Torsional, Angular, and Deficiency Disorders of the Lower Extremity

  • Frederic Shapiro


This chapter describes (i) the rotational and torsional lower extremity deformities included in the descriptive terms in-toeing and out-toeing that are generally self-correcting with growth and (ii) the relatively few femoral and tibial angular and limb deficiency disorders where the primary sites of deformation occur in the metaphyses and diaphyses that are among the most difficult childhood orthopedic conditions to treat.


Torsion and angular deformities: in-toeing, out-toeing Rotation versus torsion Femoral anteversion and retroversion Internal and external tibial torsion Clinical examination Foot progression angle Thigh-foot angle Transmalleolar axis Spontaneous correction with growth common Defined instances of non-correction with growth needing osteotomy correction Severe torsional malalignment syndrome Congenital pseudarthrosis of tibia: types, pathoanatomy, value of multimodal treatment resecting pathologic tissue, apposing healthy bone, augmenting bone repair, and applying effective stabilization Metaphyseal-diaphyseal curvature (rickets, osteogenesis imperfecta) with or without adjacent joint obliquity Self-correcting posteromedial tibial-fibular angulation with calcaneovalgus foot deformity Deficiency disorders: classifications Bone and soft tissue pathoanatomy Lower extremity length discrepancy Management with surgical correction/amputation for femoral disorders (proximal femoral focal deficiency, congenital short femur, distal femoral dysplasia) Fibular hemimelia Tibial hemimelia 


  1. 1.
    Staheli LT, Corbett M, Wyss C, King H. Lower-extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg Am. 1985;67-A:39–47.Google Scholar
  2. 2.
    Heinrich SD, Sharps CH. Lower extremity torsional deformities in children: a prospective comparison of two treatment modalities. Orthopedics. 1991;14:655–9.PubMedGoogle Scholar
  3. 3.
    Seber S, Hazer B, Köse N, Göktürk E, Günal I, Turgut A. Rotational profile of the lower extremity and foot progression angle: computerized tomographic examination of 50 male adults. Arch Orthop Trauma Surg. 2000;120:255–8.PubMedGoogle Scholar
  4. 4.
    Losel S, Burgess-Milliron MJ, Micheli LJ, Edington CJ. A simplified technique for determining foot progression angle in children 4 to 16 years of age. J Pediatr Orthop. 1996;16:570–4.PubMedGoogle Scholar
  5. 5.
    Davids JR, Davis RB, Jameson LC, Westberry DE, Hardin JW. Surgical management of persistent intoeing gait due to increased internal tibial torsion in children. J Pediatr Orthop. 2014;34:467–73.PubMedGoogle Scholar
  6. 6.
    Staheli LT. Rotational problems in children. J Bone Joint Surg Am. 1993;75-A:939–49.Google Scholar
  7. 7.
    Engel GM, Staheli LT. The natural history of torsion and other factors influencing gait in childhood. Clin Orthop Relat Res. 1974;99:12–7.Google Scholar
  8. 8.
    Staheli LT, Engel GM. Tibial torsion. A method of assessment and a survey of normal children. Clin Orthop Relat Res. 1972;86:183–6.PubMedGoogle Scholar
  9. 9.
    Dunlap K, Shands AR Jr, Hollister LC Jr, Gaul JS Jr, Streit HA. A new method for determination of torsion of the femur. J Bone Joint Surg Am. 1953;35-A:289–311.PubMedGoogle Scholar
  10. 10.
    Crane L. Femoral torsion and its relation to toeing-in and toeing-out. J Bone Joint Surg Am. 1959;41-A:421–8.PubMedGoogle Scholar
  11. 11.
    Fabry G, MacEwen GD, Shands AR Jr. Torsion of the femur. A follow-up study in normal and abnormal conditions. J Bone Joint Surg Am. 1973;55-A:1726–38.Google Scholar
  12. 12.
    Svenningsen S, Terjesen T, Auflem M, Berg V. Hip rotation and in-toeing gait. A study of normal subjects from four years until adult age. Clin Orthop Relat Res. 1990;251:177–82.Google Scholar
  13. 13.
    Kingsley PC, Olmsted KL. A study to determine the angle of anteversion of the neck of the femur. J Bone Joint Surg Am. 1948;30-A:745–51.Google Scholar
  14. 14.
