Prof. Dr. Weber Center of Limb Lengthening & Deformity Correction

Licenses :

• German & European Board Certified Orthopaedic & Trauma Surgeon
• Licensed by the Dubai Healthcare City Authority (DHCC), UAE
• Licensed by the Dubai Health Authority (DHA), UAE

This presentation contains some examples of Prof. Weber’s patients treated for limb deformities, deficiencies, discrepancies, malformations, birth defects and focuses on his unique invention to prevent limb amputation and improve limb function.

Fig. 1 A precise deformity correction planning is crucial for successful outcome of surgery

Fig.2 (a) Both legs have valgus deformity along with additional shortening in the right leg.

(b-c) The left side is treated with growth guidance by an 8-plate that temporarily stops the growth at the side of the application while inserted.

(d) After achieving the required results, the plates can be removed and the growth of the side plate resumes. Full weight-bearing is possible at all times. The right leg also has a shortening besides valgus deformity, requiring a combination of deformity correction and limb lengthening with a fixator via callus distraction.

Fig. 3 (a) After tibial growth plate injury in childhood at the ventral proximal tibia this adolescent suffered from a severe recurvatum deformity of the tibia combined with a flexion contracture of the knee.

(b) Both conditions can be corrected with two connected Taylor Spatial Frames (TSF). The upper TSF corrects the knee flexion contracture and subluxation by soft tissue and the lower TSF corrects the tibial recurvatum deformity with callus distraction. The TSF allows full weight-bearing during the treatment.

(c) Clinical picture aftercomplete correction

(d) X-Ray showing severe osseous recurvatum deformity before surgery.

(e) X-Ray showing perfect axis after correction with good callus formation.

Fig.4 (a) An 11-year-old girl with severe O-curved legs of the same degree on both sides due to Morbus Blount. She was treated successfully with TSF of the left leg.

(b) A young man with severe X-curved legs of the same degree on both sides due to Vitamin-D deficiency in childhood. He was treated with ring fixators successfully of the left leg.

(c) A man suffering from severe shortening and deformities of the right leg due to poliomyelitis in childhood. Note the tilted pelvic line.

(d) Same patient (fig.4c) after correction of the shortening and all deformities. Note the pelvic line. He can walk without his brace now.

Fig.5 (a) Severe type of fibular hemimelia with severe shortening, tibial deformity and ankle instability.

(b-c) Osseous wedge osteotomy with reverse transplantation of bone-wedge above the oblique tibial growth plate giving an acute correction of the tibial deformity and ensuring further straight growth of the tibia due to acute correction of the ankle joint line axis.

(d) Simultaneous lengthening at the proximal tibia.

(e) The acute wedge correction and lengthening of the tibia is supported by a mini-ring-fixator, a smaller version of fixator allowing treatment also on infants. Prof. Weber was the first who used the mini-ring-fixator in Germany. This picture shows the fixator after 10 cm lengthening and before removal. The anchor wire and central tibia wire fixating the wedge osteotomy was removed already.

Prof. Weber invented a unique technique to create a lateral malleolus that is missing in severe types of fibular hemimelia to prevent a luxation of the foot during lengthening or to treat severe ankle instability. In this technique, a triangular free iliac crest transplant with adhering gluteal fascia is mobilised from the patient’s iliac crest and transplanted into the missing lateral malleolus of the ankle joint. The transplant with the apophysis (cartilage which is responsible for growth) ensures further temporary growth (in average 3 years). The defect at the iliac crest is healed itself. The transplanted gluteal fascia is working as stabilizing the lateral ankle tendon. The advantage of the procedure is that it gives permanent stability to the ankle joint for the lengthening and during the further growth of the leg. No luxation has been observed after this procedure.

Fig.6 To prevent a luxation of the foot during lengthening or to treat a severe ankle instability, Prof. Weber invented a unique technique to create a lateral malleolus which is missing in severe types of fibular hemimelia or if present it is not sufficient enough [8]. For this technique a triangular free iliac crest transplant with adhering gluteal fascia is mobilized from the patient’s iliac crest and transplanted into the missing lateral malleolus of the ankle joint. The transplant with the apophysis (cartilage which is responsible for growth) ensures further temporary growth (in average 3 years, upto 5 years). The defect at the iliac crest is healing by itself. The transplanted gluteal fascia is working as a stabilizing lateral ankle tendon. The advantage of this procedure is that it gives permanent stability to the ankle joint for the lengthening and during the further growth of the leg. No luxation has been observed after this procedure

(a) Incision is made to implant a skin expander.

