Management of Tibial Hemimelia

Management of
Tibial Hemimelia
Hassan El-Barbary, M.D.
--
In type I1 the proximal part
of the tibia is ossified and
Tibial deficiency, or tibial hemimelia is a rare, longitudinal
visible on radiographs at birth,
intercalary limb deficiency involving the osseous and soft tissue
but the distal tibia is not seen.
components of the medial portion of the leg. Treatment options for
such pathology varies according to type of deficiency as well as to
In type I11 the distal part of the
culture and acceptance ofparents to different treatment modalities. In
tibia is ossified and visible, but
this study we classified twenty nine limbs according to Jones
the proximal portion of the
classification into 13 type ZA, 3 type IB, 4 type ZZ, no limbs type IIZ
tibia is absent. This is the least
and 9 Iimbs type IV. W e present our protocol of treatment for such
cases and the results and follow up as we tried to salvage all limbs.
common form of tibial hemimelia. In type IV the tibia is
short and there is distal tibioINTRODUCTION
found effects on vertebrates limb
fibular diastasd4).
morphogenesis, where it can act
Most of the calses of tibial
ibial deficiency, or ti- as teratogen generating phocobial hemimelia is a melia and bone defects. A Reti- hemimelia has associated musrare, longitudinal inter- noic acid gradient, possibly culoskeletal a n ~ r n ~ a l i e s ( ' ~ ~ ~ ~ ~ ~ ) ,
calary limb deficiency involving amplified by a graded distribu- including scoliosis, hip dysplathe osseous and soft tissue tion of cellular Retinoic acid - sia, bifurcation of the femur(7),
components of the medial por- binding protein (CRABP), could ray reduction or polyductyly of
The foot in tibial
tion of the leg. It is a syndrome provide positional information the
of partial to complete absence across the antero-posterior axis hemimelia although rarely appear clinically complete, it alof the tibia at birth. It has an of the limb bud(3).
ways has osseous abnormalestimated incidence of 1 in 1
million live births. Both autoThe most widely accepted ities@).
soma1 dominant and recessive classification is that proposed
Patients with complete abpatterns are
by ones(^). The Jones system sence of the tibia (Jones type I
classifies tibial hemimelia into A) will have a k:nee flexion
The specific cause for tibial four types, based on radio- contracture('). Whien there is
hemimelia is still unknown. Limb graphic features present during complete absence of the tibia,
bud development begins ap- infancy. In type I the tibia the child normally has hamproximately at 4 weeks postovu- cannot be seen on radiographs string function but not quadlation, and continues until the at birth. In subtype IA the tibia riceps function, the patella is
end of the embryonic period at is completely absent. In this typically absent, and the foot,
approximately 8 weeks. Mechan- type the ossific nucleus of the which is fixed in severe varus,
ical or chemical insult during this distal femoral epiphysis is small has minimal functional moveperiod can cause a variety of or has not appeared at birth. In ment(''439). In patients with
different congenital deformi- subtype IB the proximal part of Jones types IB and I1 deformities('). Whatever the cause, it is the tibia is present, but because ties, hamstring and quadriceps
clear that the development of the it is not ossified at birth, it function is normal and the knee
entire sclerotome is affected. appears to be absent. In this moves normally. The fibular
However Retinoic acid has pro- type there is normal ossification head will be displaced proxiof the distal femoral epiphy- mally and laterally, and the
s~s(~).
limb will be in a varus position,
ABSTRACT
Vol. (7) No. (2)/ July 2003
125
Tibia1 Hemimelia
with significant varus instability. At the ankle joint, the foot
is displaced medially relative to
the fibula, and will also be in
varus@,'O).