    McSweeny A. A study of femoral torsion in children. J Bone Joint Surg Br. 1971;53-B:90–5.Google Scholar
  15. 15.
    Ligier JN. Anomalies rotationnelles des membres inférieurs. Orthop Traumatol. 1992;2:17–20.Google Scholar
  16. 16.
    Cahuzac J-P. Vices des torsion des membres inférieurs. Rev Chir Orthop. 2006;92:395–7.Google Scholar
  17. 17.
    Hubbard DD, Staheli LT, Chew DE, Mosca VS. Medial femoral torsion and osteoarthritis. J Pediatr Orthop. 1988;8:540–2.PubMedGoogle Scholar
  18. 18.
    Wedge JH, Munkacsi I, Loback D. Anteversion of the femur and idiopathic osteoarthrosis of the hip. J Bone Joint Surg Am. 1989;71-A:1040–3.Google Scholar
  19. 19.
    Kitaoka HB, Weiner DS, Cook AJ, Hoyt WA Jr, Askew MJ. Relationship between femoral anteversion and osteoarthritis of the hip. J Pediatr Orthop. 1989;9:306–404.Google Scholar
  20. 20.
    Weinberg DS, Park PJ, Morris WZ, Liu RW. Femoral version and tibial torsion are not associated with hip or knee arthritis in a large osteological collection. J Pediatr Orthop. 2017;37:e120–8.PubMedGoogle Scholar
  21. 21.
    Tönnis D, Heinecke A. Diminished femoral antetorsion syndrome: a cause of pain and osteoarthritis. J Pediatr Orthop. 1991;11:419–31.PubMedGoogle Scholar
  22. 22.
    Tönnis D, Heinecke A. Acetabular and femoral anteversion: relationship with osteoarthritis of the hip. J Bone Joint Surg Am. 1999;81-A:1747–70.Google Scholar
  23. 23.
    Weseley MS, Barenfeld PA, Eisenstein AL. Thoughts on in-toeing and out-toeing: twenty years’ experience with over 5000 cases and a review of the literature. Foot Ankle. 1981;2:49–57.PubMedGoogle Scholar
  24. 24.
    Staheli LT, Clawson DK, Hubbard DD. Medial femoral torsion: experience with operative treatment. Clin Orthop Relat Res. 1980;146:222–5.Google Scholar
  25. 25.
    Svenningsen S, Apalset K, Terjesen T, Anda S. Osteotomy for femoral anteversion: complications in 95 children. Acta Orthop Scand. 1989;60:401–5.PubMedGoogle Scholar
  26. 26.
    Svenningsen S, Terjesen T, Apalset K, Anda S. Osteotomy for femoral anteversion: a prospective 9-year study of 52 children. Acta Orthop Scand. 1990;61:360–3.PubMedGoogle Scholar
  27. 27.
    Payne LZ, DeLuca PA. Intertrochanteric versus supracondylar osteotomy for severe femoral anteversion. J Pediatr Orthop. 1994;14:39–44.PubMedGoogle Scholar
  28. 28.
    Gordon JE, Pappademos PC, Schoenecker PL, Dobbs MB, Luhmann SJ. Diaphyseal derotational osteotomy with intramedullary fixation for correction of excessive femoral anteversion in children. J Pediatr Orthop. 2005;25:548–53.PubMedGoogle Scholar
  29. 29.
    Le Damany P. La torsion du tibia. Normale, pathologique, expérimentale. J Anat Physiol. 1909;45:598–615.Google Scholar
  30. 30.
    Badelon O, Bensahel H, Folinais D, Lassale B. Tibiofibular torsion from the fetal period until birth. J Pediatr Orthop. 1989;9:169–73.PubMedGoogle Scholar
  31. 31.
    Hutchins PM, Rambicki D, Comacchio L, Paterson DC. Tibiofibular torsion in normal and treated clubfoot populations. J Pediatr Orthop. 1986;6:452–5.PubMedGoogle Scholar
  32. 32.
    Bruce WD, Stevens PM. Surgical correction of miserable malalignment syndrome. J Pediatr Orthop. 2004;24:392–6.PubMedGoogle Scholar
  33. 33.
