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Fibular hemimelia
Published in Benjamin Joseph, Selvadurai Nayagam, Randall Loder, Ian Torode, Paediatric Orthopaedics, 2016
Fibular hemimelia is a relatively common deficiency of the lower extremity. The incidence rate is about one or two per 100 000 live births. Although fibular hemimelia can occur as an ‘isolated’ deficiency, it is the author’s belief that one should treat all children with fibular deficiency as having whole limb involvement to a greater or lesser extent (Figure 35.1a,b). As noted in Chapter 37, Congenital short femur and proximal focal femoral deficiency, fibular hemimelia is associated with femoral deficiency in 50 percent of cases (Figure 35.1c). Fibular hemimelia can be classified into types I and II: type I is mere fibular hypoplasia or partial absence of the fibula and type II is complete absence of the fibula.1 While it is traditional to name the deficiency by the major bone absence, in fibular hemimelia, the extent of involvement of the other bones of the limb often dictates management.
Systematic review of complications with externally controlled motorized intramedullary bone lengthening nails (FITBONE and PRECICE) in 983 segments
Published in Acta Orthopaedica, 2020
Markus W Frost, Ole Rahbek, Jens Traerup, Adriano A Ceccotti, Søren Kold
To our knowledge, this is the first systematic review on complications related to bone lengthening nails. The primary outcome was the risk of type IIIB complications resulting in a new pathology or permanent sequelae. This review found such IIIB complications in 3% of lengthened segments. Furthermore, a complication of any type was found in 34% of lengthened segments, and 5% of segments did not achieve the planned lengthening due to a complication (IIIA). In 15% of segments treated with intramedullary PRECICE and FITBONE lengthening nails, a complication (II) resulted in substantial change in treatment, such as unplanned re-surgery. 6% (11/177) of time-determined complications occurred intra- or perioperatively prior to start of distraction, and 94% of complications (166/177) occurred during or after the end of distraction. The high diversity of complications demonstrates that several means must be applied to reduce the high number of complications in intramedullary bone lengthening. Concerning the primary outcome, where the (type IIIB) complication resulted in a new pathology or permanent sequelae, the majority of complications were a result of joint-related complications such as contracture, subluxation, or dislocation. It is likely that a reduction in joint-related complications is accomplished by improved patient selection and attention to soft-tissue release as well as individualized protocols for lengthening, temporary extraarticular screw arthrodesis, splints/orthoses, or physiotherapy. The risk of joint subluxation and dislocation was 6 and 1 per 1,000 segments, respectively. Joint contracture was seen in 5% (53/983) of the segments, and primary soft-tissue release might be a key to address this complication; this was, however, only reported in 5 of the 41 studies (Shabtai et al. 2014, Paley et al. 2015, Laubscher et al. 2016, Rozbruch 2017, Calder et al. 2019). Calder et al. made a systematic division of the iliotibial band (ITB) if the planned lengthening was above 3 cm. They found that, in femoral lengthening, females lost joint movement in the hip and knee earlier than males. Moreover, it took substantially more time to regain range of motion in patients treated with retrograde compared with antegrade nails. However, we believe that higher rates of severe joint complications must be anticipated in high-risk patients such as congenital femoral deficiency and fibular hemimelia. We believe there is a need for systematic reporting of primary soft-tissue release as there is a lack of knowledge of benefits and challenges concerning this issue.