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EDITORIAL
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 1-2

Why are deformity concepts still not a mainstream part of orthopedics?


1 Paley Institute, 901 45th St., West Palm Beach, Florida 33407, USA
2 Paley Institute, 901 45th St., West Palm Beach, Florida 33407

Date of Web Publication17-May-2016

Correspondence Address:
Dror Paley
Paley Institute, 901 45th St., West Palm Beach, Florida 33407
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-3719.182566

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How to cite this article:
Paley D. Why are deformity concepts still not a mainstream part of orthopedics?. J Limb Lengthen Reconstr 2016;2:1-2

How to cite this URL:
Paley D. Why are deformity concepts still not a mainstream part of orthopedics?. J Limb Lengthen Reconstr [serial online] 2016 [cited 2019 Jul 17];2:1-2. Available from: http://www.jlimblengthrecon.org/text.asp?2016/2/1/1/182566




Since 1741, deformity was at the essence of orthopedic surgery and was even reflected in the name given it by Nicholas Andry, "Orthopaedics: Straightening children." Deformity was the sequelae of many orthopedic conditions including trauma, growth disturbances, infections and neuromuscular conditions. Even arthritic conditions were best known for the deformities they created. From the 1970's to 1980's when joint replacement and sports medicine gradually became the most mainstream parts of orthopedic surgery, the understanding and treatment of deformity rapidly lost its central role in orthopedic surgery. Many of the most crippling and deforming diseases, such as polio and tuberculosis, were prevented and the vast knowledge of treating these deforming diseases was forgotten. Osteotomy surgery became increasingly unpopular. Both industry and training programs focused more of their efforts on trauma and arthroplasty and less on osteotomy solutions. Deformity surgery got its renaissance with the introduction of the Ilizarov technique. The consideration of gradual correction of even very severe deformity, and the accuracy of correction with external fixation, opened a new chapter of deformity surgery and possibilities. The Ilizarov technique got introduced to Western Europe in 1981 via the Italian groups from Lecco, Bergamo, and Milan. It did not see its debut in North America until 1987 when I introduced it first to Canada and then to the USA in the same year.

At the time of introduction of the Ilizarov method, deformity surgery was primarily performed by acute correction using closing wedge osteotomy with internal fixation. I was taught deformity by rules such as: correct valgus deformity of the knee with a varus osteotomy of the distal femur and correct varus deformity of the knee with a valgus osteotomy of the proximal tibia. There were arbitrary rules about how much correction could be done with any osteotomy. Severe deformity was often treated with amputation. There were no objective criteria to guide the surgeon based on geometry or principles.

This all changed in early 1987 because of the Ilizarov apparatus. This apparatus uses hinges to correct angular deformity. When I first started using this apparatus, while I was working at a Hospital for Sick Children in Toronto, I tried to place the hinge at the apex of the deformity. This was easily done for diaphyseal deformities since the apex is obvious. With metaphyseal deformities, the Russians would always place the hinge just metaphyseal to the adjacent ring. It seemed to me that the hinge point should not always be at the same level. I strove to identify a geometric point that corresponded to the apex of deformity in the metaphyseal-epiphyseal parts of the bone. I decided that to do this, it would be necessary to work off of the joint lines. In diaphyseal deformities, it was possible to characterize the axis lines of the bone using the mid-diaphyseal lines. The intersection point of the upper and lower mid-diaphyseal lines, I called the Center of Rotation of Angulation (CORA). This point corresponded to the placement of the hinge. With metaphyseal deformities, it was not possible to draw a mid-diaphyseal line representing the metaphyseal segment. A few years earlier (1983), I had read Ken Krakow's article on joint orientation. In this publication, he discussed that the joint orientation of the lower femur and upper tibia was very specific. I quickly realized that the joint orientation angles could be used to generate the corresponding axis line for the metaphyseal segment of the bone. This was the beginning of the CORA method of planning. Over the next 2 years, I tested out this method on hundreds of radiographs. Review of the literature and our own study identified the average range of joint orientation angles for the hip, knee, and ankle in both frontal and sagittal planes. What remained was to create a nomenclature for these angles. I named them according to the side of the bone (anterior, posterior, medial, and lateral), level in the bone (proximal vs. distal), and name of the bone (femur, tibia). This simple to remember nomenclature has stuck and is used throughout orthopedics. With these angles, it was finally possible to identify if a valgus deformity of the knee was from the distal femur or proximal tibia. An objective reason to correct the deformity in the femur or tibia was based on the joint orientation angles (medial proximal tibial angle and lateral distal tibial angle) measured relative to the normal range. I published the CORA planning method for the first time in 1992. This culminated in the publication of my book "Principles of Deformity Correction" in 2001. The nomenclature is now accepted worldwide and is the standard way to refer to joint orientation angles. The CORA is also a well-recognized concept. The diffusion of the deformity concepts has been slow and steady since then. Nevertheless, it is less than one might expect for such important concepts. Why has this deformity knowledge taken a back seat and not been popularized and taught more than it is?

I think that the blame goes primarily to the external fixator. Most surgeons shy away from using external fixators unless there is no other choice. The deformity concepts have been linked with to external fixation, and many consider that if they don't use external fixation, they don't need to know these deformity principles. Mainstream orthopedics is more interested in arthroplasty and sports medicine and less so in deformity and osteotomy. Deformity and osteotomy are not taught well in most orthopedic residency programs. Perhaps, this is true around the world to a lesser extent. Treating deformity is associated with high complication rates and greater postoperative follow-up, and the need to know much more than is required for performing arthroplasty surgery. It is therefore less attractive to practicing orthopedic surgeons to develop a deformity/osteotomy practice than an arthroplasty one. Industry too drives this interest. There is so much money invested in arthroplasty compared to other aspects of orthopedic surgery. Greater industry support for arthroplasty implants vs. osteotomy implants, translates into less incentive to pursue osteotomy surgery vs. arthroplasty surgery. In the end, it is the lack of teaching deformity surgery during the apprenticeship of residency that promotes continued lack of interest in this field. To change this mindset, we need to educate future generations of residents in deformity/osteotomy surgery. To accomplish this, we need to get surgeons who specialize in arthroplasty, sports medicine, foot and ankle, orthopedic trauma, pediatric orthopedics, etc., to learn that these concepts apply equally as importantly to each of their fields. We need them to help promote and teach deformity principles to residents and fellows. Understanding deformity principles needs to be part of the foundation of orthopedic teaching. If we only teach this to those who have indicated an interest in deformity, we are preaching to the choir and are not making these concepts as ubiquitous as they should become.



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[Pubmed] | [DOI]



 

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