Fibular transfer for congenital absence of the tibia

Deformity Reconstruction Surgery for Tibial Hemimelia

Tibial hemimelia is a rare congenital deficiency with a wide spectrum of pathology and deformity. This paper aims to give a comprehensive review of tibial hemimelia, with a concise summary of the history, pathology, and clinical findings of tibial hemimelia, while providing treatment recommendations and a review of the current literature. Classifications and surgical treatments are discussed, including amputation, limb reconstruction, and lengthening. Type-specific treatments are also discussed, including staged distraction correction of joint contractures of knee and ankle, Weber patelloplasty, fibular centralization, knee and ankle arthrodesis, implantable articulated distractors, and the role of femoral shortening. Amputation is a simpler and easier solution for many patients; however, reconstruction options continue to evolve, improve, and provide better functional outcomes in many cases. Factors favoring surgical reconstruction include the presence of a knee joint/proximal tibia, and the presence of a patella and quadriceps mechanism.

Femoro-pedal distraction in staged reconstructive treatment of tibial aplasia

AIMS

The treatment of tibial aplasia is controversial. Amputation represents the gold standard with good functional results, but is frequently refused by the families. In these patients, treatment with reconstructive limb salvage can be considered. Due to the complexity of the deformity, this remains challenging and should be staged. The present study evaluated the role of femoro-pedal distraction using a circular external fixator in reconstructive treatment of tibial aplasia. The purpose of femoro-pedal distraction is to realign the limb and achieve soft tissue lengthening to allow subsequent reconstructive surgery.

METHODS

This was a retrospective study involving ten patients (12 limbs) with tibial aplasia, who underwent staged reconstruction. During the first operation a circular hexapod external fixator was applied and femoro-pedal distraction was undertaken over several months. Subsequent surgery included reconstruction of the knee joint and alignment of the foot.

RESULTS

The mean follow-up was 7.1 years (2 to 10). The mean age of the patients at the time of the application of the fixator was 2.3 years (1.1 to 5.0). The mean time under distraction was 139.7 days (81.0 to 177.0). A mean fibular distalization of 38.7 mm (14.0 to 67.0) was achieved. Pin infections occurred in four limbs (33.3%) and osteitis in one. A femoral fracture occurred in one patient. Premature removal of the frame was not required in any patient. Sufficient realignment of the leg as well as soft tissue lengthening was achieved in all patients, allowing subsequent reconstruction. All patients were able to mobilize fully weight bearing after reconstruction. Functional outcome was limited in all limbs, and five patients (50.0%) required additional reconstructive operations.

CONCLUSION

Regarding the functional results in the treatment of tibial aplasia, amputation remains superior to limb salvage. The latter procedure should only be performed in patients whose parents refuse amputation. Femoro-pedal distraction efficiently prepares the limb by realigning the leg and soft tissue lengthening. Minor complications are frequent, but usually do not hinder the continuation of distraction. Even though a fully weight-bearing limb is achieved, the functional outcome of reconstructive treatment remains limited. Recurrent deformities frequently occur and may require further operations. Cite this article: Bone Joint J 2020;102-B(9):1248-1255.

Successful management of unilateral congenital patellar tendon aplasia: case report

Anatomical variation is discovered frequently in humans, and much such variation in the musculoskeletal system has been reported. We present a rare case of unilateral congenital patellar tendon aplasia with concomitant apparent shortness of the bilateral halluces as a result of shortened first metatarsals as an anatomical variant.

Congenital Tibial Deficiency

Congenital tibial deficiency is a rare condition characterized by partial to complete absence of the tibia, an intact but frequently overgrown fibula, variable degrees of knee deformity and function, and an abnormal equinovarus foot. It can occur in isolation but also presents concurrently with other orthopaedic anomalies and syndromic conditions. Among these, congenital abnormalities of the hand and femur are most commonly observed. Many theories exist regarding its etiology and some genetic mutations have been identified; however, the underlying mechanism remains unknown. The prognosis and treatment differ based on the clinical severity. The goal of treatment is always to create a stable, functional limb, most commonly with amputation and use of prosthetics. Controversy exists over the level of amputation and the usefulness of reconstructive procedures to preserve the foot and limb length. Current investigation on this complex disorder is focused on identifying its origins and further developing a classification-based treatment algorithm to improve patient outcomes.

Femoral bifurcation and bilateral tibial hemimelia: case report

Femoral bifurcation and tibial hemimelia are rare anomalies described as a variant of Gollop-Wolfgang complex. This article presents a case of Gollop-Wolfgang complex without hand ectrodactyly. A 5-year old patient presented with bilateral tibial hemimelia and left femoral bifurcation. The patient's left limb lacked knee extensor mechanism, disarticulation was done. The right leg which had Jones type 2 tibia hemimelia was treated with tibiofibular synostosis. Currently patient is ambulant with prosthesis on the left limb and ankle foot orthosis on the right. In the absence of proximal tibial anlage, especially in patients with femoral bifurcation, the knee should be disarticulated. Tibiofibular synostosis is a good choice in the presence of a proximal tibial anlage with good quadriceps function.