In Jones type 111 deformity,
the knee is unstable and there
are extra digits distally. The
tibia1 shaft is palpable, and
there is a severe varus deformity of the leg. In patients with
a Jones type IV deformity, in
which there is a diastasis of the
distal tibia and fibula, the limb
is moderately short and the foot
is in a severe, rigid varus,
positioned between the tibia
and
Treatment options for such
pathology varies according to
type of deficiency as well as to
culture and acceptance of parents t o different treatment
modalities especially amputation. Also surgical technique
and the development of proper
prosthetic manufactures have
great role in treatment opt i o n ~ ( ' ~ ~ ~ ~In~ *this
~ ~ study
-'~).
29 nine limbs are classified
and treated trying to preserve
limbs in all cases and patients in
different age groups were assessed after different treatment
modalities.
MATERIAL & METHODS:
In this study, 29 limbs in 22
patients with this extremely
rare anomaly were treated during the period of September 99
to December 2002. Some cases
were treated by a way o r
another before presenting to us.
The age of patients ranged
from one to seventeen years
with a mean of 6.8 years. The
study included 16 (73%) (5
bi1ateral)males and 6 (27%) (2
bilatera1)females with a ratio of
126
2.7 : 1.
According to Jones classification, we had thirteen limbs
(45%) with type I-A defect,
three (10%) with type I-B defect, four (14%) with type 11,
none with type 111 and nine
with type IV (31 %) (Fig. 1).
Nine patients had positive
family history (40%), we had
two brothers and their two
cousins (all boys) with variable
degrees of affection, only one
parent was affected but their
grand father had type I unilateral affection. Another boy
with type IV had his cousin
(girl) with one side type IV and
the other side type 11. Bilateral
affection was found in 7 patients of the 22 patients (32%).
All patients had associated
anomalies, the commonest was
lobster hand 13 patients (59%)
(Fig.2), bifurcation of the femur 6 cases(27%) (Fig.3), ray
reduction of the feet 12 cases
(55%) and polydactyly in 4
cases(l8%). However non of
the cases had a normal big
toe. We didn't diagnose any
anomaly in the cardiac, genitourinary or gastrointestinal
systems although we did abdominal ultrasonographic examination to all patients.
Foot deformity in the form
of equinovarus deformity and
knee flexion deformity with
varying degrees was present in
all cases despite the fact that
some cases had previous trials
to correct the foot. Shortening
varied according to age, severity of affection and previous
trials to correct the defect,
however the limb length inequality ranged from 7 cm to
18 cm in unilateral cases and
even in bilateral cases a difference of 4 cm was found in one
patient.
All cases underwent thorough history taking, examination, radiographic assessment
by both X-ray and some times
scanogram when lengthening
was planned. Abdominal ultrasonography and rcutine lab
investigations were done in all
cases prior t o any surgical
interference.
Our plan of treatment was as
follows:
We never tried foot ablation
as advised by many authors as
this is not accepted in our
culture in Egypt and was always refused by parents of
children. First we try to explain
the magnitude of the problem
and that multiple and repeated
surgeries are needed and that
the problem is ongoing and
ends only after adolescence.
Also we explain to the parents
that amputation might be the
only choice during any time
through the coune of the treatment. Also parents should be
informed that tlhe type of gait
for unilateral type IA defect is
much worse than with a well
done prosthesis.
We tried daily manipulation
and stretching exercise by the
babies mother and used plastic
splints in the best allowed position till the age of one year.
Release was done to all feet
and centralization of the fibula
to the talus was done in all
cases above the age of one year
(Fig.3). Fibular shortening was
needed in older children (above
3 years). Bilateral cases were
done simultaneously. Protection of these feet in splints
continued till the next operation.
In type IV, Correction of
Pan Arab J. Orth. Trauma
Hussun El-Burbary, M D
Fig. (I):
(a) incidence of different
types in our study.
(b) Different types of tibial hemimelia:
1. Type Ia
2. Type 1 b
3. Type Ii
4. Type IV
Vol. (7) No. (2)/ July 2003
Fig. (2)
(a) Photos of hand
anomalies.
