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Updated: Jun 14 2021

Fibular Deficiency (anteromedial bowing)

Images shot 2012-07-16 at 9.25.40 pm.jpg - knee - col_moved.jpg photo - courtesy Miller_moved.jpg shot 2012-07-18 at 8.57.18 am.jpg shot 2012-07-18 at 8.56.32 am.jpg
  • summary
    • Fibular Deficiency is a congenital condition caused by shortening or absence of the fibula which typically presents with anteromedial bowing of the tibia and a leg length discrepancy.
    • Diagnosis is made with radiographs of the tibia.
    • Treatment may be observation or operative depending on degree of fibular deficiency, presence and severity of bowing, and severity of leg length discrepancy. 
  • Epidemiology
    • Anatomic location
      • three types of tibial bowing exist in children and are described based on the deformity apex
        • anterolateral bowing (neurofibromatosis)
        • posteromedial bowing (physiologic)
        • anteromedial bowing (this topic)
  • Etiology
    • 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
      • talipes equinovalgus
      • tarsal coalition (50%)
      • absent lateral rays
      • femoral abnormalities (PFFD, coxa vara)
      • developmental dysplasia of the hip
      • 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
      • Achterman and Kalamchi Classification
      • Characteristics 
      • Treatment
      • Type IA
      • A portion of fibula remains present but proximal fibular epiphysis is distal to level of proximal tibial physis while distal fibula is proximal to the talus.
      • Heel lift (if LLD >2cm)
      •  Contralateral epiphysiodesis
      •  Limb lengthening (at/near maturity)
      • Type IB
      • Partial absence of the fibula (30-50%)
      • Distal portion is unable to support the ankle joint
      • Contralateral epiphysiodesis
      •  Limb lengthening
      •  Supramalleolar osteotomy (to correct ankle valgus)
      •  Corrective foot procedures to achieve stable, plantigrade foot
      •  Proximal tibial osteotomy (for genu valgus)
      • Type II
      • Complete absence of fibula
      • Multiple Ilizarov surgeries to equalize limb lengths, achieve stable ankle, plantigrade foot
      • Foot ablation/amputation
    • 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 alone
        • indications
          • mild projected LLD (<5cm or <10%)
          • stable, plantigrade foot
      • limb lengthening procedure alone
        • indications
          • plantigrade, functional foot with a stable ankle
          • LLD < 10%
        • technique
          • involves resection of fibular anlage to avoid future foot problems
      • contralateral epiphysiodesis + limb lengthening procedure
        • indications
          • moderate LLD (10-30%)
      • Syme amputation (preferred to Boyd amputation)
        • Boyd is more bulbous and only about 1cm longer
        • indications
          • nonfunctional, deformed, unstable foot
          • LLD > 30%
          • unable to cope psychologically with multiple limb lengthening procedures
          • cosmesis
        • technique
          • amputation usually done at ~1 year of age to allow early prosthesis fitting, better psychosocial acceptance
        • results
          • 88% satisfaction with amputation vs 55% satisfaction with limb lengthening
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