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Fibular Deficiency (anteromedial bowing)

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Topic updated on 06/08/16 6:32pm
Introduction
  •  Three types of tibial bowing exist in children
    • anterolateral bowing (neurofibromatosis) 
    • posteromedial bowing (physiologic) 
    • anteromedial bowing (this topic)
  • Fibular deficiency
    • consists of shortening or entire absence of the fibula
    • previously known as fibular hemimelia
    • the most common congenital long bone deficiency
    • usually involves the entire limb
  • Genetics
    • no known inheritance pattern
    • linked to sonic hedge-hog gene
  • Associated conditions   
    • anteromedial tibial bowing 
      • most common cause is fibular hemimelia
    • ankle instability 
      • secondary to a ball and socket ankle 
    • equinovalgus foot deformity
    • tarsal coalition (50%)
    • absent lateral rays
    • femoral abnormalities (PFFD, coxa vara)
    • cruciate ligament deficiency
    • genu valgum
      • secondary to lateral femoral condyle hypoplasia
    • significant leg length discrepancy
      • shortening of femur and/or tibia 
Classification
  • Achterman & Kalamchi
    • based on amount of fibula present
  • Birch Classification
    • based on limb length and foot function
    • directs treatment
Presentation
  • Physical exam
    • classic findings  
      • short limb
      • skin dimpling over midanterior tibia
      • equinovalgus foot
    • other findings
      • often missing lateral toes
      • genu valgum
Imaging
  • Radiographs 
    • fibula is either absent or shortened
    • tibial spines are underdeveloped
    • intercondylar notch is shallow
    • ball and socket ankle joint
      • secondary to tarsal coalitions
Treatment
  • Goals
    • treatment determined by the stability and level of foot and ankle function, as well as the degree of limb shortening
      • not based on amount of fibula present
  • Nonoperative
    • observation
      • shoe lift
      • bracing
  • Operative
    • contralateral epiphysiodesis
      • indications
        • mild projected LLD (<5cm)
        • stable, plantigrade foot
    • limb lengthening procedure
      • indications
        • plantigrade, functional foot with a stable ankle
        • LLD < 30%
      • technique
        • involves resection of fibular anlage to avoid future foot problems
    • Syme or Boyd amputation
      • indications
        • nonfunctional, unstable foot
        • LLD > 30%
      • technique
        • amputation usually done at ~1 year of age

 

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Gait of a patient with fibular hemimelia and rigid foot/ankle deformity
7/18/2012
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