Tibial hemimelia: new classification and reconstructive options

Tibial hemimelia is a rare congenital lower limb deficiency presenting with a wide spectrum of associated congenital anomalies, deficiencies and duplications. Reconstructive options have been limited, and the gold standard for treatment has remained amputation with prosthetic fitting. There is now a better understanding of the genetics, etiology and pathoanatomy of tibial hemimelia. Armed with this knowledge, I present here a new classification to guide treatment and prognosis and then discuss new treatment strategies and techniques for limb reconstruction based on this new classification scheme.

Functional Assessment in Tibial Hemimelia (Can We Also Save the Foot in Reconstruction?)

BACKGROUND

The congenital absence of the tibia is a rare disease, and an orthopaedic surgeon may not encounter such cases during the course of his/her career. This is the largest report to date of the management of such cases by a single surgeon. The foot and leg were persevered in the majority of the cases, and a functional evaluation system was used to report outcomes.

METHODS

Thirty-six patients with tibial hemimelia, who had been under the direct care of the authors since infancy, were evaluated clinically and radiographically. The patients or their parents filled out the Pediatric Quality of Life and the parents' satisfaction forms. The surgical interventions performed, and their effects on school attendance and, and also the shoe type they wore were documented.

RESULTS

Thirty-six patients (19 girls and 17 boys) with 48 tibial-deficient limbs (19 right, 5 left, and 12 both right and left sides) were studied. The patients were assessed at 12 years (2.5 to 32.5 y), with a mean follow-up of 9 years (2 to 23 y). The 48 limbs included 14 type I, 16 type II, 11 type IV, and 7 unclassified by using the Jones classification; and 6 type I, 11 type II, 16 type III, 1 type IV, and 14 type VII by using the Weber classification. Primary amputation was performed in 8 patients (10 limbs) and limb preservation surgeries on 38 legs (28 patients). Tibiofibular synostosis, centralization of the ankle, and Ilizarov lengthening were the most common procedures. Nonunion of tibiofibular synostosis (2 cases) and knee stiffness (6 cases) were the main complications. Among the reconstructed limbs, 12 were in regular and 18 in modified shoes. The Pediatric Quality of Life of 68 points in the reconstructed group was a significant achievement, and it was also better than the score of patients who had undergone amputation.

CONCLUSION

Reconstruction of tibial hemimelia with foot preservation provides good functional outcome in the majority of cases.

LEVEL OF EVIDENCE

Level IV.

Foot centralization for tibial hemimelia

Nineteen foot centralizations were performed in 14 patients with Jones type I and II tibial hemimelia. All feet showed equinovarus deformity and were treated by foot centralization by means of calcaneofibular arthrodesis. The average age of patients at the time of surgery was 1.3 years (range 0.4-3.8 years). The average follow-up postoperative period was 10.2 years (range 2.2-22.9). At the time of the final follow-up, four of the operated feet were plantigrade without secondary surgery. The remaining 15 limbs, however, required secondary surgery to treat postoperative early loss of correction and/or recurrent foot deformities such as equinus, varus and adduction, in addition to talipes calcaneal deformities, and fibular angular deformity at the fibular shortening osteotomy site. The deformities were treated either by repeat foot centralization, or fibular or calcaneal osteotomy. Careful observation for recurrence of the deformity is necessary until the distal fibular epiphysis closes, and the cartilagenous distal fibular end and calcaneus finally achieve ankyloses.

[Congenital tibial hemimelia]

BACKGROUND

The congenital tibia hemimelia, also called tibial deficiency, is a rare disorder with unknown cause, showing many associated abnormalities or varying syndromes.

METHODS

The correct diagnosis can be easily established using radiographs and/or magnetic resonance imaging in the postpartum setting. However, treatment may be difficult and needs to take into consideration the given anatomic situation in the knee and ankle joint.

CONCLUSION

Prosthetic fitting may be possible in mild cases. Nevertheless, the majority of patients need to undergo surgical reconstruction in order to restore a functional, mobile, and stable knee and ankle joint.

Congenital tibial deficiencies: treatment using the Ilizarov's external fixator

INTRODUCTION

Congenital longitudinal deficiency of the tibia is a rare and often syndromic anomaly. Amputation is usually the preferred treatment option in complete absence of the tibia; however, a conservative management might be implemented in partial forms or in case of amputation refusal. Our experience with the Ilizarov fixator, convinced us this device was the best suited for progressive correction of lower limbs length discrepancies and articular or bone angular limb deformities (ALD). The aim of this study is to highlight the interest of the Ilizarov fixator in the multistage conservative treatment of congenital tibial deficiencies.

MATERIAL AND METHODS

A retrospective study was conducted in nine patients suffering from Type I or II congenital tibial deficiencies (Jones) and sequentially managed using the Ilizarov technique. The functional outcome after treatment completion was then clinically assessed.

RESULTS

The different stages of correction were recorded for each individual patient. Patients were assessed at a mean follow-up of 18,3 years (4-32 years). The mean maximum knee flexion was 35 degrees (0 degrees -90 degrees ) in type I deficiencies and 118 degrees (90 degrees -140 degrees ) in type II deficiencies. One patient underwent amputation and a bilateral knee arthrodesis was performed in another case.

