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Fibular Hemimelia

  • Author: Michael C Holmstrom, MD; Chief Editor: Thomas M DeBerardino, MD  more...
 
Updated: Nov 24, 2014
 

Background

Fibular hemimelia was described initially as a condition that is related to aplasia or hypoplasia of the fibula.[1] As is evidenced by its historic name, the fibular abnormality is a primary feature of this condition and may range from a minimal shortening of the fibula to its complete absence. Coventry and Johnson, and later Achterman and Kalamchi, provided early classification systems.[2, 3] These are primarily based on and concerned with treatment of the accompanying limb-length discrepancy.

Fibular hemimelia cannot be characterized fully by any single anatomic feature. It encompasses a constellation of lower-extremity features, which should be evaluated and treated individually when appropriate. The association of these features has led to the suggestion that the term postaxial hypoplasia of the lower extremity may be a more appropriate and better description of the entire pattern of abnormalities seen with this syndrome than the term fibular hemimelia.[4]

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History of the Procedure

Historically, the recommended treatment for postaxial hypoplasia of the lower extremity (fibular hemimelia) was amputation, but only as a last resort. However, Herring et al showed that patients who undergo amputation after several failed attempts at salvage are at high risk for emotional problems.[5, 6] Therefore, determining which patients fare better with immediate amputation is important. Generally, these are patients with a nonfunctional foot or a limb-length discrepancy of more than 20-30%.[7]

Subsequently, the need arose to establish criteria for the indications for amputation. The first recommendations used a projected limb-length discrepancy of 3 in. (~7.5 cm) at maturity as an appropriate cutoff. However, as limb-lengthening techniques have improved, this length criterion has increased, and limb salvage is regarded more often as a feasible option. Other features of postaxial hypoplasia have also been investigated, and treatments have been defined.

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Epidemiology

Frequency

Postaxial hypoplasia of the lower extremity (fibular hemimelia) is rare and has variable expression, ranging from mild deformity (which the patient may never notice) to severe deformity.

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Etiology

A number of causes have been suggested for postaxial hypoplasia of the lower extremity (fibular hemimelia). One theory postulates that interference with limb-bud development plays an important role. Widespread pathology throughout the limb has been noted, even in mild cases of fibular deficiency.[8] During the fetal period, the fibular field of the limb bud controls development of the proximal femur, explaining the frequent association of femoral abnormalities.

Other associated abnormalities of the knee, leg, ankle, and foot also are related to the fibular field of the lower limb bud.[9, 10, 11] Therefore, postaxial hypoplasia of the lower extremity is a descriptive term that encompasses this constellation of abnormalities.

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Presentation

Presentations of postaxial hypoplasia of the lower extremity (fibular hemimelia) vary widely, ranging from what appears to be merely an absent fifth toe in a newborn or a minimal difference in limb lengths to severe fibular deformities that are immediately apparent.[12] The clinician must also look for associated abnormalities, including problems with alignment and stability, and must realize that the clinical picture may evolve with growth and development.

Clinical findings may include the following:

  • Fibular abnormality, ranging from minimal shortening to complete absence of the fibula (see the first and second images below)
  • Femoral hypoplasia with external rotation
  • Lateral patellar subluxation
  • Hypoplastic lateral femoral condyle
  • Genu valgus with lateral mechanical axis displacement
  • Flattened tibial eminence with absent cruciate and a positive Lachman sign
  • Short or bowed tibia (see the third image below)
  • Ankle valgus
  • Ball-and-socket ankle (see the fourth image below)
  • Absent tarsal bones (see the fifth image below)
  • Absent foot rays
    Type II fibular hemimelia (complete absence) in 4- Type II fibular hemimelia (complete absence) in 4-month-old girl. Note skin dimple in midtibial area and 2-ray foot. Image courtesy of Dennis P Grogan, MD.
    Type II fibular hemimelia (complete absence) in 1- Type II fibular hemimelia (complete absence) in 1-year-old girl. Note that foot is in significant valgus position. Image courtesy of Dennis P Grogan, MD.
    Type II fibular hemimelia and significant anterior Type II fibular hemimelia and significant anterior bowing of tibia in 9-month-old boy. Image courtesy of Dennis P Grogan, MD.
    Fibular hemimelia. Ball-and-socket ankle joint is Fibular hemimelia. Ball-and-socket ankle joint is common finding in fibular hemimelia. In and of itself, it is usually not problematic, but it is commonly associated with limb-length discrepancy and tarsal coalition. Image courtesy of Dennis P Grogan, MD.
    Fibular hemimelia in 4-month-old girl. Fibula is a Fibular hemimelia in 4-month-old girl. Fibula is absent, as is proximal tibial ossification center. Two metatarsals are associated with 3 phalanges, 2 of which are fused to form only 2 toes. Image courtesy of Dennis P Grogan, MD.
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Indications

In patients presenting with postaxial hypoplasia of the lower extremity (fibular hemimelia), it is essential to evaluate the entire limb, specifically examining for all of the previously mentioned clinical features. This is important and helpful for developing a treatment plan, both to guide the physician's treatment decisions and to inform the family of what they might expect.

The ultimate goal is to enable the child to gain maximal function by achieving adequate lower-extremity alignment, length, and stability. If this goal is not achievable, the goal should be an appropriately timed amputation to allow the child's development with the use of a functional prosthesis. Goals and expectations must be realistic. When treatment alternatives are discussed, the social and psychological state of the child and the child's family must be considered, especially if multiple surgical procedures are anticipated.

