination, X-rays, and often MRI and functional tests.

2 Mileage

The procedure is carried out under general anesthesia and often involves several components:

Open repositioning of the hip joint - removal of obstacles blocking proper alignment of the head of the femur (e.g., a hobnail ligament, an oversized acetabulum),
Pelvic osteotomy - usually Dega, Pemberton or Salter, aimed at improving the coverage of the femoral head by the acetabulum,
Femoral osteotomy - correction of the cervicothoracic angle and/or rotation,
Stabilization with implants - plates, screws, flexible nails (ESIN).
The most important aspect of this method is that there is no need for plaster dressings - stability is achieved with modern materials and surgical techniques, which allows the patient to be up and running faster.

3 Advantages

No immobilization in a plaster dressing - fewer skin complications, sores, muscle atrophy.
Faster return to verticalization and rehabilitation.
Reduced discomfort for the child and caregivers.
Possibility of more accurate post-operative control due to free access to the limbs.
Better quality of life after surgery - ability to return to function sooner.

4 Author's modifications

Specialized centers, such as the Paley European Institute, use:

The use of intraoperative X-ray and 3D CT to precisely control implant positioning,
3D reconstruction planning using imaging from MRI and CT scans,
Personalized management of rehabilitation, started as early as the first day after surgery.
complete abandonment of the use of plaster dressings
Minimizing the risk of blood transfusion.

5. recovery

The patient is often uprighted within 1-3 days after surgery.
Rehabilitation begins almost immediately, first in the form of passive exercises, then active exercises.
Children are taught to walk with assistance (balcony, orthoses).
Implants are usually removed after a few months, when the bone adhesions are stable.
Full recovery is possible within a few months, and the results are evaluated long-term (up to 1-2 years).

1. indications

Transverse bone transport (transverse bone transport) is a method of treating hard-to-heal wounds and ulcers in diabetic foot syndrome, especially in cases:

lack of improvement after conservative treatment (antibiotic therapy, dressings, pressure relief),
Chronic ulcers with associated osteolysis of the metatarsal bones or phalanges,
The risk of amputation due to ischemia and tissue infection,
The presence of an ischemic background of lesions with microangiopathy.

2 Mileage

The procedure involves performing an osteotomy of one of the metatarsal bones, usually in its distal part, and then slowly moving the severed fragment laterally (i.e. in the direction of the wound) using an external fixator, such as an Ilizarov apparatus or LRS apparatus.

This controlled micro-transport of bone:

Stimulates angiogenesis (formation of new blood vessels),
Improves local blood supply within the wound,
Promotes wound debridement and granulation formation.
Once the microcirculatory effect is achieved, the transported fragment is stabilized in its new position, and the regeneration process continues naturally.

3 Advantages

Radical improvement in local blood supply without revascularization procedures,
Highly effective in wound healing while minimizing the risk of amputation,
The possibility of also treating patients with comorbidities (e.g., kidney failure, heart disease),
Stimulation of the body's natural regenerative processes without the need for transplants or biomaterials.

4 Author's modifications

In advanced orthopedic centers, it is common to use:

customized modifications of external cameras (including lightweight hybrid systems),
Use of specialized osteotomy techniques (e.g., minimally invasive cuts),
Antibiotic and debridement protocols selected based on microbiology and wound biomechanics.

5. recovery

Wearing time: usually 6-12 weeks, depending on the extent of the transport and the course of healing,
Load on the limb: dependent on the progress of the healing process, often partial from the first weeks,
Outpatient checks: regular (every 1-2 weeks) to assess the position of the transported fragment and the condition of the wound,
After treatment - recommended rehabilitation and appropriate orthopedic supplies (such as pressure relieving shoes) to prevent recurrence.

1. indications

The procedure is indicated for patients with established contracture of the knee joint that limits range of motion, impairs gait or prevents the function of lower limb prostheses. The most common causes of contracture are congenital defects (e.g., arthrogryposis), complications from trauma, infections, previous surgeries or neurological diseases. In cases where there are secondary bony changes or significant displacement of the limb's axis, a combination of soft-tissue surgery and bony intervention is necessary.

2 Mileage

The procedure takes place in several stages:

Capsulotomy of the knee joint - surgical cutting of the joint capsule to release stiff structures, both from the anterior (more often) and posterior (less often, but with significant contractures necessary).
Femoral osteoplasty - modeling or removal of hypertrophied portions of the femur (e.g., the posterior condyle) that block the full straightening of the knee.
Femoral shortening - resection of a section of the shaft of the femur to reduce soft tissue tension and help achieve joint extension. The procedure can be performed as an osteotomy with plate or nail fixation.
If necessary, the procedure is supplemented by lengthening the knee flexor muscles, releasing the sciatic nerve, and reconstructing other periarticular structures.

3 Advantages

Significant improvement in range of motion in the knee joint, especially in extension.
Enabling the patient to move independently or to use orthoses or prostheses properly.
Improving limb alignment and gait biomechanics.
Reduce pain associated with pathological limb positioning.

