Proximal Femoral Focal Deficiency

1. PRIYANKA RAWAT, ROHAN GUPTA
BPO Final year
PDU NIPPD

2. INTRODUCTION
 The new term for PFFD is LDFP i.e., longitudinal
deficiency of the femoral, partial
 LDFP is a complex congenital absence of part or all
the femur that is associated with other lower limb
soft tissue and osseous abnormalities.
 It may be unilateral or bilateral.
 Hip joint is variably involved ranging from normal
to complete absence of both side joints.

3. ETIOLOGY
 Unknown
 Various embryonic & teratologic etiologies have been
proposed, these include
- vascular epiphyseal disruption,
-infection
-medication like thalidomide.

4. CLINICAL PRESENTATION
 Shortened lower limb
 Thigh is thickened and funnel shape[ship’s funnel
appearance]
 Fibular deficiencies
 Foot deformities
 Spine, heart, upper limbs may also be involved
 The affected lower limb is generally held in flexed,
abducted, and externally rotated position.
 Children tend to use modified gait such as walking on the
knee, on the sound side or flexing the sound side hip and
knee.

5. CLASSIFICATION OF PFFD
 Most commonly used classification is ATIKEN
classification
 LDFP was classified into 4 types by radiographic
appearance of the proximal femur and acetabulum.

7. TREATMENT OPTIONS
There are numerous options of treatment for LDFP.
Several important orthopaedic issues should be considered
when formulating a treatment plan. These are:-
 Ultimate limb length descrepency
 Joint instability
 Inadequacy of musculature
 Malrotation
 Functional need, cosmesis, bilaterality must also be considered.
treatment
Surgical Non-surgical

8. SURGICAL TREATMENT
 Ankle disarticulation:-
 Knee arthrodesis with food ablation
 Femoral –pelvic fusion[Brown procedure]
 Van Ness rotation plasty
 Amputation.

9.  ROTATIONPLASTY
Another alternative for enabling the use of BK
prosthesis.
Rotation plasty was first described in 1930 by
Borggreve, who performed a rotation
through the femur.
Van ness described his technique in 1950,
rotating the foot 180 degree through the
tibia so that the toes point posteriorly and
ankle function as knee.
The gastrocnemius-soleus complex act as an
extensor of the new knee and can help
to limit heel rise of the prosthetic lower
segment.
The rotationplasty may gradually derotate
with growth.
The rotationplasty is cosmetically
unacceptable to many patient because of
the reversed

11. NON-SURGICAL TREATMENT
 LDFP presents unique anatomic challenges for prosthetic fitment.
 The aitken categories of A,B,C and D help to organize the required
prosthetic treatment in accordance with level of severity of
involvement.
AITKEN TYPE A
 Treatment will depends on the total length of the femur compared with
the opposite side and must take into consideration any associated
anamolies.
1. A shoe lift

12. 2. Prosthosis
3. A plantigrade AFO that is attached to a pylon with adjustable pyramid
components for alignment, connected to a SACH or seattle foot.
4. If a fibular deficiency that results in a valgus ankle deformity is present,
then the orthosis will contribute stability.
5. Another design places the anatomic foot in equinus position to reduce
the height difference and cosmetically conceal the foot.

13. AITKEN TYPES B, C, D
 Aitken type B,C,D are anatomically difference have common prosthetic
solution. Soon after the birth the surgical decision to amputation is
made.
 Typical treatment is a syme’s procedure that leaves the affected side of
approximately the same level as the knee on the opposite side
 The surgery is recommended during the 1st year to enable the child to
begin walking at an age appropriate time. A knee joint may be
introduced.

14.  The design of the socket is
unconventional because of unique
shape of the limb.
 The important goal is to maintain
total contact fit for maximum
transfer of load to supplement
end bearing.
 Both quadrilateral and ischial
containment sockets can be given.
The anterior wall encloses the bundle
of muscles, the bulk of which is
inversely proportionate to the length
of the femur and the altitude of
flexion/extension at the knee.

15.  After surgical fusion of knee the anterior thigh bulk is reduced, the
lateral wall can remain high for hip stability. It act as stable lever arm.

16. SUSPENSION
 the use of an expanded polyethylene foam liner or a
window for the syme’s conversion may be adequate if a
bulbous end is present . An inner flexible bladder is
another option.
 Silesian belt or TES belt is the main auxillary
suspension
 Suction socket is generally not a realistic approach
because of the unique shape of the residual limb.
 A hip jt. With a pelvic band is also uncommon, but it
may be indicated for a grossly instable hip or extremely
short residual limb.

17. KNEE JOINT
 While implementing the first knee, outside
hinges are usually the only way to match knee
height to the opposite side.
 When the space allows, a four bar knee offer
advantages in cosmesis, durability and function
but placement is still often lower than the
opposite side.
 More severe categories of LDFP with less hip
stability can benefit from a hydraulic knee,
which offers better control in gait.
TRANSTIBIAL AMPUTATION IS AVOIDED
• There is a risk of bony overgrowth that may
necessitate another TT amputation.

18. Gait pattern for LDFP patient-
 The more normal the hip jt. And the longer the femur, the smoother
the gait will result.
 Stride length is affected if the knee heights are not same.
 Vaulting to clear the toe is also a common gait deviation.
 Because the thigh is abducted, flexed, and externally rotated, the leg is
advanced by the adductors and sartorius, coupled with a pelvic twist.

19. THANK YOU