(b) With a skin expander the skin can be expanded by filling the balloon with fluid through a syringe. With the needle of the syringe, the port (white rubber circle) of the skin expander is punctured every week and a certain volume is applied. Usually, after six weeks the skin has grown enough to cover the transplant.

(c) X-ray: Ongoing lengthening with ring fixator after malleolus transplantation.

(d) X-ray: Tibial bone after deformity correction, malleolus transplant and 10 cm lengthening.

(e) X-ray: Detail of malleolus transplant at ankle joint.

Fig.7 The foot has no normal joint between talar and calcaneal bone but a solid osseous fusion. This leads beside a missing motion in the lower ankle joint to a lateral shift of the foot with a severe imbalance of the mechanical axis. Additionally, the joint line of the ankle is about 15 degrees’ oblique which increases the axis problem.

(a) Frontal X-ray of the foot and ankle with the described malformation and deformities.

(b) For treatment of the talocalcaneal fusion, the bony bridge between the talus and calcaneus is cut and the calcaneus shifted into the corrected position

(c-d) The upper ankle joint shows a valgus deformity of 15 degrees.

(e) With a dome osteotomy, the deformity is corrected acutely. All corrections are done with a TSF application where all deformities were corrected and the lower limb leg discrepancy equalized. The clinical pictures are shown in Fig. 8.

Fig. 8 (a) This patient has undergone a Weber-Malleolus-Plasty, deformity correction of the tibia and 10 cm lengthening of the lower limb before. (b) The foot and ankle show the deformities described above.

(c) After correction of ankle deformity and the talocalcaneal fusion including, the second lengthening of 7 cm the foot is perfectly aligned with the mechanical axis of the leg and the leg length discrepancy is equalized.

(d-e) The range of motion of the upper ankle joint is very good.

Fig. 9 Prof. Weber’s classification of Tibial Hemimelia [3] with the main twelve different types according to the severity of the malformation and respecting the cartilaginous anlage discovered by Prof. Weber (black = bones; blue = cartilaginous anlage)

Fig. 10 (a) The child has all four limbs malformed.

(b) After lengthening with a Mini-Ring-Fixator and performing the Weber-Transformation-Surgery (patella is used as a tibial plateau, the fibula is used as the tibia) for creating a knee joint and a tibia on the right leg the patient has full weight-bearing with a very good range of motion.

(c) The affected left leg was also treated successfully Worldwide this technique is the only procedure preventing lower extremity limb amputation in children suffering from type VII-b Tibial Hemimelia.

(d)The treatment of the hands was performed later and the boy was able to play soccer after that.

Fig. 12 The Congenital Crural Segmental Dysplasia (CCSD, also called congenital tibial pseudarthrosis) is one of the most challenging diseases in paediatric orthopaedics. In the literature you will find that most of the cases were treated unsuccessfully more than 20 times and are often ending with amputations [9,12]. One of the reasons for insufficient results is that this disease is misdiagnosed[13] as a normal fracture in childhood. Own researches have shown that the periosteum (bone skin) which is normally responsible for bone growth and nutrition shows severe pathological changes not fulfilling any longer this task. The blood supply and nutrition of the bone are disturbed by the pathological periosteum which weakens the bone until it gets fractured. Additionally, this pathological periosteum prevents the fractured bones from healing. In Germany, Prof. Weber has treated most cases with a success rate of over more than 95%. The reason for the excellent result lies in a well-defined treatment concept that originates from the results of the researches according to the origin of the disease as well as its proprietary techniques[2,5].In Dr. Weber’s classification (Fig. 12) the main different types of CCSD are represented with the focus on appropriate treatment options regarding each different type. For the first time in the literature the importance of the fibula is respected. Type a represents an intact fibula, type b represents a broken fibula.

Fig. 13 (a) A 5-year-old boy suffering from a Type-Vb CCSD with fracture and pseudarthrosis of the fibula and tibia.

(b) The model shows the principle of the Weber-Cable-Technique. A cable is attached to the bone segment which will be transported and directed internally along with the bones and led out to pulleys. These pulleys redirect the cable to distractors mounted on the ring fixator. By turning the distractors, the mobilized bone segment can be transported internally (1mm/day) after a callus (red) has formed. The transport is stopped when the bone defect is closed. The callus will maturate into normal high-quality bone tissue. The docking of the transported bone segment with the opposite bone heals like a fracture.

