Orthopedic treatment vs. surgery for longitudinal fibular deficiency.

OBJECTIVE: Fibular hemimelia or longitudinal fibular deficiency is the most frequent congenital malformation of lower limbs. It causes sometimes major limbs shortening. Different treatments could be considered depending on the severity of the malformation: contralateral epiphysiodesis, corrective foot and knee osteotomies, leg-lengthening surgery with external fixation, prosthesis. For the most severe cases (15-20cm bone length discrepancies or unstable knee or foot), leg-lengthening surgery with external fixation is not recommended. In both cases, there are two potential treatments: orthopedic treatment wearing orthoprosthesis or trans-tibial amputation surgery. Choice is complex and there is no clear objective recommendation for one or the other option. Some parents prefer amputation with removal of portions of the legs to prepare them for prosthetic use. This usually takes place during the first few years of their child. Others will let the child decide when they become teenagers or adults. What are the key factors that could help physical medicine and rehabilitation doctors to guide family in taking this tough decision?

OBSERVATIONS: We followed a 13-year-old boy suffering from longitudinal fibular deficiency before and after his treatment with trans-tibial amputation. We researched objective data on walk analysis based on a representative sample combined with a subjective study on quality of life using the VSP-A questionnaire. We collected data one month before the amputation and one month, four months and one year post-amputation.

DISCUSSION/CONCLUSION: We could not clearly find out significant objective walk criterion before or after surgery. In both cases, we observed compensatory and adaptive mechanisms to anatomical asymmetry initially and acquired later on. Nevertheless, subjective questionnaires highlighted an improvement on a few parameters regarding quality of life after surgery and a major satisfaction from an aesthetic standpoint. This study should be carried out on a bigger scale with a more representative sample population.