Fibular deficiency is the congenital failure of formation with associated conditions. Prosthosis management is presented.

1. Congenital Fibular deficiency and
management
Abhishek Tripathi
Lecturer, Prosthetics
NILD, Kolkata
abhishekpo2013@gmail.com

2. Objectives
• Understanding fibular deficiency
• Characteristics of Fibular deficiency and
associated conditions
• Classification in fibular deficiency
• Treatment options
Reference: AAOS Atlas of Amputations & Limb Deficiencies, 3rd edition

3. Introduction: Fibular deficiency
• It’s a congenital
abnormality with
unknown etiology
• Neither inherited or
transmitted, has got
sporadic occurrence
• Usually apparent at birth
and may appear normal
(forme fruste)
• Mainly characterized by
shortened leg and
deformed foot

4. Initial evaluation (morphological
changes/clinical presentation)
• Fibular status: Severity ranges from mild hypoplasia of
fibula with minimal functional disturbance to complete
absence
• Status of the ankle and foot
– Associated absence lateral rays and associated tarsals
– Mal-alignment joints
– Condition of hind foot: stiff hind foot means coalition of the
tarsal bones, so that ankle joint may appear as ball and socket
joint.
– Greater ankle valgus means more deficient fibula
– Ankle instability
– Tibial bowing with a dimple over the apex at antero-medial
(known as procurvatum)

5. Associated clinical presentation
• The lateral femoral
condyle may be hypo-
plastic,
• ACL found deficient
frequently
• Smaller patella
• PFFD (LDFP)
• Club foot
• Varieties of hand anomaly
• Kyphosis or scoliosis

6. Classification of fibular deficiency
A. Achterman & Kalamchi classification: Divides fibular deficiency in
two parts:
1. Fibula present
2. Fibula absent
B. Lett’s classification: it is based on projected LLD at maturity and
ankle and foot condition
C. Birch classification focuses on quality of the foot
D. Latest classification by Stanitski and stanitski have recommended
that ankle morphology should be important criteria for
classfication
– Note: LLD in fibular deficiency follows Shapiro type I pattern: in this,
percentage of difference between sound and affected side remain
same throughout the growth phase.
– Shortening of the tibia don’t correlate with the deficient fibula

7. Kalamchi classification
Typ
e
characteristics
1 Fibula present
1a Physis of proximal
fibula distal to
proximal tibial
physis; distal fibular
physis proximal to
dome of talus
1b Only partial fibula
present
2 Fibula absent
Letts Classification
Type characteristics
A Affected side< 10% shorter than opposite side;
discrepancy projected to be < 6cm at maturity;
foot nearly normal; minimal femoral shortening
B Affected side 10% to 20% shorter than opposite
side; Discrepancy projected to be 6cm to 10cm
at maturity; Minimal foot deformities; Minimal
femoral shortening
C Affected side >= 30% shorter than opposite
side; Discrepancy projected to be > 10 cm at
maturity; severe foot deformity; severe femoral
shortening
D Bilateral fibular deficiency or LDFP

8. Achterman & Kalamchi classification in
fibular deficiency
Type characteristics
1 Fibula present
1a Physis of proximal fibula distal to
proximal tibial physis; distal fibular
physis proximal to dome of talus
1b Only partial fibula present
2 Fibula absent

9. Birch classification
Type characteristics
I Functional foot
A 0% to 5% predicted LLD at maturity
B 6% to 10% Predicted LLD at maturity
C 11% to 30% predicted LLD at maturity
D > 30% LLD at maturity
II Non-functional foot
A Functional upper limb
B Non functional upper limb

10. Management based on Lett’s
Classifcation
Management:
– Type A: Just a shoe lift (predicted LLD < 6 cm)
– Type B: Leg equalizer procedure (predicted LLD <
10cm)
– Type C: Amputation of the foot (controversial)
– Type D: Surgical procedure followed by Prosthosis.
• Notable fact is that many times fibular
deficiency is associated with LDFP, which
magnifies the problem

