Fibular Hemimelia Treatment, Symptoms, and Causes
Fibular hemimelia is congenital deficiency of fibula in leg. Child can present in various manner depending upon degree of fibula deficiency, ankle & foot deformity. In this problem part or all of the fibular bone, is undeveloped, partially develop of malformed along with hypoplasia, dysplasia of tibia and foot. Severity ranges from mild to severe bony deficiency. Some time it may be associated with knee ligaments deficiency and femoral hypoplasia. Most of the time, it is not inheritable condition. Incidence of fibular hemimelia is 1 in 35000 to 50000. Child with fibular hemimelia may have limb length discrepancy, foot and ankle deformity tibial deformity, genu valgum and knee instability. Drohr Paley has classified it into four types.
Type 1: Stable Ankle
Type 2: Dynamic Valgus Ankle
Type 3: Fixed Equino Valgus Ankle
3a) Malorientation of Ankle Joint
3b) Malunited Subtalar Joint
3c) Combination Ankle and Subtalar Joint Deformity
Type 4: Fixed Equino Varus Ankle
Surgical intervention is based on associated ankle deformity.
In type 1 limb lengthening is only required.
In type 2, tibial shortening, varus osteotomy and alignment of distal tibiofibular joint is required.
In type 3 a varization of distal tibia with tibial lengthening
Type 3b talo calcaneal alignment with tibial lengthening
Type 3c correction of ankle and subtalar joint
Type 4 equinovarus deformity needs correction
Drohr Paley has described various procedures for treatment of Fibular hemimelia according to associated foot and ankle deformity
Shortening osteotomy realignment distal tibia for dynamic ankle deformity with fibular hemimelia. In this procedure, shortening and varization of distal tibia along with realignment of remnant distal fibular physis with distal tibial physis is being done.
Super Ankle Procedure:
Systemic utilization procedure for extremity reconstruction. This procedure achieves stable & plantigrade foot. Usually this procedure is being done between the age of 18 months to 2 year. In this procedure removal of fibular analogue, varus distal supramalleolar osteomy with valgus ankle, subtalar oteotomy in malformed talocalcancaneal junction followed by limb lengthening by ilizarrow.
Limb length alignment:
Serial limb lengthening in 2-3 stage & epiphysiodesis along with SHORDT & super ankle approach leads to limb length equalization and plantigrade supple painless & functional foot. With this concept most of the fibular hemimelia leg can be saved from amputation. Earlier most of the cases with fibular hemimelia were undergoing syme amputation.
Fibular hemimelia is a congenital anomaly in which fibula is not developed completely or part of the fibula is absent. Till now, no clear cut cause (Aetiology) is defined for this problem. Most of the time fibular hemimelia will be associated with foot & ankle problem along with leg shortening. Sometimes they may be associated with a defect in femur and deficiency of lateral foot rays. An infant will present with leg shortening, angulations of tibia, the partial or complete absence of fibula, ankle deformity. Drohr Paley has classified fibular hemimelia on the basis of foot & ankle issues. Type 1 variety will have stable ankle joint, type 2 will have a dynamic valgus deformity. Type 3 is further classified into four categories on the basis of talocalcaneal issues. Treatment of Fibular hemimelia is based on extent & type of foot deformity. In this surgical reconstruction, we need to excise fibular analogue, supracondylar osteotomy for correction of valgus ankle, maintenance of proper subtalar alignment & lengthening of tibia by application of ilizarov technique. Usually, this surgery is contemplated at the age of 1.5 year to 2 year. Whole surgical procedure is known as super ankle surgery. A child may need second lengthening at the age of a 7-8 year and final length equalization at 13 year age. With the successful planning of surgery, a child can walk, run and can do all activity. With sever foot deformity child may need syme amputation at the ankle joint. Usually, we defer in doing the amputation. Because a child will need a prosthetic fitting for whole life. Maintenance & change of prosthesis will be requiring at regular interval. Trishla foundation under the supervision of Dr. Jitendra Kumar Jain, the pediatric orthopedic surgeon has given new lease of life in many children affected by Fibular hemimelia problem.