(b) X-rays of hand
anomalies.
foot deformity and tibiofibular
synostosis after fibular osteotomy with or without tibia1
osteotomy was done in all
cases. We tried to centralize
the talus in a trough in the
distal end of the fibula and
tibia. Again fibular shortening
might help in some cases.
Concerning Knee pathology,
we found it easier to deal with
after the age of two years. For
type IA, inserting the proximal
fibula in a small trough in the
distal femur was done and kept
in position with K wire (Fig.3).
For type IB, inserting the proximal fibula into the cartilage
remnant of the tibia and fixing
them by K wire was done
(Fig.4). In type 11, tibiofibular
synostosis was done after having good bone stock to get a
successful fusion, this is usually
done after three years of age
(Fig.5). All cases were protected in above knee splints till
the age of five years, to protect
the correction and to help the
child to walk.
Above the age of five, any
limb length inequality, knee or
foot deformity were gradually
corrected by Ilizarov ring fixator. In type IA lengthening is
done through two focuses, the
femur and the tibialised fibula
(Fig.6). In all other types, only
the tibia is lengthened but bridging the knee is extremely mandatory as it is always unstable
(Fig. 7).
Ilizarov fixator was used for
lengthening and or correction
of deformities in eleven limbs,
seven with unilateral pathology
and two with bilateral pathology. All eleven cases are presented in table 1.
After achieving full limb
length correction t o equal
length or even t o a longer
length and after correcting all
deformities, the fixators were
removed after a total time ranging between three and eight
months with a mean of 5.8
months.
The summary of treatment
protocol adopted in our study
is shown in table 2.
RESULTS:
The follow up time ranged
from six months t o thirty
months with a mean of 17
months, and as this is an ongoing pathology, the ultimate
result is best evaluated after
skeletal maturity when the problem is stationary.
All our patients were able to
walk without walking aids. All
limb length inequality for patients younger than the proper
age of lengthening used shoe
lifts or plastic braces to be able
to walk. Also all cases with
bilateral type IA used above
knee braces to walk without
walking aids below the age of
two.
We had all feet clinically
improved, but residual equines
was found in thirteen feet nine
of them type IA and four type
Pan Arab J. Orth. Trauma
Fig. (3)
(a) Photos of 6 month old boy with
bilateral type I tibia1 hemimelia.
(b) X-ray of same boy after proximal
and distal centralization (note femoral bifurcation on rt side).
(c) Photo of same child at 2 years of
age with full weight bearing.
ib)
Fig. (4)
(a) X-ray of type IB preoperative.
Vol. (7) No. (2)/ July 2003
(b) 6 month post operative.
(4
(b)
Fig (5):
(a) X-ray of normal side
--
-
(b) X-ray of type II preoperative
(c>
(c) X-ray after tibio fibular fusion
Table I:Cases treated by llizarov
11
11
Cases
-
T v ~ eIA
Type IA
-
-
-
Type IA
Type IA
11
Type IA
Type II
Type II
I
Procedure
I Lenqtheninq 18cm (bifocal)and correction of knee flexion and ankle equines
-
--
-
-
11
11
Lengthening 1&m (bifocal)and correction of knee flexion and ankle equines
Lengthening 9 cm (bifocal)and correction of knee flexion and ankle equines
Lengthening 8cm (bifoca1)and correction of knee flexion and ankle equines
I Lengthening
9cm (bifoca1)and correction of knee flexion and ankle equines
Lengthening 14cm (monofocal) and correction of ankle deformity
11
Lengthening 9cm (monofocal) and correction of ankle deformity
Type II (bilateral)
Correction of sever equines and external rotation together with lengthening of both sides (8
& 4 cm) to equalize length and to have better appearance
Type IV (bilateral)
Correction of sever equines and varus deformity at 13 years of age
Table 2: Treatment protocol adopted in our study.
