sunit hazra. ms, hae-ryong song. md., dept. of orthopedics, korea university, guro hospital, seoul
TRANSCRIPT
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