4 Author's modifications

Centers specializing in pediatric reconstructive surgery, such as the Paley European Institute, often use modifications involving:

Use of modern intraoperative imaging techniques (e.g., 3D navigation) for precise osteotomy planning.
Using implants that minimize the risk of soft tissue irritation.
Using microsurgical techniques to protect the sciatic and fibular nerve.

5. recovery

Hospitalization: usually 2-3 days, depending on the extent of the procedure and the patient's overall condition.
Immobilization: usually in a knee brace in extension for several weeks.
Rehabilitation: started as early as possible, includes manual therapy, passive and active exercises, and learning to walk.
Return to function: full recovery can take several months to a year. In complex cases, further stages of reconstruction or lengthening of the limb are necessary.

1. indications

Osseointegration is an innovative method of treating patients with limb amputations, especially of the thigh or lower leg. This procedure is indicated for patients who:

Have difficulty wearing a conventional prosthesis due to stump soreness, skin irritation or instability of the funnel,
do not achieve satisfactory mobility and comfort with a classic prosthesis,
want to increase ground sensation ("osseoperception") and control of the prosthesis,
Do not have contraindications to a titanium implant (e.g., no active infection, adequate bone quality).

2 Mileage

The osseointegration procedure involves surgical placement of a titanium implant directly into the stump bone. It is a single surgical procedure, divided into two stages.

Stage I - an implant (usually made of titanium) is inserted into the marrow canal of the bone - the so-called endo-module. This stage is followed by several weeks of healing and osteointegration (fusion of the implant with the bone).
Stage II - an external component is brought out through the skin - - to which the prosthesis is attached. This allows the body to be directly connected to the prosthesis, without the need for a funnel.

Rehabilitation begins soon after the second stage - the loading of the limb is gradually introduced.

3 Advantages

No denture funnel - eliminating abrasions, wounds and pain associated with the use of a classic denture,
Improved ground sensation (osseoperception) - patients feel contact with the ground, which affects stability and control,
Increased mobility and freedom of movement,
Faster insertion and removal of the prosthesis,
Improved quality of life - greater independence, reduced pain, easier movement, even barefoot at home.

4 Author's modifications

At our center, the osseointegration procedure is performed as a one-step procedure, which reduces recovery time.

In addition, various implant systems are used.

Personalize the technique according to the length of the stump, the quality of the bone, or the needs of the patient.

It is also common to combine osseointegration with stump-modeling procedures (e.g. skin grafts, soft tissue corrections) or with neurosurgical procedures aimed at reducing phantom pain (e.g. TMR - targeted muscle reinnervation).

5. recovery

After surgery, the patient moves around on crutches, and there is a period of osteointegration (usually 6-8 weeks).
Once the implant has healed - gentle weight-bearing of the limb with the help of a physical therapist, using a temporary prosthesis, begins.
In the following weeks - there is an increase in the use of the prosthesis and the load. Full rehabilitation can take from 3 to 6 months, depending on the individual patient's capabilities. The effects are usually very positive, especially in active patients.

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Operations

Surgical treatment - selected procedures

Forearm bone lengthening

1. indications

2 Mileage

3 Advantages

4 Author's modifications

5. recovery

Reconstruction of the radial-arm joint in MHE

1. indications

2 Mileage

3 Advantages

4 Author's modifications

5. recovery

Release of syndactyls

1. indications

2 Mileage

3 Advantages

4 Author's modifications

5. recovery

Reconstruction of congenital hip dislocation using the RESCUE Hip method

1. indications

2 Mileage

3 Advantages

4 Author's modifications

5. recovery

Policyzation of the index finger

1. indications

2 Mileage

3 Advantages

4 Author's modifications

5. recovery

VDRO osteotomy of the femur

1. indications

2 Mileage

3 Advantages

4 Author's modifications

5. recovery

Supportive osteotomy of the femur

1. indications

2 Mileage

3 Advantages

4 Author's modifications

5. recovery

Upright osteotomy of the femur

1. indications

2 Mileage

3 Advantages

4 Author's modifications

5. recovery

Reconstruction of the knee extension apparatus in patellofemoral joint instability

1. indications

2 Mileage

3 Advantages

4 Author's modifications

5. recovery

Administration of botulinum toxin (BTX) to the iliac-lumbar muscle

1. indications

2 Mileage

3 Advantages

4 Author's modifications

5. recovery

Administration of botulinum toxin (BTX) to the iliac-lumbar muscle

1. indications

2 Mileage

3 Advantages

4 Author's modifications

5. recovery

Release of the iliac-lumbar muscle using the over the brim method

1. indications

2 Mileage

3 Advantages

4 Author's modifications

5. recovery

Posterior tibial muscle tendon transfer

1. indications

2 Mileage

3 Advantages

4 Author's modifications

5. recovery