Sunit Hazra. MS, Hae-Ryong Song. MD.,

Dept. of Orthopedics, Korea University, Guro Hospital, Seoul.

Complete Fibular Hemimelia

Commonest bone to be absent congenitally

Complete Fibular Hemimelia mostly treated by amputation

Recently Limb salvage procedure are reported with success

M / 3 yrs

C.C:

LLD, difficulty in walking

Anteromedial bowing of tibia

Femoral hypoplasia

Tibial shortening

LLD

Femur: 1 cm

Tibia: 6.5 cm

Total: 7.5 cm

LLD at maturity

Femur: 2.2 cm

Tibia: 14.5 cm

Total: 16.5 cm

Multiplier method by Paley. D

Multiplier factor- 2.2

Other methods- Moseley, Anderson Green

Missing two lateral rays of foot

Equinovalgus deformity of foot

Tarsal Coalition

Examination of Foot

Preoperative Plan

Post operative X-ray

Post OP 5 months – 10 cm Distraction

Post OP 6 months – Ant. Angulation + Fracture at distraction site

Acute correction for Ant. Angulation & lengthening -1.5 cm

Post OP – 8 Months (Age-3yr 8 mth)

Total lengthening - 11.5 cm

Initial LLD (R<L)- 7.5cm

Present LLD (R>L)- 2 cm

Genu valgumMAD- 35mm

Acute correction for Valgus deformity & Lengthening

Lengthening- 5cm

MAD - 3mm

Total lengthening- 16.5cm

Initial LLD(R<L)- 7.5 cm

Present LLD (R>L)- 5cm

F/U—1yr 9mth Age- 4yr 9mth

Last F/U – Age- 5yr 4mth

Duration of f/u- 2yr 6mo

Total lengthening - 16.5cmInitial LLD(R<L) - 7.5 cmPresent LLD (R>L) - 4.5 cm

M / 4yr 4mo

C.C :

LLD & walking difficulty

Complete fibular hemimelia

Femoral hypoplasia

Tibial shortening

Missing one lateral ray

Mild equinus deformity

Examination of Foot

LLD

Femur: 2.5 cm

Tibia: 6 cm

Total: 8.5 cm

LLD at maturity

Femur: 4.7 cm

Tibia: 11.3 cm

Total: 16 cm

Multiplier method by Paley. D

Multiplier factor- 1.8

Other methods- Moseley, Anderson Green

Tibial & femoral lengthening

Femoral lengthening : 5cm

Tibia lengthening : 10cm

Post OP - 1yr 5mo Age- 5 yr 9 mths

Genu valgum deformity

MAD - 24mm

Total lengthening- 15cm

Initial LLD(R<L)- 8.5 cm

Present LLD (R<L)- 1cm

Fx. Shaft of femur- Slip down injury

Last F/U - 3yr Age- 7yr 4mths

Genu valgum deformity

MAD - 35mm

Total lengthening- 15cm

Initial LLD(R<L)- 8.5 cm

Present LLD (R<L)- 1cm

Our major Complications

Fracture during consolidation- two cases Axial deviations:

Genu valgum(both), Ant. Angulation of tibia.(1 Case).

Equino valgus deformity of foot

But, no ankle pain during walking. No progression of Equinovalgus ankle Parent and patient are satisfied with good walking ability

Amputation vs Limb salvage

•30 limb in 25 patient30 limb in 25 patient15-amputation/ 10-lengthening15-amputation/ 10-lengtheningAmputation is better than lengtheningAmputation is better than lengtheningLess complication, single stage procedureLess complication, single stage procedureFoot deformity lead to delayed amputationFoot deformity lead to delayed amputation

McCarthy et al; J Bone Joint Surg(Am);2000McCarthy et al; J Bone Joint Surg(Am);2000

4 complete fibula hemimelia(15 yr F/U)4 complete fibula hemimelia(15 yr F/U)Amputation is better than lengtheningAmputation is better than lengtheningLess complication, single stage procedureLess complication, single stage procedure

Tomas-Gil et al; Acta Orthop Belg;2002Tomas-Gil et al; Acta Orthop Belg;2002

Amputation vs Limb salvage

4 fibula hemimelia using Ilizarov E/F (LLD:8.7 cm)

Ilizarov E/F is good Treatment option for fibula hemimelia

Basbozkurt et al; Acta orthop Traumatol Turc; 2005

How to reduce complication ?

1. Lengthening with varus direction.

2. Protection of callus for longer period.

3. Management of foot deformity

M. Patel et al, J bone Joint Surg(84);2002

How to manage the foot problem?

Progressive Ankle Valgus (Jack C. Y. Cheng et al,JBJS [Br] 1998)

During lengthening - foot should be included in fixator

After completion of lengthening Mild- AFO

Severe- soft tissue release &/or supramalleolar corrective osteotomy

Unstable ankle valgus- ankle arthrodesis (Deborah F. Stanitski et al,JPO,2003)

Conclusions

LengtheningLengthening is alternative method for treatment of Complete Fibula Hemimelia.

Foot deformity & more number of Complications– Main Obstacle for limb salvage procedure

Thank you for your kind Thank you for your kind attentionattention