11
I
Type
IA
I
Procedure
Tibialisation of distal fibula and correction of foot deformity at 1 year age or age of presentation
Tibialisation of proximal fibula at 2 years or age of presentation.
Lengthening of both femur and fibula simultaneously to correct shortening and any residual deformity was
done after age of five
IB
Tibialisation of distal fibula and correction of foot deformity at 1 year age or age of presentation
Inserting proximal fibula into the cartilaginous analogue of the proximal tibial at 3 years of age.
Lengthening of tibialised fibula to correct shortening and any residual deformity was done after age of five
II
Tibialisation of distal fibula and correction of foot deformity at 1 year age or age of presentation
Tibiofibular svnostosis after 3 vears of aqe.
Lengthening bf tibialised fibulato correct shortening and any residual deformity was done after age of five
IV
Correction of foot deformity and tibiofibular synostosis after fibular osteotomy with or without tibial
osteotomy
Lengthening to correct shortening and any residual deformity was done after age of five
Pan Arab J. Orth. Trauma
(4
Fig.
(a)
(b)
(c)
(d)
(6)
X-ray of type la preoperative in 3 years old girl.
Photo of same girl.
X-ray showing bifocal lengthening through fernur and tibialised fibula
Photo of same girl after full lengthening.
Vol. (7) No. (2)/ July 2003
Tihial Hernimcliu
Fig. (7)
(a) X-ray of girl with type II defect after foot corr~ctionand tibiofibular fusion.
(b) X-ray showing the girl during lengthenir~g.
(c) X-ray of sarne girl after removal of Ilizarov.
(d) Scanogram showing equalization of limb length.
(e) Photos of same girl 1 year after lengthening with good alignment and
perfect knee range.
Pan Arab J. Orth. Trauma
fIu.s.san El- Barbary, M D
Photo of 3 month old boy with bilateral type IV defect (I
I years
before presenting to us).
X-ray at age of 2 years (operation
done before presenting to us).
X-ray of same child with equines.
X-ray after correction by Ilizarov.
X-ray after removal of Ilizarov.
Photos of same child 18 months
later with plantigrade foot.
Vol. (7) No. (2)/ July 2003
Fcdenco
Svhoeneckcr
Our stud\
Fig. (9):
Incidence of different types of tibial hemimelia in different studies.
IV. The equines was mild about
10 degrees in all but two limbs
with type IV and didn't affect
the ability of walking well.
These two feet (type IV) with
fixed equinovarus deformity of
about 40 degrees needed a redo
operation where we did a tibial
osteotomy and corrected the
deformity.
Another major problem in
type I and type I1 was instability of the fibulo-talar articulation in three feet (Fig.3). Two
of them needed a redo operation at the age of five to fuse the
joint, after the arthrodesis all
three patients walked well without a brace.
Skin sloughing occurred in
two feet (type IV) and both
healed by repeated dressing for
a month.
Concerning knee pathology,
all cases with type IA deformity, the knee was found to be
stiff in most cases with about 10
to 20 degrees of knee flexion
deformity. Flail knee was never
encountered in our study.
Tibio-fibular union occurred
in all but one limb in types IB
and one in type 11. This cases
had successful union after revision of the operation (Fig.5).
All knees had satisfactory range
of flexion and extension (Fig.
7,8), mild varus valgus instability could be elicited in all limbs
with type IB and in 2 limbs with
type 11.
In nine limbs the Ilizarov
was used to treat shortening,
limb deformity, knee flexion
and ankle deformities. Lengthening of nine limbs with average length gain of 9.9 cm.
The lengthening index for
type IA (bifocal) was 2.3 cm/
month (Fig.6) and for other
types w a s 1 . 3 c m l m o n t h
(Fig.7). All of the deformities
were originally corrected but
partial relapses were encountered during follow up (mild
varus and flexion deformitv).
