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PubMed This is a summary of 15 peer-reviewed journal articles Updated
Pediatric Orthopedics · Proximal Femoral Focal Deficiency

Treatment Strategies: Lengthening, Rotationplasty, and Prosthetics

At a Glance

Treatment for Proximal Femoral Focal Deficiency (PFFD) depends on the predicted leg length difference. Limb lengthening is generally used for differences under 20 cm, while rotationplasty or amputation offer highly functional, efficient mobility for larger differences.

Choosing a treatment path for PFFD/CFD is not a one-size-fits-all decision. Instead, it is a journey that depends on the severity of the deficiency and your family’s goals for your child’s mobility. Doctors generally look at the predicted Limb Length Discrepancy (LLD) at maturity to help guide this decision [1][1].

The Reconstructive Path: Limb Lengthening

If the predicted difference in leg length is under 15–20 cm and the hip joint is stable, your team may suggest reconstruction [2]. This path aims to make the two legs equal in length through a series of surgeries.

  • The SUPERhip Procedure: Before lengthening can begin, the hip must be strong. In many cases of PFFD, the hip is “unstable” or has a deformity called coxa vara. The SUPERhip surgery realigns the hip and uses hardware (and sometimes specialized bone grafting) to create a stable “foundation” for future lengthening [3][4].
  • The Timeline: The SUPERhip stabilization is often done around age 2 to 3. The first actual limb lengthening procedure typically begins between ages 4 and 6, when the bone is strong enough to handle the hardware [5].
  • The Lengthening Process: Once the hip is stable, the femur is lengthened, often using an external fixator (a metal frame outside the leg) or a motorized intramedullary nail (an internal rod) [6][7].
  • The Commitment: Reconstruction is a multi-year process. It typically requires 3 to 4 separate lengthening surgeries over the course of a child’s growth, with each procedure requiring months of healing and physical therapy [5][7].

The Functional Path: Rotationplasty and Prosthetics

If the predicted difference is greater than 20 cm, or if the hip cannot be stabilized, lengthening may not be the most functional choice. In these cases, surgery is used to make the limb a “perfect fit” for a high-activity prosthesis [8].

  • Van Nes Rotationplasty: This is a specialized surgery where the limb is shortened, and the lower leg is rotated 180 degrees before being reattached. This allows the child’s ankle joint to function as a knee joint [9].
    • The Benefit: Because the ankle now bends like a knee, children can use their own muscles to control a prosthetic leg. It is energetically more efficient than a standard amputation, meaning the child uses less energy to walk or run [10][11].
    • The Appearance: A backward foot can be difficult to visualize at first. However, in clothing, the prosthesis fits seamlessly over the foot and looks exactly like a typical leg. Watching videos of children running and playing with rotationplasty often brings tremendous emotional relief to parents.
  • Syme or Boyd Amputation: In some cases, the best path is to remove the foot (at the ankle) [12]. Surgeons may additionally perform a knee fusion (knee arthrodesis). Fusing the knee turns the upper and lower leg into one single, strong lever, allowing the child’s hip to effectively power a standard above-knee prosthesis [13].

Making the Decision

It is common for parents to feel an “emotional weight” when discussing rotationplasty or amputation. It is important to know that these procedures are not “failures”—they are strategic choices to give a child the most active life possible with the fewest number of surgeries [1].

Factor Limb Lengthening Rotationplasty / Amputation
Surgical Burden High (multiple stages, years of frames) [5]. Lower (usually 1–2 main procedures) [9].
Mobility Goal Two feet on the ground [2]. High-activity sports & stability [11].
Appearance Leg looks “typical” but may have scars [14]. Foot is rotated/removed; prosthesis covers it in clothes [9].

Ultimately, whether you choose reconstruction or a prosthetic-based path, children with PFFD grow up to be mobile, independent, and active. Studies consistently show that long-term quality of life is excellent regardless of which surgical path is chosen [15][14].

Common questions in this guide

How do doctors decide between limb lengthening and rotationplasty for PFFD?
Doctors primarily look at the predicted leg length difference your child will have when fully grown. If the difference is expected to be under 15 to 20 centimeters and the hip is stable, lengthening is usually suggested. If the difference is greater, functional paths like rotationplasty or amputation are often recommended.
What is the SUPERhip procedure?
The SUPERhip procedure is a reconstructive surgery that realigns and stabilizes a deformed or unstable hip. It is typically performed when a child is two or three years old to create a strong, stable foundation before limb lengthening surgeries can begin.
How does Van Nes rotationplasty work?
During a Van Nes rotationplasty, the limb is shortened and the lower leg is rotated 180 degrees before being reattached. This allows the child's ankle to bend and function just like a knee joint, giving them natural muscle control over a prosthetic leg.
How many surgeries are required for PFFD limb lengthening?
Limb lengthening is a multi-year commitment that typically requires three to four separate surgeries as the child grows. Each lengthening phase involves using internal or external hardware and requires months of healing and daily physical therapy.
Will my child be active after a rotationplasty or amputation?
Yes, procedures like rotationplasty and amputation are strategic choices designed to give children the most active life possible. These surgeries create a perfect fit for high-activity prosthetics, allowing children to participate in running and high-impact sports.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Given my child's predicted LLD at maturity, how many separate lengthening procedures would be required to achieve leg equality?
  2. 2.Is my child a candidate for the SUPERhip procedure, and what is the typical timeline for that surgery?
  3. 3.If we choose the rotationplasty path, how does the ankle joint function as a knee, and what kind of physical therapy will be needed?
  4. 4.What are the typical 'surgical holidays' (breaks between surgeries) in a limb-lengthening reconstruction plan?
  5. 5.Are there other families in your practice who have chosen rotationplasty or amputation that we could speak with?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (15)
  1. 1

    Atypical Bilateral Proximal Femoral Focal Deficiency: A Case Report and Review of Literature.

