The purpose of the study was to evaluate the usefulness of the techniques introduced for correction of the deformities associated with fibular hemimelia.

Material. 10 children (6 boys and 4 garils) with affected 11 limbs were analyzed. All presented Achterman-Kalamchi type II fibular hemimelia (absence of the fibula, anterior tibial bowing and hypoplastic foot). Limb length discrepancy ranged from 2 to 9 cm. Only 2 feet had 5 rays, 4 – 4 rays and 5 three rays. In 10 feet talo-calcaneal synostosis was diagnosed intra-operatively. Age at operation ranged from 7 to 23 months (mean 13.2). Follow-up was 4.7 years (1 – 8.5).

Technique. Two groups of patients were analyzed.

The 1st group consisted of 3 children (3 affected limbs) operated on by partial or complete release of the ankle. Correction of the equinus and valgus deformity was possible by rotation of the talus in the ankle joint in coronal and sagittal plain (the oval shape of talar dome allowed its rotation in the ankle joint). In 2 patients the tibial osteotomy were made as a separate procedure.

The 2nd group consisted of 7 children (8 affected limbs) operated on by one-stage technique consisting of (1) trapezoid resection of the tibia for correction of anterior bowing and internal torsion (2) posterior and lateral release of the foot with lengthening of tendo Achilles and peroneals tendons (3) •opening wedge osteotomy through talo-calcaneal synostosis with bone graft taken from the tibia for correction of valgus and equinus deformity (4) skin plasty with subcuteneous flap for wound covering. In this group relationships between talus and tibia were not changed by operation (flat top talus).

Results. Both techniques resulted in stabile and properly aligned tibia and hindfoot. Five children were treated later by Ilizarov method at age of 57 months (53 – 80). Other five patients walked independently in orthopaedic or normal shoes. Two of them wait for limb lengthening. The method used in the 2nd group was especially useful for patients with bilateral deformity. The relapse of hindfoot valgus deformity was observed after limb lengthening.

Conclusion. One-staged correction of the complex deformity in fibular hemimelia is safe and cost effective. The treated limb was properly prepared for lengthening, wear-bearing in shoes (bilateral cases), orthosis or pros-thesis.

The assortment of primary operative techniques starts with posterior release and ends with the most sophisticated ones such as complete subtalar release. The proper selection of one of them is a key to success and has to be done on the basis of clinical and radiographic parameters.

Posterior release: The indication for this procedure is determined by persistent equinus. On AP and lateral radiographs the normal talocalcaneal angle is visible AP greater than 20; lateral greater than 35 degrees). On the lateral radiograph in corrected equinus or standing, the angle between the calcaneus and tibia should be smaller than 80 degrees. A physical examination con- firms equinus position more precisely. Attention should be paid to the possibility of iatrogenic rocker bottom deformity. In such cases posterior release should be combined with dorsal release of the calcaneocuboid and talonavicular joint.

Posteromedial release: Clinical indications for this procedure are hindfoot equinus and varus and passively corrected medial spin measured with a bimalleolar angle less than 85 degrees. This angle should be checked during surgery when the posteromedial release is completed. If overcorrection is not achieved, the procedure has to be extended in sequence to lateral release or complete subtalar release. Radiographic indications are as follows: diminished talocalcaneal angle on AP (less than 20 degrees) and/or on lateral radiographs (less than 35 degrees), as well as partial overlap of the talus and calcaneus on AP radiographs.

Posteromedial-lateral, posterolateral-medial and partial subtalar release: Indications for these techniques are the same as for posteromedial release. The difference concerns the not corrigible medial spin. The decision about which technique should be used is made before surgery, but its conversion during surgery to another one is possible and depends on obstacles appearing during release. Intraoperative radiographs may help in making the decision.

Complete subtalar release: The clinical indication for this technique is primarily stiff varus and medial spin. The selection of this procedure may be the result of the primary decision or incomplete correction after less extensive procedures. To overcome the obstacles, the talocalcaneal interosseous ligament must be completely cut. Radiographic indications are the same as for posteromedial- lateral or partial subtalar release. Complete overlapping of the talus and calcaneus on AP radiograph inclines the surgeon to choose this method.

All techniques mentioned can be extended to the correction of forefoot adduction. A metatarsal first ray angle lower than 70 degrees is indicated for correction. For small children, the opening of the cuneonavicular and first cuneometatarsal joint with a slight transposition of the tibialis anterior is preferred. In older children, open wedge osteotomy of the medial cuneiform is done. For correction of calcaneocuboid displacement, no open reduction is performed even if a +2 displacement of the cuboid is seen on AP radiograph, because self-existent reduction occurred. However, closed stabilisation of this joint by K-wire is performed. A stable subtalar complex can be rotated as a block during partial or complete subtalar release.