(c) X-Ray showing fracture and pseudarthrosis of the lower leg.

(d) X-ray of ongoing cable transport before docking. Good callus formation.

(e) X-ray showing complete permanent healing of the pseudarthrosis.

Fig. 14 (a) The patient undergoing the bone transport after resection of a bone tumour can have the full weight bearing on the leg because the bone fragments are stabilized with a ring-fixator (patients with ring-fixators can walk, go to school or university, do household work or work in an office etc.).

(b) The X-ray picture shows the two bone cuts to mobilize both bone segments for bifocal transport and the bone defect of 12 cm is closed in 60 days. At these bone cuts, the bone attempts to heal by producing a healing tissue called callus. This callus is soft and can be extended.

(c-d) With the attached cables at both bone ends the bone segments can be pulled towards each other at a growth rate of 1mm a day. Once the bone ends have reached each other (docking) the transport is stopped and the bone can heal together at the docking area.

(e) In the gaps of distraction, the callus produced by the bone maturates to high-quality own bone tissue

Fig. 15 (a) This young man had a severe sports injury with damage to his talar bone. In the following years, he developed necrosis of the complete bone and cartilage so that it had to be removed. With Weber’s TCNC-Arthrodesis it is possible to give the foot stability again and to enable the patient full weight-bearing and to return to sports.

(b) With the ring fixator, the tibial bone can be osteo-synthesized to the calcaneal, navicular and cuboidal bone after resection of the talus. Additionally, with the fixator, the resulting shortening of the bone can be equalized by lengthening the tibia simultaneously.

(c) Schematic drawing of the resection of the talus and affected joint cartilage.

(d) TCNC-Arthrodesis. e. Postoperative X-ray of the successful Arthrodesis. Prof. Weber’s TCNC-Arthrodesis was awarded during the 22nd SICOT Conference in Sydney, Australia. This proprietary technology can be used to prevent amputations in all ailments where the talus has to be removed due to infection after failed ankle arthrodesis, necrosis due to trauma or in the diabetic foot, tumor, neurological or congenital diseases for stabilizing the foot[11,16]..

Fig. 16 (a) A young lady who suffered from a birth defect of her fourth metatarsal bone. Due to its shortening, the healthy digits are shifting already into the resulting gap. This leads to pain and problems with shoe wearing. See the interrupted midfoot arch line (red wave).

(b) After cutting the bone in the midshaft a mini-ring-fixator is applied to perform the lengthening.

(c) The X-ray shows the corrected length of the toe and midfoot arch. The patient can wear normal shoes and do sports. The development of secondary deformities of the healthy digits is prevented

Fig. 17 (a) X-ray, this 7-year-old boy was suffering from a complete malformation and hypoplasia of the first ray left (red arrow). The digits 2 – 5 are deviating into the gap of the short first ray (white arrows).

(b) After realignment of the three bone segments of the first ray, the metatarsal bone is lengthened with a mini-ring-fixator.

(c) The X-ray shows the reconstructed first ray with corrected length. The toe deviation 2-4 have started correcting itself.

(d) The result after removal of the fixator

Fig. 19 Schematic drawing shows the different treatment options of clubfoot according to the age of the patient and the severity of disease which Prof. Weber is performing successfully for 24 years. If the patient is treated immediately after birth in most cases the foot can be corrected with several casts according to the Ponseti method and only minor surgeries like Achilles’ tendon lengthening is needed. So much older the patients, so more rigid the deformity, so more invasive the surgery. These surgeries range from peritalar release to fixator treatment without or with osteotomies of the deformed foot bones. During all different kinds of treatments, physiotherapy is always included in the treatment concept as well as custom made special braces to reduce the risk of reoccurrence.

Fig. 20 (a-b) This seven-year-old boy suffered from severe deformed neurological clubfeet due to spina bifida. His feet were twisted and he was walking on the back of his feet.

(c) The ring fixator treatment was done according to the principles of the Ponseti method correcting the different deformities step by step with several pain-free re-mountings of the fixator in the outpatient clinic.

(d) The postoperative result is perfect. For prevention of recurrence of club foot and to compensate the paralyzed feet muscles the patient has to wear a stabilizing inner shoe.