    Dodgin DA, De Swart RJ, Stefko RM, Wenger DR, Ko J-Y. Distal tibial/fibular derotation osteotomy for correction of tibial torsion: review of technique and results in 63 cases. J Pediatr Orthop. 1998;18:95–101.PubMedGoogle Scholar
  34. 34.
    Delgado ED, Schoenecker PL, Rich MM, Capelli AM. Treatment of severe torsional malalignment syndrome. J Pediatr Orthop. 1996;16:484–8.PubMedGoogle Scholar
  35. 35.
    Paget J. Ununited fractures in children. Chapter 13. London: Longmans, Green and Company; 1891. p. 130–5.Google Scholar
  36. 36.
    Hefti F, Bollini G, Dungl P, Fixsen J, Grill F, Ippolito E, Romanus B, Tudisco C, Wientroub S. Congenital pseudarthrosis of the tibia: history, etiology, classification and epidemiologic data. J Pediatr Orthop B. 2000;9:11–5.PubMedGoogle Scholar
  37. 37.
    Andersen KS. Radiological classification of congenital pseudarthrosis of the tibia. Acta Orthop Scand. 1973;44:719–27.PubMedGoogle Scholar
  38. 38.
    Crawford AH. Neurofibromatosis in children. Acta Orthop Scand. 1986;57(Suppl 218):8–60.Google Scholar
  39. 39.
    Boyd HB. Pathology and natural history of congenital pseudarthrosis of the tibia. Clin Orthop Relat Res. 1982;166:5–13.Google Scholar
  40. 40.
    Keret D, Bollini G, Dungl P, Fixsen J, Grill F, Hefti F, Ippolito E, Romanus B, Tudisco C, Wientroub S. The fibula in congenital pseudarthrosis of the tibia: the EPOS multicenter study. J Pediatr Orthop B. 2000;9:69–74.PubMedGoogle Scholar
  41. 41.
    Ducroquet R. A propos des pseudarthroses et enflexion congénitale du tibia. Mem Acad de Chir. 1937;63:863–8.Google Scholar
  42. 42.
    Barber CG. Congenital bowing and pseudarthrosis of the lower leg: manifestations of von Recklinghausen’s neurofibromatosis. Surg Gynecol Obstet. 1939;69:618–26.Google Scholar
  43. 43.
    Green WT, Rudo N. Pseudarthrosis and neurofibromatosis. Arch Surg. 1943;46:639–51.Google Scholar
  44. 44.
    Aegerter EE. The possible relationship of neurofibromatosis, congenital pseudarthrosis and fibrous dysplasia. J Bone Joint Surg Am. 1950;32-A:618–26.PubMedGoogle Scholar
  45. 45.
    McElvenny RT. Congenital pseudo-arthrosis of the tibia. The findings in one case and a suggestion as to possible etiology and treatment. Q Bull Northwest Univ Med Sch. 1949;23:413–23.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Boyd HB, Sage RP. Congenital pseudarthrosis of the tibia. J Bone Joint Surg Am. 1958;40A:1245–70.Google Scholar
  47. 47.
    Blauth M, Harms D, Schmidt D, Blauth W. Light- and electron-microscopic studies in congenital pseudarthrosis. Arch Orthop Trauma Surg. 1984;103:269–77.PubMedGoogle Scholar
  48. 48.
    Ippolito E, Corsi A, Grill F, Wientroub S, Bianco P. Pathology of bone lesions associated with congenital pseudarthrosis of the leg. J Pediatr Orthop B. 2000;9:3–10.PubMedGoogle Scholar
  49. 49.
    Van Nes CP. Congenital pseudarthrosis of the leg. J Bone Joint Surg Am. 1966;48-A:1467–83.Google Scholar
  50. 50.
    Grill F, Bollini G, Dungl P, Fixsen J, Hefti F, Ippolito E, Romanus B, Tudisco C, Wientroub S. Treatment approaches for congenital pseudarthrosis of tibia: results of the EPOS multicenter study. J Pediatr Orthop B. 2000;9:75–89.PubMedGoogle Scholar
  51. 51.
    Morrissy RT, Riseborough EJ, Hall JE. Congenital pseudarthrosis of the tibia. J Bone Joint Surg Br. 1981;63-B:367–75.PubMedGoogle Scholar
  52. 52.
