Management of fibular hemimelia using the Ilizarov method at Siriraj Hospital in Thailand.

BACKGROUND: Fibular hemimelia is one of the most common congenital longitudinal bone deficiencies. Previous treatment protocols called for amputation of the deficient limb; while others made attempts to save the limb. The objective of treatment is to restore function and achieve patient satisfaction. The authors evaluated the outcomes of the Ilizarov technique for the treatment of leg-length discrepancy and bone associated deformities in patients with fibular hemimelia. The present study also evaluated and assessed complications, knee and ankle function, and patient satisfaction with the treatment. MATERIAL AND METHOD: Nine patients with fibular hemimelia who underwent tibial lengthening using the Ilizarov method were reviewed in the present study. Initial condition data, including age, gender type offibular hemimelia, initial limb-length discrepancy, predicted limb-length discrepancy, and the data were collected and analyzed. Activity level, patient satisfaction, complications, and residual leg-length discrepancy were assessed at the end of treatment. RESULTS: According to Achterman and Kalamchi classification, there were 4 patients with Type IA, 3 patients with Type IB, and 2 patients with Type II. In Type IA, the affected leg-length discrepancy and mean age at the initial treatment were 3.25 cm and 7.75 years, respectively. In type IB, the affected leg-length discrepancy and mean age at the initial treatment were 5.83 cm and 4.3 years, respectively. In Type II, the affected leg-length discrepancy and mean age at the initial treatment were 5.5 cm and 5 years, respectively. The mean follow-up was 5 years (range: 7-10). The mean lengthening was 7.52 cm (range: 4-13). The lengthening index was 1.28 mo/cm. The mean residual leg-length discrepancy was 0.94 cm. There was ankle joint stiffness and mild equinous foot in type II cases, but patients could walk well without gait aid. No patients were experiencing pain by the end of treatment. All patients expressed satisfaction with this technique. CONCLUSION: The Ilizarov technique for bone lengthening of the tibia has shown satisfactory results in the treatment of all types of congenital fibular hemimelia and should be considered an attractive alternative to amputation, as measureable functional improvement can be expected.

Timing of premature physeal closure in Legg-Calve-Perthes Disease.

PURPOSE: Premature physeal closure of the proximal femoral physis has been reported in Legg-Calve-Perthes Disease (LCPD). However, the timing of its occurrence had not yet been reported. We proposed (1) to determine the timing of premature physeal closure in unilateral LCPD with serial radiographic evaluation, and (2) to evaluate the relationship between the premature physeal closure and Herring classification, leg-length discrepancy (LLD), Stulberg classification, and trochanteric overgrowth. METHODS: We performed a retrospective study with serial radiographs of 27 patients diagnosed with LCPD. The difference in the timing of physeal closure between the hips was calculated. The involved hip was classified according to Herring classification. The LLD and ATD index at latest follow up was measured. The mean values were calculated and statistical comparison of variables was done using the Fisher's exact test. RESULTS: The mean difference of physeal closure at the involved hip compared to the uninvolved side was 3.5 years (range, two to five years). Hips demonstrating premature physeal closure were associated with Herring B/C and C (p = 0.01) and LLD >1 cm (p = 0.02). There is no correlation between Stulberg classification, trochanteric overgrowth and premature physeal closure (p = 0.06 and p = 0.19). CONCLUSIONS: We may expect premature physeal closure of the proximal femoral physis in patients with LCPD to occur 3.5 years earlier than normal hips. Presence of premature physeal closure can be an adjunct diagnostic tool in the prognostication of LCPD outcomes. Future studies directed toward premature physeal closure in LCPD and associated growth disturbances are necessary.

Limb length inequality: clinical implications for assessment and intervention.

The purpose of this paper is to review relevant literature concerning limb length inequalities in adults and to make recommendations for assessment and intervention based on the literature and our own clinical experience. Literature searches were conducted in the MEDLINE, PubMed, and CINAHL databases. Limb length inequality and common classification criteria are defined and etiological factors are presented. Common methods of detecting limb length inequality include direct (tape measure methods), indirect (pelvic leveling), and radiological techniques. Interventions include shoe inserts or external shoe lift therapy for mild cases. Surgery may be appropriate in severe cases. Little agreement exists regarding the prevalence of limb length inequality, the degree of limb length inequality that is considered clinically significant, and the reliability and validity of assessment methods. Based on correlational studies, the relationship between limb length inequality and orthopaedic pathologies is questionable. Stronger support for the link between low back pain (LBP) and limb length inequality is provided by intervention studies. Methods involving palpation of pelvic landmarks with block correction have the most support for clinical assessment of limb length inequality. Standing radiographs are suggested when clinical assessment methods are unsatisfactory. Clinicians should exercise caution when undertaking intervention strategies for limb length inequality of less than 5 mm when limb length inequality has been identified with clinical techniques. Recommendations are provided regarding intervention strategies.