In one patient with bilateral
type IV defect, Ilizarov was
used to correct equinovarus
deformity with foot adduction
and the fixator was removed
after 3 months. The foot was
completely corrected and the
child gait much improved
(Fig.8).
During the lengthening procedures, minor complications
as pin tract infection, episodes
of pain was encountered and all
resolved by proper cleaning and
antibiotic therapy. After removal of the Gxator. knee stiffness and mild flexion deformity
developed in types IB, I1 and
IV, but after proper physiotherapy good range was obtained
with no flexion deformity. No
major complications as neurovascular injury or skin sloughing were encountered.
To summarize the results, in
type IA, all p,atients below the
age of 5 can walk with braces,
shoe lifts in unilateral cases.
Above the age: of 5 years, after
Pan Arab1 J. Orth. Trauma
Hassan El-Barbary. M D
lengthening and correction of
deformity, they can walk without any aid, but of coarse, the
gait is ugly and needs more
energy expenditure than if
through knee amputation and
prosthesis were used.
For type IB, type I1 and type
IV, all patients below the age of
five can walk with braces, shoe
lifts in unilateral cases. Above
the age of 5 years, after lengthening and correction of deformity, they can walk without
any aid, they had good knee
range, stiff ankles but their gait
is comparable to cases treated
by amputation and prosthesis
and even better because they
have a sensible foot.
DISCUSSION:
In this series we vresent
twenty nine limbs in this extremely rare anomaly. Our
study included 21 limbs in 16
males (73%) and 8 limbs in 6
females (27%) with a ratio of
2.6:l. In the study of Federico
F.et a ~ . , ( there
~)
were 7 males
(39%) and 11 females (61%)
and Javid M et a1.(12)presented
3 limbs in males (33%) and 6
limbs in females (67%). The
study of Schoenecker p1(14) included 14 males (67%) and 7
females(33%).
The different types of tibial
hemimelia according to Jones
classification is shown in table 3
and figure 9. The series of Javid
M et
included no cases
type I because only cases treated by Ilizarov are included. In
all other series including ours,
type I was the commonest
followed by type IV then type
I1 and type I11 was the most
rare(12'14). However type 111
wasn't encountered at all in
our series. The incidence of
bilateral affection was 32% in
our series, 18% in the series of
and 31 % in
Federico F.et
the series of Schoenecker p1(I4).
in our series was both autosoma1 dominant and recessive.
Richieri - Costa A et a ~ . (had
~)
the same conclusion that both
modes of inheritance are found,
however Federico F. et al. and
Schoenecker P1 reported only
autosomal dominaint inheritance('2,'4)
Concerning the incidence of
various associated ;anomalies,
table 4 shows the prevalence
of the most common anomalies
in different studies.
The protocol of treatment
we adopted in this study differs
for Type IA with other
aUthors(l,4.6,8,931
1-16) hi^ is be-
cause foot ablation or knee
disarticulation adopted by
others is not accepted in our
country. One of our patients
had been scheduled for ampuThe incidence of familial tation two times before our
inheritance was found in 40% treatment and his mother reof our patients (9 patients with fused the operation ait the night
14 limbs). This is a very high of the operation till he preincidence in comparison to sented to us at the age of eight
Federico F.et a ~ . ((18%)
~)
and years with no previous treatSchoenecker p1(13) (23%) and ment for unilateral tibial hemitype IA. Another girl
Richieri - Costa A et a ~ . ( ~ melia
)
(3 1%). The mode of inheritance presented at the age of seven
Table 3: Incidence of different types in different studies
I
Type
Type
Type
Type
Type
Total
IA
I6
11
111
IV
Federico F.et al("
1
Javid M et a\('')
I
0
0
5 (56%)
1 (11%)
3 (33%)
9
9 (41%)
4 (18%)
3 (14%)
2 (9%)
4 (18%)
22
Schoenecker
I
our (s-
8 (38%)
3 (15%)
4 (19%)
13 (45%)
1 (5%)
5 (24%)
21
0
9 (31%)
29
Table 4: Associated anomalies in different studies.