    Farmer AW. The use of a composite pedicle graft for pseudarthrosis of the tibia. J Bone Joint Surg Am. 1952;34-A:591–600.Google Scholar
  53. 53.
    Hardinge K. Congenital anterior bowing of the tibia: the significance of different types in relation to prognosis. Ann Roy Coll Surg Eng. 1972;51:17–30.PubMedGoogle Scholar
  54. 54.
    McFarland B. Pseudarthrosis of the tibia in childhood. J Bone Joint Surg Br. 1951;33-B:36–46.PubMedGoogle Scholar
  55. 55.
    Boyd HB. Congenital pseudarthrosis. Treated by dual bone grafts. J Bone Joint Surg. 1941;23:497–515.Google Scholar
  56. 56.
    Charnley J. Congenital pseudarthrosis of the tibia treated by the intramedullary nail. J Bone Joint Surg Am. 1956;38-A:283–90.PubMedGoogle Scholar
  57. 57.
    Strong ML, Wong-Chung J. Prophylactic bypass grafting of the prepseudarthrotic tibia in neurofibromatosis. J Pediatr Orthop. 1991;11:757–64.PubMedGoogle Scholar
  58. 58.
    Ofluoglu O, Davidson PS, Dormans JP. Prophylactic bypass grafting and long-term bracing in the management of anterolateral bowing of the tibia and neurofibromatosis-1. J Bone Joint Surg Am. 2008;90-A:2126–34.Google Scholar
  59. 59.
    Bassett CA, Caulo N, Kort J. Congenital pseudarthrosis of the tibia: treatment with pulsing electromagnetic fields. Clin Orthop Relat Res. 1981;154:136–49.Google Scholar
  60. 60.
    Ohnishi I, Sato W, Matsuyama J, Yajima H, Haga N, Kamegaya M, et al. J Pediatr Orthop. 2005;25:219–24.PubMedGoogle Scholar
  61. 61.
    Pannier S. Congenital pseudarthrosis of the tibia. Orthop Traumatol Surg Res. 2011;97:750–61.PubMedGoogle Scholar
  62. 62.
    Shah H, Rousset M, Canavese F. Congenital pseudarthrosis of the tibia: management and complications. Indian J Orthop. 2012;46:616–26.PubMedPubMedCentralGoogle Scholar
  63. 63.
    Khan T, Joseph B. Controversies in the management of congenital pseudarthrosis of the tibia and fibula. Bone Joint J. 2013;95:1027–34.PubMedGoogle Scholar
  64. 64.
    Elefteriou F, Kolanczyk M, Schindeler A, Viskochil DH, Hock JM, Schorry EK, et al. Skeletal abnormalities in neurofibromatosis type I: approaches to therapeutic options. Am J Med Genet A. 2009;149A:2327–38.PubMedGoogle Scholar
  65. 65.
    Sofield HA. Congenital pseudarthrosis of the tibia. Clin Orthop Relat Res. 1971;76:33–42.PubMedGoogle Scholar
  66. 66.
    Anderson DJ, Schoenecker PL, Sheridan JJ, Rich MM. Use of an intramedullary rod for the treatment of congenital pseudarthrosis of the tibia. J Bone Joint Surg Am. 1992;74-A:161–8.Google Scholar
  67. 67.
    Dobbs MB, Rich MM, Gordon JE, Szymanski DA, Schoenecker PL. Use of an intramedullary rod for treatment of congenital pseudarthrosis of the tibia. J Bone Joint Surg Am. 2004;86-A:1186–97.PubMedGoogle Scholar
  68. 68.
    Joseph B, Mathew G. Management of congenital pseudarthrosis of the tibia by excision of the pseudarthrosis, onlay grafting and intramedullary nailing. J Pediatr Orthop B. 2000;9:16–23.PubMedGoogle Scholar
  69. 69.
    Johnston CE II. Congenital pseudarthrosis of the tibia. Results of technical variation in the Charnley–Williams procedure. J Bone Joint Surg Am. 2002;84-A:1799–810.PubMedGoogle Scholar
  70. 70.
    Weiland AJ, Weiss A-PC, Moore JR, Tolo VT. Vascularized fibular grafts in the treatment of congenital pseudarthrosis of the tibia. J Bone Joint Surg Am. 1990;72-A:654–62.Google Scholar
  71. 71.
