1. Fibular Hemimelia Syndrome
Sunit Hazra. MS, Hae-Ryong Song. MD.,
Dept. of Orthopedics, Korea University, Guro Hospital, Seoul.

2. Complete Fibular Hemimelia
Commonest bone to be absent congenitally
Complete Fibular Hemimelia mostly treated by amputation
Recently Limb salvage procedure are reported with success

3. CASE 1

4. M / 3 yrs
C.C:
LLD, difficulty in walking

5. Anteromedial bowing of tibia
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
Femoral hypoplasia
Tibial shortening
Anteromedial bowing of tibia

6. Examination of Foot Missing two lateral rays of foot
Equinovalgus deformity of foot
Tarsal Coalition

7. Preoperative Plan

8. Post operative X-ray

9. Post OP 5 months – 10 cm Distraction

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

11. Acute correction for Ant. Angulation & lengthening -1.5 cm

12. Post OP – 8 Months (Age-3yr 8 mth)
Total lengthening cm
Initial LLD (R<L) cm
Present LLD (R>L)- 2 cm
Genu valgum
MAD- 35mm

13. Acute correction for Valgus deformity & Lengthening
F/U—1yr 9mth Age- 4yr 9mth
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

14. Last F/U – Age- 5yr 4mth Duration of f/u- 2yr 6mo
Total lengthening cm
Initial LLD(R<L) cm
Present LLD (R>L) cm

15. CASE 2

16. M / 4yr 4mo
C.C :
LLD & walking difficulty

17. Complete fibular hemimelia
Femoral hypoplasia
Tibial shortening

18. Examination of Foot
Missing one lateral ray
Mild equinus deformity

19. LLD Femur: 2.5 cm Tibia: 6 cm Total: 8.5 cm LLD at maturity
Multiplier method by Paley. D
Multiplier factor- 1.8
Other methods- Moseley, Anderson Green

20. Tibial & femoral lengthening
: 5cm
Tibia lengthening
: 10cm

21. 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

22. Fx. Shaft of femur- Slip down injury

23. 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

25. 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

26. Amputation vs Limb salvage
30 limb in 25 patient
15-amputation/ 10-lengthening
Amputation is better than lengthening
Less complication, single stage procedure
Foot deformity lead to delayed amputation
McCarthy et al; J Bone Joint Surg(Am);2000
4 complete fibula hemimelia(15 yr F/U)
Tomas-Gil et al; Acta Orthop Belg;2002

27. 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

28. How to reduce complication ?
Lengthening with varus direction.
Protection of callus for longer period.
Management of foot deformity
M. Patel et al, J bone Joint Surg(84);2002

29. 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)

30. Conclusions
Lengthening is alternative method for treatment of Complete Fibula Hemimelia.
Foot deformity & more number of Complications– Main Obstacle for limb salvage procedure

31. Thank you for your kind attention