Associated anomaly
Lobster hand
Polydactyly of hand
bifurcation of the femur
Ray reduction of the foot
Cardiac, genitourinary and gastrointestinal anomalies
Vol. (7) No. (2)/ July 2003
Schoenecker p1(I4)
Federico F.et a16)
6 (27%)
7 (32%)
4 (18%)
1 (4.5%)
2 (9%)
I
9 (43%)
2 (9.5%)
5 (24%)
0
0
15 (52%)
4 (14%)
8 (28%)
18 (62%)
0
1
Tibia1 Hemimelia
with repeated trials of correction and wearing a bulky AKA
prosthesis and refusing any
kind of amputation. A third
girl presented at the age of
sixteen with short deformed
type I1 hemimelia and wearing
a bulky BKA prosthesis and
refusing any amputation for the
right side and untreated type IV
on the other side.
Although our results are
much inferior to other authors
concerning appearance, gait,
energy expenditure and the fact
that multiple surgeries are
needed, still in our country foot
preservation is a priority even
with a worse function than with
a prosthesis('36393'4916)
Concerning other types, several treatment options are
adopted by different authors
according to culture, parents
acceptance to amputation, expenses of surgery and governmental sponsorship, surgeons
experience and the development
of proper prosthetic manufactures (1,6,9,10,12,14,16).ln the series of Federico F. et a ~ , (in
~ )22
limbs amputation was the solution in 13 limbs and foot ablation in five while only four
limbs with type IV defect
needed correction of foot deformity and lengthening. In the
series of Schoenecker p1,(I4) all
limbs had either knee disarticulation or syme amputation after
tibiofibular fusion.
having younger age group in
our series, also the two limbs
that needed only correction of
their deformity without lengthTable 5 analyses different
ening had the Ilizarov only
treatment strategies, Javid M
applied for 2.5 months. In our
et a1.(12) is the closest to our
series as well as in others(12,15),
strategy of treatment and that's
all deformities were corrected
why his series will be compared
to acceptable results and no
to ours.
major complications were enIn our series, Ilizarov was countered.
used in eleven limbs to correct
Refracture complicated one
deformities and limb length limb of type I1 after lengthening
inequality simultaneously in (14 cm) and healed after casting
nine limbs and to correct ankle in mild varus of 10 degrees. In
deformity only in two limbs. In our series the residual deformithe series of Javid M et a1.(12), ties are varus of about 20
Ilizarov was used in nine limbs degrees together with flexion
for lengthening and correction of 15 in one limb (type IA)
of ankle deformities simulta- and we intend to correct them
neously. The lengthening index in the next lengthening procein our series was 2.3 for bifocal dure.
lengthening and 1.3 for monofocal which is comparable to Conclusion
Treatment of tibia1 hemimeJavid M et a1.(12)series where it
was 1.1 for monofocal length- lia, although lengthy and tiring
ening and 1 for monofocal can yield good results and
lengthening in Watts HG(15) acceptable function. Even if it
series. The more rapid consoli- is worse than prosthesis (type
dation in our series might be IA), it is much accepted by
explained by the fact that parents refusing amputation.
younger age group were length- Parent education prior to treatened in our series. Also the ment is mandatory and the
average time for fixator re- option of amputation versus
moval was 5.8 months in our trial of limb salvage should be
series compared to 7.6 months given to th,e parents after exin Javid M et a1.(12)series and 8 plaining the duration and psymonths in Watts HG(15)series. chological impact of different
This might be explained also by treatment options. The use of
Table 5: Treatment strategies in different studies.