Fibular hemimelia: a new classification system.

A new classification system for fibular hemimelia is proposed based on the authors' experience with 32 patients with 33 involved limbs representing a spectrum of involvement. The data demonstrate the broad and unpredictable relationships among the fibula, ankle, and foot in this disorder. The classification system, based on fibular and ankle morphology, hindfoot coalition, and foot ray deficits, is designed to improve communication about the condition. Because of the variability and unpredictability of the multiple relationships, limb salvage criteria should also include the nature of the foot and ankle and not merely depend on the length discrepancy or the presence or absence of the fibula.

Pediatric leg length discrepancy: causes and treatments.

Leg length discrepancies have multiple causes with a number of treatment options available to accomplish a goal of equal or near equal leg lengths at skeletal maturity. The management of a deformity in the lower extremity can be a complex undertaking requiring the skill and expertise of a multidisciplinary health care team. The purpose of this article is to provide an overview of how a treatment plan is formulated after careful evaluation through ongoing assessment, diagnosis, treatment, and follow-up. The plan of care needs to fit the needs of the child and those of the family through realistic goal setting, ongoing teaching, and support.

[Management of fibular hemimelia]. / Die Behandlung der fibularen Hemimelie.

Fibular hemimelia is a congenital longitudinal deficiency that represents a spectrum of deformities. The management of this condition is controversial and our treatment options are changing with developments in limb reconstruction techniques. For the severely affected child with a predicted limb length discrepancy greater than 25 cm at maturity and with a poor foot and ankle amputation is generally agreed to be the best option. For less severely affected limbs, particularly those with a predicted limb discrepancy of 10 cm or less and with a foot with 3 or more rays which can be made plantigrade, limb reconstruction is recommended. Controversy remains about the best way to manage children with an intermediate deformity.

[Cogenital femoral defect. Indication, therapy and complication management]. / Kongenitaler Femurdefekt. Indikation, Therapie und Komplikationsmanagment.

Congenital femoral deficiencies remain a surgical challenge. There is no common classification: both radiological and clinical methods are recommended. Depending on the severity of the deformity, reconstructive and lengthening techniques are performed, while accompanying deformations are taken into consideration. In addition, amputation or fusion techniques together with orthotic devices are used. A total of 35 patients (37 extremities) with congenital femoral deficiencies have been treated at the Orthopaedic Hospital Vienna-Speising, from 1982 to 1998. 24 extremities were treated with reconstructive and/or lengthening techniques. Results and complications are reported.

Proximal femoral focal deficiency.

Proximal femoral focal deficiency (PFFD) is an uncommon congenital defect that involves the femur and acetabulum in varying degrees. It may occur with or without fibular hemimelia and can be unilateral or bilateral in presentation. Children with PFFD and their families are faced with many treatment decisions, both nonsurgical and surgical. Nursing care is central in the care of these children and their families both for psychosocial support and teaching during the decision-making process and for being a patient advocate to help meet postoperative and rehabilitation goals.

Fixed pelvic obliquity after poliomyelitis: classification and management.

We classified fixed pelvic obliquity in patients after poliomyelitis into two major types according to the level of the pelvis relative to the short leg. Each type was then divided into four subtypes according to the direction and severity of the scoliosis. In 46 patients with type-I deformity the pelvis was lower and in nine with type II it was higher on the short-leg side. Subtype-A deformity was a straight spine with a compensatory angulation at the lower lumbar level, mainly at L4-L5, subtype B was a mild scoliosis with the convexity to the short-leg side, subtype C was a mild scoliosis with the convexity opposite the short-leg side, and subtype D was a moderate to severe paralytic scoliosis with the convexity to the short-leg side in type I and to the opposite side in type II. A combination of surgical procedures improved the obliquity in most patients. These included lumbodorsal fasciotomy, abductor fasciotomy and stabilisation of the hip by triple innominate osteotomy with or without transiliac lengthening. In patients with type ID or type IID appropriate spinal fusion was usually necessary.

Transfibular osteotomy in the correction of ankle joint incongruity.