    Hammad A, Merkabaoui HE, Moukaddam H, et al.

    Case reports in pediatrics 2026; (2026()):7521784 doi:10.1155/crpe/7521784.

    PMID: 42272856
  2. 2

    Use of Paley Classification and SUPERankle Procedure in the Management of Fibular Hemimelia.

    Kulkarni RM, Arora N, Saxena S, et al.

    Journal of pediatric orthopedics 2019; (39(9)):e708-e717 doi:10.1097/BPO.0000000000001012.

    PMID: 31503232
  3. 3

    Can Adding BMP2 Improve Outcomes in Patients Undergoing the SUPERhip Procedure?

    Paley D, Shannon CE, Nogueira M, et al.

    Children (Basel, Switzerland) 2021; (8(6)) doi:10.3390/children8060495.

    PMID: 34200672
  4. 4

    SUPERhip Reconstruction Treatment in Patients with Congenital Femoral Deficiency of Paley's Classification Type 1b.

    Violante Júnior FH, Farcetta Júnior F, Prina DMC, Nogueira MP

    Children (Basel, Switzerland) 2024; (11(1)) doi:10.3390/children11010075.

    PMID: 38255388
  5. 5

    Antegrade femoral lengthening and simultaneous hemiepiphysiodesis for congenital femoral deficiency.

    Georgiadis AG, Albright PD, Huser AJ, et al.

    Journal of children's orthopaedics 2024; (18(2)):200-207 doi:10.1177/18632521241229619.

    PMID: 38567040
  6. 6

    Lengthening in Congenital Femoral Deficiency: A Comparison of Circular External Fixation and a Motorized Intramedullary Nail.

    Black SR, Kwon MS, Cherkashin AM, et al.

    The Journal of bone and joint surgery. American volume 2015; (97(17)):1432-40 doi:10.2106/JBJS.N.00932.

    PMID: 26333739
  7. 7

    Motorized Plate Lengthening of the Femur in Children: A Preliminary Report.

    Georgiadis AG, Gannon NP, Dahl MT

    Journal of pediatric orthopedics 2022; (42(10)):e987-e993 doi:10.1097/BPO.0000000000002253.

    PMID: 36084628
  8. 8

    Management of severe congenital femoral deficiency: Does surgical intervention enhance prosthetic function?

    Calder P, Elsheikh A, Cross G, et al.

    Prosthetics and orthotics international 2024; (48(2)):149-157 doi:10.1097/PXR.0000000000000303.

    PMID: 38019004
  9. 9

    Rotationplasty for Severe Congenital Femoral Deficiency.

    Fuller CB, Lichtblau CH, Paley D

    Children (Basel, Switzerland) 2021; (8(6)) doi:10.3390/children8060462.

    PMID: 34205839
  10. 10

    Gait biomechanics and energy cost of walking after rotationplasty: A systematic review and meta-analysis compared to above-knee amputation and healthy participants.

    Krebbekx GGJ, Waterval NFJ, Brehm MA, et al.

    Clinical biomechanics (Bristol, Avon) 2025; (128()):106626 doi:10.1016/j.clinbiomech.2025.106626.

    PMID: 40714732
  11. 11

    Long-term functional outcome and quality of life following rotationplasty for treatment of malignant tumors.

    Gradl G, Postl LK, Lenze U, et al.

    BMC musculoskeletal disorders 2015; (16()):262 doi:10.1186/s12891-015-0721-0.

    PMID: 26403306
  12. 12

    Proximal Femoral Focal Deficiency/Congenital Femoral Deficiency: Evaluation and Management.

    Nossov SB, Hollin IL, Phillips J, Franklin CC

    The Journal of the American Academy of Orthopaedic Surgeons 2022; (30(13)):e899-e910 doi:10.5435/JAAOS-D-21-01186.

    PMID: 35486897
  13. 13

    Outcomes of knee arthrodesis in proximal femoral focal deficiency.

    Westberry DE, Carpenter AM, Lee M

    Journal of pediatric orthopedics. Part B 2021; (30(3)):250-256 doi:10.1097/BPB.0000000000000712.

    PMID: 31895293
  14. 14

    Comparison of Outcomes by Reconstructive Strategy in Patients with Prostheses for Proximal Femoral Focal Deficiency.

    Floccari LV, Jeans KA, Herring JA, et al.

    The Journal of bone and joint surgery. American volume 2021; (103(19)):1817-1825 doi:10.2106/JBJS.20.02001.

    PMID: 34270496
  15. 15

    Lengthening With External Fixation Is Effective in Congenital Femoral Deficiency.

    Prince DE, Herzenberg JE, Standard SC, Paley D

    Clinical orthopaedics and related research 2015; (473(10)):3261-71 doi:10.1007/s11999-015-4461-0.

    PMID: 26194561

This page provides educational information about PFFD and CFD treatment options. Always consult with an experienced pediatric orthopedic specialist to determine the best surgical or prosthetic plan for your child.

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