    Gilbert A, Brockman R. Congenital pseudarthrosis of the tibia. Long-term followup of 29 cases treated by microvascular bone transfer. Clin Orthop Relat Res. 1995;314:37–44.Google Scholar
  72. 72.
    Dormans JP, Krajbich JI, Zuker R, Demuynk M. Congenital pseudarthrosis of the tibia: treatment with free vascularized fibular grafts. J Pediatr Orthop. 1990;10:623–8.PubMedGoogle Scholar
  73. 73.
    Sakamoto A, Yoshida T, Uchida Y, Kojima T, Kubota H, Iwamoto Y. Long-term follow-up on the use of vascularized fibular graft for the treatment of congenital pseudarthrosis of the tibia. J Orthop Surg Res. 2008;3:13. [BioMed Central].
  74. 74.
    Paley D, Catagni M, Argnani F, Prevot J, Bell D, Armstrong P. Treatment of congenital pseudarthrosis of the tibia using the Ilizarov technique. J Pediatr Orthop. 1997;17:668–74.Google Scholar
  75. 75.
    Grill F. Treatment of congenital pseudarthrosis of the tibia with the circular frame technique. J Pediatr Orthop B. 1996;5:6–16.PubMedGoogle Scholar
  76. 76.
    Guidera KG, Raney EM, Ganey T, Albani W, Pugh L, Ogden JA. Ilizarov treatment of congenital pseudarthrosis of the tibia. J Pediatr Orthop. 1997;17:668–74.PubMedGoogle Scholar
  77. 77.
    Richards BS, Oetgen BE, Johnston CE. The use of rhBMP-2 for the treatment of congenital pseudarthrosis of the tibia. A case series. J Bone Joint Surg Am. 2010;92-A:177–85.Google Scholar
  78. 78.
    Lee FY-I, Sinicropi SM, Lee FS, Vitale MG, Roye DR Jr, Choi IH. Treatment of congenital pseudarthrosis of the tibia with recombinant human bone morphogenetic – 7 (rhBMP-7). A report of five cases. J Bone Joint Surg Am. 2006;88:627–33.PubMedGoogle Scholar
  79. 79.
    Fabeck L, Ghafi D, Gerroudj M, Baillon R, Delincé PH. Bone morphogenetic protein 7 in the treatment of congenital pseudarthrosis of the tibia. J Bone Joint Surg Br. 2006;88-B:116–8.Google Scholar
  80. 80.
    Birke O, Schindler A, Ramachandran M, Cowell CT, Munns CF, Bellemore M, Little DG. Preliminary experience with the combined use of recombinant bone morphogenetic protein and bisphosphonates in the treatment of congenital pseudarthrosis of the tibia. J Child Orthop. 2010;4:507–17.PubMedPubMedCentralGoogle Scholar
  81. 81.
    Masserman RL, Peterson HA, Bianco AJ Jr. Congenital pseudarthrosis of the tibia. A review of the literature and 52 cases from the Mayo Clinic. Clin Orthop Relat Res. 1974;99:140–5.Google Scholar
  82. 82.
    Pappas AM. Congenital posteromedial bowing of the tibia and fibula. J Pediatr Orthop. 1984;4:525–31.PubMedGoogle Scholar
  83. 83.
    Hofmann A, Wenger DR. Posteromedial bowing of the tibia. Progression of discrepancy in leg lengths. J Bone Joint Surg Am. 1981;63-A:384–8.Google Scholar
  84. 84.
    Carlioz H, Langlais J. Les courbures congénitales de jambe à concavité antérieure: 18 observations chez l’enfant. Rev Chir Orthop. 1986;72:259–66.PubMedGoogle Scholar
  85. 85.
    Napiontek M, Shadi M. Congenital posteromedial bowing of tibia and fibula: treatment option by multi-level osteotomy. J Pediatr Orthop B. 2014;23:130–4.PubMedGoogle Scholar
  86. 86.
    Frantz CH, O’Rahilly R. Congenital skeletal limb deficiencies. J Bone Joint Surg Am. 1961;43-A:1202–24.Google Scholar
  87. 87.
    Henkel L, Willert HG. Dysmelia. A classification and a pattern of malformation in a group of congenital defects of the limbs. J Bone Joint Surg Br. 1969;51-B:399–414.Google Scholar
  88. 88.
