SUPERankle (Super Ankle) - DNB Orthopaedics

What is SUPERankle?

Background - Fibular Hemimelia

• Anteromedial tibial bowing
• Equinovalgus foot deformity (with or without absent lateral rays)
• Ball-and-socket ankle joint (due to tarsal coalition)
• Ankle and knee instability
• Leg length discrepancy (LLD)
• Femoral shortening / coxa vara / PFFD
• ACL insufficiency
• Skin dimpling over the tibia

Steps of the SUPERankle Procedure

1. Step 1 - Excision of fibrocartilaginous fibular anlage
   • The anlage is a fibrous remnant of the absent fibula
   • It tethers the ankle and tibia, producing progressive valgus deformity
   • Removal facilitates subsequent lengthening and prevents recurrent valgus
2. Step 2 - Lengthening of peroneal tendons and Achilles tendon
   • Peroneus brevis is lengthened (in a conjoined tendon, it attaches to the lateral calcaneus)
   • Achilles tendon lengthening corrects equinus deformity
3. Step 3 - Decompression of peroneal and posterior tibial nerves
   • Prevents nerve damage from the deformity correction
4. Step 4 - Talus reshaping (in dysplastic ankles - added 2009)
   • Normally the talus has a cylindrical joint surface
   • In dysplasia, the talus is flattened, causing impingement anteriorly (dorsiflexion) and posteriorly (plantarflexion), severely limiting ROM
   • Dr. Paley described groove deepening at the front and back of the ankle to allow the tibia to rock freely on the talus, improving ROM
   • The calcaneus may also be reshaped
5. Tibia bowing correction (if present):
   • If combined with lengthening: correction is gradual using an external fixator
   • If without lengthening: a wedge osteotomy is performed, fixed with internal pins and cast

SUPERankle vs. Syme Amputation

Key Exam Points

• SUPER = Systematic Utilitarian Procedure for Extremity Reconstruction
• Invented by Paley, 1996
• Indicated in fibular hemimelia (Paley types 3 & 4)
• The fibular anlage must always be resected - it causes valgus deformity and tethers lengthening
• Talus reshaping modification added in 2009
• Can be combined with limb lengthening (external fixator) or done as a standalone procedure
• The procedure achieves a plantigrade foot (flat on the ground) without amputation
• Campbell's Operative Orthopaedics, 15th Ed. 2026, Fibular Hemimelia section
• Miller's Review of Orthopaedics, 9th Ed., Tibial Bowing/Fibular Hemimelia
• Paley Institute - SUPERankle
• Orthopedic Reviews - SUPERankle in Fibular Hemimelia

SUPERknee (Super Knee) - DNB Orthopaedics

What is SUPERknee?

• Congenital Femoral Deficiency (CFD) - formerly called Proximal Femoral Focal Deficiency (PFFD)
• Fibular Hemimelia (FH)
• Tibial hemimelia

Historical note: The "SUPER" name originated as a billing code for the SUPERhip (a multi-step procedure with multiple CPT codes). The SUPER prefix was then backronymed. John Birch of Dallas prefers to call these "Paley hip/knee/ankle" procedures.

Why is SUPERknee Needed?

1. Cruciate ligament hypoplasia/absence - ACL and/or PCL deficient → knee instability/subluxation
2. Knee flexion contracture - tight posterior capsule and hamstrings
3. Patellar malalignment - patella not centred, may be subluxated or hypoplastic

Three Goals of SUPERknee

1. Reconstruct the knee ligaments (ACL and PCL) using fascia lata
2. Correct knee flexion contracture (posterior capsulotomy + knee flexor releases)
3. Realign the patella (Grammont patellar tendon realignment + lateral release)

Steps of the SUPERknee Procedure

Step 1 - Fascia Lata Harvest and Preparation

• The fascia lata is harvested from its musculotendinous junction proximally down to its insertion at Gerdy's tubercle on the tibia
• Split longitudinally into two ligaments (FL1 and FL2)
• The posterior half (FL2) is tubularized with non-absorbable suture using a Krackow whipstitch

Step 2 - ACL Reconstruction: MacIntosh Extra-articular + Intra-articular (FL1)

• Extra-articular component (MacIntosh technique): FL1 is passed from Gerdy's tubercle, under the lateral collateral ligament, and around the intermuscular septum
• Intra-articular component: FL1 is then passed under the intercondylar fossa (the notch between the femoral condyles), through a tibial tunnel, and fixed with an interference screw
• A notchplasty is performed first because dysplasia of the distal femur in CFD/FH causes a narrow notch that would pinch the intra-articular ACL graft

Step 3 - PCL Reconstruction: Reverse MacIntosh / "Paley's Ligament" (FL2)

• This is the Paley modification - sometimes called "Paley's ligament"
• FL2 is passed under the patellar tendon, then around the medial retinaculum, and through the intermuscular septum
• FL2 is sutured back onto itself, creating an extra-articular PCL

Step 4 - Patellar Realignment (Grammont technique)

• Lateral release of the patella
• Grammont patellar tendon realignment to centre the patella
• In severe cases: modified Langenskiöld (Paley) procedure for patellar reduction

Step 5 - Posterior Capsulotomy + Flexor Tendon Releases

• Addresses knee flexion contracture
• Posterior capsule is released
• Tight hamstrings and other knee flexors are lengthened as needed

SUPERknee in Context: Indications by CFD Type

The SUPER Procedure Family (Paley)

Key Exam Points

• SUPER = Systematic Utilitarian Procedure for Extremity Reconstruction (Paley)
• SUPERknee invented 1994 by Paley (earlier than SUPERankle 1996)
• Three goals: ligament reconstruction + flexion contracture correction + patellar realignment
• Graft: Fascia lata split into FL1 (ACL) and FL2 (PCL/Paley's ligament)
• ACL = MacIntosh technique (extra-articular) + intra-articular component
• PCL = Reverse MacIntosh / Paley's ligament (extra-articular)
• Notchplasty is required because of dysplastic narrow intercondylar notch
• In CFD: SUPERknee must be done before limb lengthening
• In fibular hemimelia: SUPERknee required only if knee subluxates in full extension or is symptomatic