Dr. Dror Paley
Dr. Dror Paley is a member of our Foundation's Scientific and Medical Advisory Board.  Dr. Paley and our Foundation have jointly
developed educational video project.

Dr. Paley is the director of the Paley Advanced Limb Lengthening Institute at St. Mary’s Hospital in West Palm Beach, Florida. Dr.
Paley was the founder and director of the Rubin Institute for Advanced Orthopedics and the co-director of the International Center
for Limb Lengthening until May 2009.

Please see the
Video Library to view start of this new series of videos.

Dr. Paley is one of the very top limb lengthening surgeons in the world. He has performed more than 10,000 limb lengthening and
reconstruction-related procedures on patients from all over the United States and from more than 70 countries from six continents.

Our foundation would like to thank Dr. Paley for his continuous support of all our foundations efforts and for his leadership in this new
educational video project. We thank Dr. Paley for presenting limb lengthening on behalf of our foundation at the
5th Annual
International Pediatric Orthopaedic Symposium (IPOS) held Dec 2008. Dr. Paley also authored the guides to Multiple
Exostoses / Multiple Osteochondroma of the Forearm and Lower Limb that appear on our website and are also located in
Connection Corner Guide to MHE / MO / HME.

Dr. Paley's new website below (
click this link to go directly to Dr. Paley's site) http://lengthening.us
Dr. Paley serves on the Scientific and Medical Advisory Board of the MHE Research Foundation and was the first  President of ASAMI North
America, Limb Lengthening and Reconstruction Society (LLRS)
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List of Publications via PubMed
(NIH National Library of Medicine)
US National Library of Medicine (NLM) and PubMed
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2009 Conference abstract
Multiple Osteochondromas treatment of the Lower Limb Deformities

Paley, D

Paley Advanced Limb Lengthening Institute, 901 45th Street Kimmel Building West Palm Beach, FL 33407.


There are a variety of problems related to the exostoses of Hereditary Multiple Osteochondromas.  The majority of these problems
relate to bothersome bony protrusions with their affect on surrounding joints, muscles, tendons, nerves, blood vessels and skin.
Osteochondromas can also affect growth plates and lead to limb deformities and length discrepancies.  The focus of this talk will be
on the limb deformities and discrepancies secondary to the multiple osteochondromas.

Treatment of the Lower Limb Deformities

Femero-acetabular impingement
The best way to treat this problem is ‘safe’ surgical dislocation of the hip according to the technique of Ganz from Switzerland. This
safeguards the circulation of the femoral head avoiding avascular necrosis of the femoral head. The osteochondromas can be
resected under direct vision and the femoral head templated with a spherical template to acertain if the femoral head is spherical.
The range of motion of the hip greatly improves after this surgery. It can be combined with a varus osteotomy using a blade plate
for fixation.

Valgus Knee Deformity (Knock knee deformity)
This deformity is usually in the upper tibia.  There is usually a large osteochondroma involving the upper end of the fibula. The
fibular osteochondroma often tethers or envelops the peroneal nerve.  This is a very important nerve that is responsible for
controlling the muscles that pull the foot up and out.  Injury to this nerve results in a drop foot (inability to pull the foot up).  
Correction of the valgus deformity of the upper tibia requires an osteotomy (bone cut) of the upper tibia.  All osteotomies of the
upper tibia to correct valgus stretch the peroneal nerve even in patients without HME.  In patients with HME and a fibular exostosis
the nerve is very tethered and stretched even before surgery.  The nerve can actually be inside the bone if the osteochondroma
envelops it.  Therefore to correct the deformity safely the nerve must first be found above the fibula and decompressed around the
neck of the fibula.  The osteochondroma of the fibula should be resected  If the upper fibular growth plate is considered to be
damaged beyond recovery then a segment of the fibula should be removed so that the two ends of the fibula do not join together
again to prevent re-tethering of the tibia.  Only after all of this is performed can an osteotomy of the tibia be carried out safely to
correct the valgus deformity.  The valgus deformity can either be corrected all at once or gradually.  Correcting it all at once is
usually performed by taking out a wedge shaped piece of bone and then closing the wedge to straighten the tibia.  This can be fixed
in place with a metal plate or with an external fixator. Gradual correction is carried out by minimal incision technique to cut the
bone.  The correction is achieved by use of an external fixator.  This is a device that fixes to the bone by means of screws or wires
that attach to an external bar or set of rings.  Adjustment of the external fixator slowly corrects the deformity.  This opens a wedge
instead of closes a wedge of bone. This has the advantage of adding length to the leg which if the leg is short already is
advantageous.  This type of external fixator is also used for limb lengthening.  Therefore if there is a LLD the angular correction can
be performed simultaneous with lengthening. Gradual correction is safer than acute (all at once) correction for correction of the
valgus deformity.  

Another way to address the valgus knee deformity without addressing limb length discrepancy is hemi-epiphyseal stapling of the
growth plate.  This is perhaps the most minor procedure possible and involves insertion of one or two metal staples on the medial
side (inside) of the growth plate of the upper tibia. The metal staple straddles the growth zone on the medial side preventing
growth of the medial growth plate while permitting growth on the lateral side.  This allows the tibia to slowly autocorrect its
alignment.  It is a very slow process and may require several years.  Once the tibia is aligned the staple can be removed permitting
resumption of growth from the medial side. There is a small risk of damaging the medial growth plate which could lead to a varus
bowing deformity of the tibia. Stapling can also be used in the distal tibia to correct the ankle deformity.  

Valgus deformity of the ankle
Patients complain of walking on the outer border of the foot.  Viewed from behind this posture of the foot is very apparent.  This
deformity is often well tolerated. The lower end of the tibia tilts outwards towards the fibula.  The lower end of the fibula is the
lateral malleolus.  It is important for stability of the ankle.  Since the fibula grows less than the tibia the lateral malleolus is often
underdeveloped leading to lateral shift of the talus (ankle bone).  This can eventually lead to arthritis of the ankle.  Lateral tilt of the
ankle joint is compensated by the subtalar joint (joint under the ankle) by inversion of the foot (turning of the foot in).  Since this is
a longstanding process the subtalar joint becomes fixed in this position of compensation for the ankle joint.  Therefore if one tries
to fix the ankle joint tilt completely the foot will end up tilted inwards and the patient will be standing on the outer border of the
foot.  Therefore one either has to accept the valgus ankle or correct it together with the subtalar joint fixed deformity.  This is best
done with a circular external fixator (Ilizarov device).  This correction involves gradual correction of a minimally invasive osteotomy of
the lower tibia and fibula together with distraction (pulling apart) of the subtalar joint contracture.

Flexion deformity of the knee
This deformity is usually related to tethering or locking of the soft tissues around the knee by distal femoral or proximal tibial
osteochondromas.  The treatment involves resection of the offending exostosis and lengthening of the hamstring tendons if needed.

Flexion deformity of the hip/subluxation of the hip/valgus upper femur
This is treated by resecting the offending osteochondroma of the femoral neck.  This hip capsule has to be opened to access these.  
At the same time to reduce the hip subluxation (hip coming out of joint) a varus osteotomy of the upper femur should be done
(bending the femur inwards towards the joint).  The bone can be fixed either by an internal metal plate or an external fixator.  
Conference abstract book 2009
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