    Kay HW, Day HJ, Henkel HL, et al. The proposed international terminology for the classification of congenital limb deficiencies. Dev Med Child Neurol Suppl. 1975;34:1–12.Google Scholar
  89. 89.
    Freund A. Congenital defects of the femur, fibula and tibia. Arch Surg. 1936;33:349–91.Google Scholar
  90. 90.
    Shapiro F. Developmental patterns in lower-extremity length discrepancies. J Bone Joint Surg Am. 1982;64-A:639–51.Google Scholar
  91. 91.
    Aitken G. Proximal femoral focal deficiency. In: Swinyard CA, editor. Limb development and deformity: problems of evaluation and rehabilitation. Springfield: Charles C Thomas; 1969. p. 456–76.Google Scholar
  92. 92.
    Amstutz HC, Wilson PD Jr. Dysgenesis of the proximal femur (coxa vara) and its surgical management. J Bone Joint Surg Am. 1962;44-A:1–24.PubMedGoogle Scholar
  93. 93.
    Ring PA. Congenital short femur; simple femoral hypoplasia. J Bone Joint Surg Br. 1959;41-B:73–9.PubMedGoogle Scholar
  94. 94.
    Vlachos D, Carlioz H. Les malformations du femur. Leur évolution spontanée. Rev Chir Orthop. 1973;59:626–40.Google Scholar
  95. 95.
    Pappas AM. Congenital abnormalities of the femur and related lower extremity malformations: classification and treatment. J Pediatr Orthop. 1983;3:45–60.PubMedGoogle Scholar
  96. 96.
    Paley D, Chong DY, Prince DE. Congenital femoral deficiency reconstruction and lengthening surgery. In: Sabharwal S, editor. Pediatric lower limb deformities. Heidelberg: Springer; 2016. p. 361–425.Google Scholar
  97. 97.
    Kostuik JP, Gillespie R, Hall JE, Hubbard S. Van Nes rotational osteotomy for treatment of proximal femoral focal deficiency and congenital short femur. J Bone Joint Surg Am. 1975;57-A:1039–46.Google Scholar
  98. 98.
    Lange DR, Schoenecker PL, Baker CL. Proximal femoral focal deficiency: treatment and classification in forty-two cases. Clin Orthop Relat Res. 1978;135:15–25.Google Scholar
  99. 99.
    Coventry MB, Johnson EW Jr. Congenital absence of the fibula. J Bone Joint Surg Am. 1952;34-A:941–55.PubMedGoogle Scholar
  100. 100.
    Farmer AW, Laurin CA. Congenital absence of the fibula. J Bone Joint Surg Am. 1960;42-A:1–12.PubMedGoogle Scholar
  101. 101.
    Epps CHJ, Schneider PL. Treatment of hemimelias of the lower extremity. Long-term results. J Bone Joint Surg Am. 1989;71:273–7.PubMedGoogle Scholar
  102. 102.
    Kruger LM. Recent advances in surgery of lower limb deficiencies. Clin Orthop Relat Res. 1980;148:97–105.Google Scholar
  103. 103.
    Hiroshima K, Kurata Y, Nakamura M, Ono K. Ball-and-socket ankle joint: anatomical and kinematic analysis of the hindfoot. J Pediatr Orthop. 1984;4:564–8.PubMedGoogle Scholar
  104. 104.
    Catagni MA, Cattaneo R, DeRosa V. Le traitement de l’hemimelia externe avec la methode d’Ilizarov. In: Dimeglio A, Caton J, Herisson C, Simon L, editors. Les inegalites de longueur des membres. Paris: Masson; 1994. p. 177–81.Google Scholar
  105. 105.
    Pappas AM, Hanawalt BJ, Anderson M. Congenital defects of the fibula. Orthop Clin North Am. 1972;3:187–99.PubMedGoogle Scholar
  106. 106.
    Achterman C, Kalamchi A. Congenital deficiency of the fibula. J Bone Joint Surg Br. 1979;61-B:133–7.PubMedGoogle Scholar
  107. 107.
    Birch JG, Lincoln TL, Mack PW, Birch CM. Congenital fibular deficiency: a review of thirty years’ experience at one institution and a proposed classification system based, on clinical deformity. J Bone Joint Surg Am. 2011;93-A:1144–51.Google Scholar
  108. 108.