-
Knee
IA
Knee disarticulation
Knee disarticulation
IB
Knee disarticulation
Syme or Chopart amputation after
tibio fibular sinostosis
Syme or Chopart amputation after
tibio fibular sinostosis
Syme or Chopart amputation after
tibiofibular sinostosis
Astragelectomy and closure of diastasis and Syme amputation
II
Ill
I
Schoenecker PI('^)
Federico F.et al@)
Type
IV
Syme or Chopart amputation after
tibiofibular sinostosis
Syme or Chopart amputation after
tibiofibular sinostosis
I Astragelectomy and closure of dia( stasis and lengthening
I
1
I
I
I
I
I
Pan Arab J. Orth. Trauma
Hassan El-Barbary, M D
Ilizarov helped a lot and treatment strategies are changed
after the use of such a tool.
REFERENCES:
1. Herring JA: Limb deficiencies:
Tachdjians Pediatric Orthopedics
3rd edition. W.B. Saunders Company, 1745-1810, 2002.
2. Richieri-Costa A, Ferrareto 1, Masiero D, et at: Tibial hemimelia:
report on 37 new cases, clinical and
genetic consideration. Am J Med
Genet, 27367, 1987.
3. Pavone L, Viljoen D, Ardito S: Two
rare developmental defects of the
lower limbs with confirmation of
the Lewin and Opitz hypothesis of
the fibular and tibial development.
Am J Med Genet, 33:161-164,
1989.
4. Jones D, Barnes J, Liloyd-Roberts
G: Congenital aplasia and dysplasia with intact fibula: classification
and management. J Bone joint
surg, 60-13:31, 1978.
5. Anderson 111, Hansen AK. Tibial
hypo/aplasia with preaxial syn-
Vol. (7) No. (2)/ July 2003
and polydactyly. Arch Orthop
Trauma Surg, 109:231-3, 1990.
6. Federico-Palazzi F, Bendahan J,
and Rivas S: Congenital Deficiency
of the Tibia: A Report on 22 Cases.
Journal of Pediatric Orthopedics
Part B, 7:298-302, 1998.
7. Yetkin H, Cila E, Bilgin Guzel V, et
al.: Femoral bifurcation associated
with tibial hernimelia. Orthopedics,
24(4) p389-90, Apr 2001.
8. Miller LS, Armstrong PF. The
morbid anatomy of congenital deficiency of the tibia and its relevance to treatment. Foot Ankle,
13:396-9, 1992.
9. Schuch CM: Prosthetic principles
in fitting myoelectronic children.
In Herring JA, Birch J G (eds): The
Child With a Limb Deficiency, p
405. Rosemont, IL, American
Academy of Orthopedic Surgeons,
1998.
10. Blauth W, Hippe P. The surgical
treatment of partial tibial deficiency and ankle diastasis. Prosthet
Orthot Int, 15:127-30, 1991.
11. Brown FW, Pohber WH: Construction of a knee joint in meromielia
tibia (congenital absence of the
tibia). J Bone Joint Surg Am,
54:1333- 9, 1972.
12. Javid M, Shahcheraghi GH, Nooraie H: Ilizarov lengthening in
centralized fibula. J P e d i a t r
Orthop, 20(2) p160-2, Mar-Apr
2000.
13. Schoenecker PL, Capelli AM, Millar EA, et at: Cong deficiency of the
tibia. J Bone Joint Surg, 71, 1989.
14. Schoenecker PL: Tibial deficiency.
In Herring JA , Birch J G (eds): The
Child With a Limb Deficiency, p
209. Rosemont, IL, American
Academy of Orthopedic Surgeons,
1998.
15. Watts HG: Lengthening of short
residual limbs in children. In Herring JA, Birch JG (eds): The Child
With a Limb Deficiency, p 281.
Rosemont, IL, American Academy
of Orthopedic. Surgeons, 1998.
16. Loder RT: Fibular transfer for
congenital absence of the tibia
(Brown procedure). In Herring
JA, Birch JG (eds): The Child With
a Limb Deficiency, 13 223. Rosemont, IL, American Academy of
Orthopedic Surgeons, 1998.