11. Treatment in fibular deficiency
1. No surgical treatment (conservative
management)
2. Epiphysiodesis at the sound side ankle in
case LLD is < 5cm
3. Limb lengthening, in case LLD is < 15cm
(preferably Ilizarov method)
4. Amputation of the foot followed by
Prosthetic consideration

12. Fibular deficiency
management
No treatment or
conservative treatment
Shoe raise
Non-conventional slip in
Prosthesis for equinus with
LLD
Surgical treatment
Epiphysiodesis on sound
side
Limb lengthening
procedure
Surgical treatment followed
by Prosthotic management
Syme or Boyd procedure
followed by Prosthetic
fitment
Syme or Boyd procedure
with other associated
surgical procedure followed
by Prosthotic management

13. No treatment/conservative
management

14. No treatment/conservative
management
• Foot may look nearly normal in the childhood and
hence decision-making become difficult for
parents
• Later on, a non-standard step-in prosthesis may
be required because of equinus contracture with
LLD. Eg. Shoe raise or SMO with compensation.
• Also, in the conservative management all other
Prosthetic management may be considered when
no surgical treatment could be considered due to
certain reasons.

15. Epiphysiodesis with LLD< 5cm

16. Epiphysiodesis
• Characteristically Lett’s type A
• Here predicted LLD is 6cm by
maturity
• Epiphysiodesis of sound side limb
ankle so that to decrease the
growing leg of the sound side
• Followed by Conservative
management with required
compensation

17. 3. Limb Lengthening procedure
for 5cm < LLD < 10cm

18. Limb lengthening
• Is indicated when projected
LLD is >5 but <10cm at
maturity.
• Characteristically Lett’s type B
but also eligible for type C
• Also in case of Birch
classification, eligible in IB & IC
• Prosthetic management: not
required. Low profile orthosis
may be indicated after surgical
procedure.
• Unsuccessful in case of LLD is
>30% or if predicted LLD is >
15cm

19. Type C
Surgical management : limb
lengthening

20. Complications of lengthening surgery
• Ligament laxity at knee
• Genu valgum
• Progressive valgus deformity of foot and ankle
• Recurrent antero-medial bowing of the lower
tibia
• Permanent stiffness
• Growth retardation of the tibia

21. Complication of
lengthening
•AP radiograph six years after
lengthening.
•There is asymmetry of the
distal tibial epiphysis

22. 4. Amputation of foot and
Prosthetic Consideration

23. Amputation of foot
• Indication for amputation in fibular deficiency:
– Lett’s type C and D or Birch type ID and II (A&B)
• Syme or Boyd procedure is performed prior to walking in child
(between 12 months to 18 months of age)
• These procedure result in tough, resilient residual limb with many
advantages of the Syme and Boyd procedure.
• Though Boyd procedure has better outcome in children due to
– Naturally intact heel pad
– Longer lever hence less LLD
– Better suspension due to bulbous end
• Limitation: lesser space for prosthetic component and
donning/doffing difficulty
• Other associated procedure could be corrective osteotomy for tibial
bowing (if more than 30 degrees or if affecting prosthetic fitment)

24. Prosthetic consideration
• Prosthesis design:
– Socket and suspension design:
• total contact with expendable inner Polyethylene liner with distal
soft end pad
• Window (if necessary) for easy donning/doffing
• Auxiliary suspension such as sleeve suspension for children
younger than 4 years.
• Roll-on Locking liner design
– Foot components:
• Dynamic response feet are recommended
• Modified foot design
• Articulated ankle foot design do not sustained longer
– Growth adjustment:
• Longitudinal Growth in more important to adjust than transverse.

25. Summary
• Fibular deficiency is one of the most common
• Characteristic features is associated with foot and
ankle and also femoral deficiency
• Classification of management are done in order
for better prediction and surgical/non-surgical
management.
• Surgical procedure may have complications and
should be precluded.
• Boyd is a special procedure and has many
advantage, is therefore considered when foot is
amputated in fibular deficiency.