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Contraindications

As with any surgical procedure, the potential benefits must outweigh the risks. Although a number of abnormalities are related to postaxial hypoplasia of the lower extremity (fibular hemimelia), limb-length discrepancy is one of the more difficult to address. If the difference is minimal or if it is large and accompanied by a nonfunctional foot, the decision is relatively straightforward. In many situations, however, several relative contraindications to limb-lengthening salvage operations may be present.

The recommended maximum to be corrected is 7.5-15 cm. Other relative contraindications include a nonfunctional foot, a limb that may have severe cosmetic problems, or a patient who may not tolerate multiple surgical procedures over an extended period.

It must always be kept in mind, however, that each patient's situation is unique. Most patients and parents want the limb to be as normal as possible, and they may wish to undergo the long-term treatment necessary to achieve this goal despite relative contraindications.

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Contributor Information and Disclosures
Author

Michael C Holmstrom, MD Consulting Surgeon, Department of Orthopedics, The Orthopedic Specialty Hospital (TOSH)

Michael C Holmstrom, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Pediatric Orthopaedic Society of North America, American Medical Association, Utah Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Peter M Stevens, MD Professor, Director of Pediatric Orthopedic Fellowship Program, Department of Orthopedics, University of Utah School of Medicine

Peter M Stevens, MD is a member of the following medical societies: Pediatric Orthopaedic Society of North America, Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association

Disclosure: Received royalty from Orthofix Inc for independent contractor; Received royalty from Orthopediatrics, Inc for independent contractor; Received honoraria from Orthopediatrics, Inc for speaking and teaching.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Thomas M DeBerardino, MD Associate Professor, Department of Orthopedic Surgery, Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician, Orthopedic Consultant to UConn Department of Athletics, University of Connecticut Health Center

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; Ivy Sports Medicine; MTF; Aesculap; The Foundry, Cotera; ABMT<br/>Received research grant from: Histogenics; Cotera; Arthrex.

Additional Contributors

Dennis P Grogan, MD Clinical Professor (Retired), Department of Orthopedic Surgery, University of South Florida College of Medicine; Orthopedic Surgeon, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa

Dennis P Grogan, MD is a member of the following medical societies: American Medical Association, American Orthopaedic Association, Scoliosis Research Society, Irish American Orthopaedic Society, Pediatric Orthopaedic Society of North America, American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association

Disclosure: Nothing to disclose.

References
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Type IB fibular hemimelia in 3-year-old boy. Fibula is short relative to tibia, and tibia is shorter on affected side. Note that tibia is also mildly bowed. Image courtesy of Dennis P Grogan, MD.
Type IB fibular hemimelia in same patient as in preceding image. By age 5 years, limb-length discrepancy is progressive and significant. Image courtesy of Dennis P Grogan, MD.
Type II fibular hemimelia (complete absence) in 1-year-old girl. Note that foot is in significant valgus position. Image courtesy of Dennis P Grogan, MD.
Fibular hemimelia. Ball-and-socket ankle joint is common finding in fibular hemimelia. In and of itself, it is usually not problematic, but it is commonly associated with limb-length discrepancy and tarsal coalition. Image courtesy of Dennis P Grogan, MD.
Type II fibular hemimelia (complete absence) in 4-month-old girl. Note skin dimple in midtibial area and 2-ray foot. Image courtesy of Dennis P Grogan, MD.
Fibular hemimelia in 4-month-old girl. Fibula is absent, as is proximal tibial ossification center. Two metatarsals are associated with 3 phalanges, 2 of which are fused to form only 2 toes. Image courtesy of Dennis P Grogan, MD.
Type IA fibular hemimelia in 8-year-old boy. Significant valgus hindfoot is due to shortened fibula. Image courtesy of Dennis P Grogan, MD.
Type II fibular hemimelia and significant anterior bowing of tibia in 9-month-old boy. Image courtesy of Dennis P Grogan, MD.
Fibular hemimelia in same patient as in preceding image. Because tibial bowing caused prosthetic fitting problems, corrective osteotomy was performed. Image courtesy of Dennis P Grogan, MD.
Type IB fibular hemimelia in 8-year-old boy. Limb-length discrepancy is 6 cm. Patient is undergoing tibial lengthening with unilateral external fixation device. Image courtesy of Dennis P Grogan, MD.
Fibular hemimelia in 10-year-old girl. Patient is undergoing lengthening of tibia with Ilizarov device, which incorporates foot so as to maintain foot position during lengthening with lift. Device can be adjusted as lengthening proceeds and discrepancy decreases. Image courtesy of Dennis P Grogan, MD.
Fibular hemimelia. Specimen was removed at time of Syme amputation in patient with fibular hemimelia and significant limb-length discrepancy, prior to prosthetic fitting. Note separate ossification centers for the talus and calcaneus, but no joint space is evident. Image courtesy of and copyright held by Grogan DP, Holt GR, Ogden JA. Talocalcaneal coalition in patients who have fibular hemimelia or proximal femoral focal deficiency: a comparison of the radiographic and pathological findings. J Bone Joint Surg Am 1994;Sep 76(9):1363-70.
Fibular hemimelia. Clinical photograph of specimen shown in preceding image. Note that ossification centers are actually part of single solid cartilaginous anlage; 2 separate ossification centers fuse during adolescence, and only then is tarsal coalition radiographically evident. Image courtesy of and copyright held by Grogan DP, Holt GR, Ogden JA. Talocalcaneal coalition in patients who have fibular hemimelia or proximal femoral focal deficiency: a comparison of the radiographic and pathological findings. J Bone Joint Surg Am 1994;Sep 76(9):1363-70.
 
 
 
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