Introduction: Current classification schemes of fibular hemimelia concentrating on the radiographic appearance of the fibula do not adequately aid management of these patients. We reviewed our fibular hemimelia patient experience to devise a classification scheme which could serve as a better guideline for management decisions for this disorder.

Method: We reviewed the records/radiographs of all patients with the diagnosis of fibular hemimelia treated at our institution between 1957 & 1996. We excluded patients with PFFD, inadequate radiographs, or whose treatment was initiated elsewhere. We proposed a clinical management-oriented classification based on the presence/absence of a functional foot and overall limb shortening relative to the contralateral side (irrespective of the relative contributions of femoral & tibial shortening, or bilateral disease). The classification (with treatment guidelines) is:

Type I. Functional foot

Shortening 5% or less (none or epiphysiodesis)

Type II. Non-functional foot

Upper extremities functional (amputation)

A functional foot was defined as one which was or could be made plantigrade and stable with at least three rays.

Results: We identified 146 extremities in 122 patients with fibular hemimelia. 117 extremities were Type I (53 IA, 32 IB, 29 IC, and 1 ID), and 29 were Type II (28 IIA and 1 IIB). Limb length inequality remained proportional throughout growth, so that the distribution between groups did not change during growth.

Twenty-four patients had bilateral involvement. Twenty of 48 feet in these patients were Type II (nonfunctional). Nine patients with bilateral involvement had bilateral functional feet; these patients were short-statured, but were Type IA functionally.

The number of rays correlated directly with function: 100% of 5-rayed, 90% of 4-rayed, and 64% of 3-rayed feet were salvaged in this series. No feet less than 3-rayed were salvaged in this group; all such feet were associated with a completely absent fibula. Thirty-six of 63 limbs with completely absent fibula were classified as Type I. Eighty-two extremities in 65 patients have completed definitive management by virtue of skeletal maturity or amputation. A total of 39 extremities underwent Syme amputation, including 1 of 30 type IA, 1 of 11 type IB, 9 of 12 type IC, the single patient type ID, and all 27 type IIA deformities.

Conclusions: This classification system correlated well with the treatment required in our patients. While the amount of fibula present correlated with limb length inequality, 56% of patients in this series with absent fibula have been managed with limb salvage. The definition of a functional foot, and the boundary between multi-staged lengthening and amputation will remain an individual decision, but our classification scheme accurately predicted the amount of deformity present and the treatment required.

Introduction: Nonsteroidal anti-inflammatory medications such as Ibuprofen are commonly used to aid in the management of chronic pain in both children and adults. These medications are known to retard fracture consolidation and inhibit the formation of heterotopic bone in susceptible patients. We wished to determine the deleterious effects, if any, of the administration of therapeutic doses of Ibuprofen on the strength of regenerate bone in a caprine model.

Method: Twelve skeletally immature cross-bred goats were divided into two groups. In both groups, a standard four-ring, 6-wire Ilizarov apparatus was fixed to the tibia of one hindlimb and mid-diaphyseal corticotomy performed. After a five-day latency period, the operated tibiae were lengthened to 20% of their original length at rate and rhythm of 0.25mm TID. Consolidation time was standardized at 80 days. Group I received Ibuprofen at a dose of 20mg/kg BID PO during the entire postoperative period. Group II received no additional medication, and served as the control group. The animals were monitored for gatrointestinal intolerance, blood dyscrasias, and blood levels of Ibuprofen throughout the experiment. At the end of consolidation, the twelve lengthened tibiae and the contralateral tibiae were harvested for mechanical testing.

Results: In the medicated group, no adverse affects on the gastrointestinal or hematopoietic organ systems were identified. Blood Ibuprofen levels remained in the low therapeutic range during the course of the experiment (average levels 28.9 ug/ml at 1.5 hrs, 15.1ug/ml at 4 hrs., and 2.6 ug/ml at 8 hrs., after oral administration of Ibuprofen) .

One nonunion developed in each of the two treatment groups, and was unsuitable for mechanical testing. The remaining 22 tibiae (10 lengthened, and 12 contralateral unoperated, tibiae) were torqued to failure on the MTS testing machine. There were no significant differences between the unoperated tibiae of the Ibu-profen group and the unmedicated group measuring torsional toughness, stiffness, and strength. Similarly, there were no differences detected using these parameters between the lengthened tibiae of the medicated and unmedicated groups.

No adverse systemic affects were noted during the course of this experiment, in which low therapeutic levels of Ibuprofen were maintained for an average of 120 days. No affect on the torsional strength of the unoperated tibia was detected. No adverse affect on the torsional strength, stiffness, or toughness of the regenerate of the medicated group was noted compared to the control group.

Conclusions: The chronic administration of Ibuprofen was well-tolerated and did not adversely affect the strength of untreated or lengthened tibiae in this model.