PFFD

Therapy

The treatment of PFFD is very complex. Depending on the difference in leg length, knee instability and hip mobility, a completely individualized treatment plan is required. Concomitant anomalies must also be taken into account.

In early childhood, it should be attempted to achieve and preserve good hip, knee and ankle mobility. In addition to physiotherapy, correcting casts can be put on in childhood in order to hold a joint in flexion or extension—depending upon extent and type of the malformation and the desired correction.

Approximately at the age of one year, the young patient can be provided with an orthoprosthesis, which allows him/her to learn how to walk at an age-appropriate time despite the existing leg length discrepancy and hip and knee contractures.

At this time, the possibility of later surgical treatment should also be discussed. If a femoral head is present and shows mobility, then there are surgical options to correct the malposition. At the same time, a correction of the malformed acetabulum is possible. Later on, the leg may be lengthened by means of an external ring fixator or a unilateral fixator.

This procedure may have to be repeated several times, depending on the difference in leg length. Knee instability should also be addressed as early as possible, preferably prior to the repeated lengthening procedures. If the femoral head is not mobile and leg lengthening is out of the question, the focus will be on selecting the optimal prosthesis for the patient. This can be achieved by different methods. One possibility is to stop growth on the affected side in order to have the foot at the level of the healthy knee. Another possibility is performing a rotationplasty. However, this may be psychologically disturbing for both the child and family members.

New surgical lengthening methods for this type of PFFD exist, but long-term results are not yet available.

Physiotherapy for PFFD

There is no one-size-fits-all treatment for PFFD. There are far too many manifestations of this malformation. The support of an experienced and well-trained therapist is indispensable. If physiotherapy is not done correctly, it can actually be harmful.

Physiotherapy should be started very early, ideally shortly after birth. Different treatment methods are available.

Manual therapy

Manual therapy (using the Kaltenborn/Evijent or Maitland approach) is essential in order to maintain or improve hip, knee and foot mobility.

In the first few months, it is recommended to perform traction at the hip. Traction should also be performed at the knee. In addition, in the case of an existing knee instability, a ventral gliding technique should be applied on the knee in order to improve extension.

If the foot is also affected by fibular hemimelia, the lateral instability should be treated as well. Here, traction on the calcaneus (heel) is recommended.

These treatments should be supplemented with soft tissue techniques (hip stretching into extension, stretching the knee flexors, and stretching the calf muscles as well as the Achilles tendon).

Vojta therapy

Vojta therapy is an excellent method to prevent damage to the spine due to asymmetries and to optimally prepare the child's muscles for standing upright.

Due to unequal weight distribution (legs), kicking, crawling, being on all fours or standing and walking produce asymmetrical stress on the spine and thus cause considerable problems and damage. These secondary damages can already cause back pain and other problems in young children, around the age of 10–12 years.

In order to prevent this, Vojta therapy should be performed by parents on their own, several times a day, after appropriate instruction by a therapist.

Bobath therapy

This therapy form provides development-promoting support and assistance to affected children. This can be very helpful, in particular at the time the child is provided with his/her first orthoprosthesis. It should be noted that forcing physical strain before a potentially necessary hip surgery or in the case of a child without an orthoprosthesis is not advisable. The condition of the hip does not permit this, and the axis of the leg is not sufficiently stabilized without orthosis. For this reason, children receive their first treatment once they begin to stand upright.

Focal points of physiotherapeutic treatment

In the first year of life until the first lengthening, treatment focuses on the following:

  • Manual therapy to improve hip and knee mobility
  • If an additional fibular defect exists: manual therapy to improve foot mobility
  • Traction at the hip/knee
  • Translation of the knee (ventral gliding) to improve knee extension (in consultation with the treating physician—knee instability)
  • Soft tissue techniques for stretching the hip flexors and improving hip extension, as well as stretching the knee flexors to improve knee extension
  • Prevent/improve an asymmetry of the spine
  • Vojta therapy
  • Development-promoting Bobath therapy which provides assistance in coping with everyday life (e.g. playing with orthoprosthesis, provision of therapeutic appliances and much more)