DISCUSSION

Few series in the literature report a comparable length of follow-up period in the conservative management of severe congenital tibial deficiencies. In our study, the Ilizarov fixator provided satisfactory progressive corrections of severe congenital tibial deficiencies.

LEVEL OF EVIDENCE

Level IV therapeutic retrospective study.

[Malformations of the lower extremities]

Malformations with deficiencies of the lower extremities are rare. They are usually caused by toxic influences during pregnancy between the 4th and the 12th week of gestation. Some malformations have a genetic origin. The total incidence of congenital deficiencies of the lower extremities is approximately 18 in 100,000 newborns. The most common deficiencies are fibular hemimelias, followed by congenital femoral deficiencies and tibial hemimelias. Hemimelias are often associated with deficient toes or ray defects. Congenital pseudarthrosis of the tibia is less common, but this diagnosis is underestimated in epidemiological studies in neonates, because the fracture usually only occurs at walking age. Other deficiencies such as bladder exstrophy with pelvic defects, split feet and defects in association with hereditary skeletal dysplasias (Apert syndrome, constriction band syndrome) are extremely rare. Various treatment options are available, including shoe elevation, orthotic or prosthetic devices, realignment osteotomy, arthrodesis, rotationplasty, amputation and surgical leg lengthening. Complex deformities should be treated by a team of specialists such as orthopedic surgeons, orthotists, physiotherapists, psychologists and possibly other surgeons too.

Limb salvage treatment for congenital deficiency of the tibia

Nine limb salvage treatments were performed in 7 patients with congenital deficiency of the tibia. All feet showed equinovarus deformity and were centralized in a slightly equinus position by placing the distal end of the fibula into the posterior facet of the calcaneus. Tibiofibular fusion was performed in 4 patients with partial deficiency, and fibular transfer (fibular centralization; Brown procedure) in 5 with complete deficiency of the tibia. Callus distraction lengthening was performed repeatedly for leg-length discrepancy on either the femur or the centralized fibula. Satisfactory functional and cosmetic results were obtained in all limbs with partial deficiency, whereas in limbs with completely deficiency, none of the 5 knees treated by fibular transfer achieved a satisfactory functional result because of insufficient quadriceps strength, progressive knee flexion contracture, and persistent ligamentous instability. Nevertheless, in these 5 cases, all patients were ultimately able to withstand weight-bearing.

Congenital longitudinal deficiency of the tibia

We performed a clinical and radiographic review of 15 patients (19 limbs) with longitudinal deficiency of the tibia treated between 1981 and 2001. Ten limbs with Kalamchi type I deficiencies were managed by through-knee amputation. Five type II deficiencies were treated by foot ablation and tibiofibular synostosis, either at the same time or staged, but prosthetic problems may arise from varus alignment and prominence of the proximal fibula. Patients with type III deficiencies (four cases) were treated by foot ablation. Prosthetic problems relating to proximal or distal tibiofibular instability may necessitate additional surgical intervention.

Brown's procedure for congenital absence of the tibia revisited

The results of reconstructive surgery in tibial hemimelia using a modified fibular transfer procedure as described by Brown were reviewed. A modified Brown's procedure was carried out on five patients with a total of seven affected limbs. A Syme's-type amputation of the foot was carried out in each case. All of the knees had quadriceps function preoperatively, which was considered a prerequisite for surgery. Average length of follow-up was 7 years, with a range of 2-12 years. The average age at time of surgery was 12.7 months, with a range of 7-26 months. At the time of review, all patients had reasonably good function of their lower extremities. All were ambulating with patellar tendon-bearing prostheses and thigh extensions for collateral support. The average arc of motion at review was 57.4 degrees, with further passive motion possible in all cases. Average extension was -18.5 degrees, and the average active flexion was 76 degrees. We found that a fibular centralization procedure in a patient with at least grade III+ quadriceps function can give good functional results that do not appear to deteriorate over time.

Lower-limb deficiencies and amputations in children

Important differences exist in the management of child and adult amputees. Many factors, including the etiology of childhood limb deficiencies, expected skeletal growth, functional demand on the locomotor system and prosthesis, appositional bone stump overgrowth, and psychological challenges, make caring for these young patients particularly challenging. Adherence to the general principles of childhood amputation surgery will typically guide one to the optimal functional result. These principles can be summarized as follows: (1) Preserve length. (2) Preserve important growth plates. (3) Perform disarticulation rather than transosseous amputation whenever possible. (4) Preserve the knee joint whenever possible. (5) Stabilize and normalize the proximal portion of the limb. (6) Be prepared to deal with issues in addition to limb deficiency in children with other clinically important conditions. A large proportion of young amputees undergo a Syme disarticulation, modified Boyd amputation, or knee disarticulation. A modified Van Nes rotationplasty procedure is also useful in this age group. All these provide the child with a weight-bearing stump with good growth potential and no complications due to bone overgrowth. Appropriate timing of amputation procedures and prosthetic fittings is essential to maximize functional benefit to the patient.