The mechanics involved in Danis-Weber-types B and C ankle fractures may allow the fibula to seek a shortened and externally rotated position following injury. Residual talar instability secondary to fibular malalignment may ensue if proper anatomic restoration is not achieved at the time of reduction. Evaluation of ankle incongruity may take the form of clinical, radiographic, and diagnostic techniques. Three case studies are presented in which fibular osteotomies were utilized to restore proper anatomic alignment and function to the ankle mortise.

The Ilizarov apparatus in the treatment of congenital dysmetria of the leg.

The effectiveness of the treatment of congenital leg length discrepancy depends on careful evaluation and selection before embarking on a programme of treatment. Over the years several types of surgery have been used to correct leg length discrepancy, starting with Codivilla (1905), who performed osteotomy followed by gradual transcalcaneal traction. This was succeeded by external fixators of various kinds. Unknown to most of the Western world, the Russian surgeon Ilizarov devised in 1950 an external fixation device which because of its mechanical and biological features could be applied to many orthopaedic and traumatological conditions. Since 1983 we have used this for the treatment of congenital dysmetria of the lower limbs resulting in leg length discrepancy.

Proximal femoral focal deficiency: radiologic analysis of 49 cases.

Proximal femoral focal deficiency, an uncommon congenital anomaly, necessitates early radiologic classification for surgical planning and treatment. Objective radiographic criteria, including femoral length index, acetabular depth index, acetabular angle index, and shape of the proximal femur were determined in 49 patients before cartilaginous ossification of the femoral capital epiphysis; final classification was based on follow-up radiographs or findings at arthrography or surgery. These parameters were analyzed to determine the accuracy and contributions of each in classification. Correct classification into one of three groups was possible in 86% of cases with use of three of the parameters: femoral length index, acetabular depth index, and shape of the proximal femur. The acetabular angle was found to contribute insignificantly to classification. Magnetic resonance imaging, used in only one case, depicted the nonossified cartilaginous femoral capital epiphysis, thus obviating the need for invasive diagnostic procedures and facilitating early classification.

[Asymmetrical lower limbs. Lumbosacral changes and scoliosis]. / Arti inferiori asimmetrici. Alterazioni lombo-sacrali e scoliosi.

The spine and pelvis of both young and adult subjects with inequality in length of lower extremities were examined in standing position. At the lumbosacral level, alterations affecting the last intervertebral disc spaces, the basal vertebra and the sacrum were observed, caused by asymmetric weight distribution, which can modify the spine axis.

Congenital deficiency of the femur.

A classification system for congenital deficiency of the femur is introduced, based on initial radiographic appearance of the hip joint in 60 patients (70 affected limbs). Follow-up records ranging from 1 to 30 years demonstrated a relatively constant percentage of shortening in each patient with further growth (2.4% average change). Treatment programs have been established for each of the following groups: I, short femur with good hip joint (19 limbs); II, short femur and coxa vara (17 limbs); III, short femur with proximal deficiency, a well-developed hip joint, and broad angulated and sclerosed diaphysis (15 limbs); IV, dysplastic distal femoral segment with no hip joint (16 limbs); and V, total absence of the femur (3 limbs).

Developmental patterns in lower-extremity length discrepancies.

A review of lower-extremity length-discrepancy data in 803 patients demonstrated that not all discrepancies continue to increase at a constant rate with time. A classification of the developmental discrepancy patterns identified is presented: type I, upward slope; type II, upward slope-deceleration; type III, upward slope-plateau (type IIIA, downward slope-plateau; type IIIB, plateau); type IV, upward slope-plateau-upward slope; and type V, upward slope-plateau-downward slope. The patterns are dependent on the nature of the conditions causing the discrepancies and on the place and time of their occurrence. The distribution of the types of patterns in the various etiological groups is presented. The classification of developmental patterns illustrates the varying directional changes that can occur in these discrepancies and their dependence on underlying biological phenomena. Determination of the distribution of pattern types in the various conditions aids in planning the frequency of length-discrepancy studies. The patterns alone do not provide projections of final discrepancies, but when used in conjunction with the femoral-tibial length and growth-remaining charts of Green and Anderson they permit accurate projections of discrepancy to be made.

[The lengths' difference of legs in view of the general physician (author's transl)]. / Die Beinlängendifferenz aus der Sicht des Allgemeinarztes.

The present paper treats the problem of the lengths' difference of legs in view of the general physician. After a five years' research a survey has been established and a classification in four groups has been made. Moreover the question of diagnosis and therapy has been treated. The requirement has been raised to diagnose as early as possible and to apply the corresponding therapy even in case of a lengths' difference below 20 mm in order to avoid any inevitable secondary consequences. Only by acting this way arising complaints, long working incapabilities and last but not least considerable expenses can be prevented.