    Paley D. Surgical reconstruction for fibular hemimelia. J Child Orthop. 2016;10:557–83.PubMedPubMedCentralGoogle Scholar
  109. 109.
    Westin GW, Sakai DN, Wood WL. Congenital longitudinal deficiency of the fibula: follow-up of treatment by Syme amputation. J Bone Joint Surg Am. 1976;58:492–6.PubMedGoogle Scholar
  110. 110.
    Hootnick D, Boyd NA, Fixsen JA, Lloyd-Roberts GC. The natural history and management of congenital short tibia with dysplasia or absence of the fibula. J Bone Joint Surg Br. 1977;59:267–71.PubMedGoogle Scholar
  111. 111.
    Choi IH, Kumar SJ, Bowen JR. Amputation or limb-lengthening for partial or total absence of the fibula. J Bone Joint Surg Am. 1990;72:1391–9.PubMedGoogle Scholar
  112. 112.
    McCarthy JJ, Glancy GL, Chang FM, Eilert RE. Fibular hemimelia: comparison of outcome measurements after amputation and lengthening. J Bone Joint Surg Am. 2000;82-A:1732–5.PubMedGoogle Scholar
  113. 113.
    Patel M, Paley D, Herzenberg JE. Limb-lengthening versus amputation for fibular hemimelia. J Bone Joint Surg Am. 2002;84-A:317–8.PubMedGoogle Scholar
  114. 114.
    Rodriguez –Ramirez A, Thacker MM, Becerra LC, Riddle EC, Mackenzie WG. Limb length discrepancy and congenital limb anomalies in fibular hemimelia. J Pediatr Orthop B. 2010;19:436–40.PubMedGoogle Scholar
  115. 115.
    Oberc A, Sulko J. Fibular hemimelia – diagnostic management, principles, and results of treatment. J Pediatric Orthop B. 2013;22:450–6.Google Scholar
  116. 116.
    El-Sayed MM, Correll J, Pohlig K. Limb sparing reconstructive surgery and Ilizarov lengthening in fibular hemimelia of Achterman-Kalamchi type II patients. J Pediatr Orthop B. 2010;19:55–60.PubMedGoogle Scholar
  117. 117.
    Catagni MA, Radwan M, Lovisetti L, Guerreschi F, Elmoghazy NA. Limb lengthening and deformity correction by the Ilizarov technique in type II fibular hemimelia. An alternative to amputation. Clin Orthop Relat Res. 2011;469:1175–80.PubMedGoogle Scholar
  118. 118.
    Changulani M, Ali F, Mulgrew E, Day JB, Zenios M. Outcome of limb lengthening in fibular hemimelia and a functional foot. J Child Orthop. 2010;4:519–24.PubMedPubMedCentralGoogle Scholar
  119. 119.
    Jones D, Barnes J, Lloyd-Roberts GC. Congenital aplasia and dysplasia of the tibia with intact fibula. Classification and management. J Bone Joint Surg Br. 1978;60:31–9.PubMedGoogle Scholar
  120. 120.
    Schoenecker PL, Capelli AM, Millar EA, et al. Congenital longitudinal deficiency of the tibia. J Bone Joint Surg Am. 1989;71:278–87.PubMedGoogle Scholar
  121. 121.
    Kalamchi A, Dawe RV. Congenital deficiency of the tibia. J Bone Joint Surg Br. 1985;67:581–4.PubMedGoogle Scholar
  122. 122.
    Weber M. New classification and score for tibial hemimelia. J Child Orthop. 2008;2:169–75.PubMedPubMedCentralGoogle Scholar
  123. 123.
    Courvoisier A, Sailhan F, Thevenin-Lemoine C, Vialle R, Damsin JP. Congenital tibial deficiencies: treatment using the Ilizarov’s external fixator. Orthop Traumatol Surg Res. 2009;95:431–6.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Frederic Shapiro
    • 1
    • 2
  1. 1.Visiting Scholar, Stanford University School of Medicine, Department of Medicine/Endocrinology (Bone Biology)Palo AltoUSA
  2. 2.Formerly, Associate Professor of Orthopaedic Surgery, Harvard Medical SchoolBoston Children’s HospitalBostonUSA

Personalised recommendations