A percutaneous supramalleolar osteotomy with multiple drill holes and closed osteoclasis was used to correct rotational deformities of the tibia in patients with cerebral palsy. The technique is described and the results in 247 limbs (160 patients) are reported. The mean age at the time of surgery was 10.7 years (4 to 20). The radiographs were analysed for time to union, loss of correction, and angulation at the site of the osteotomy. Bone healing was obtained in all patients except one in a mean period of seven weeks (5 to 12). Malunion after loss of reduction at the site of the osteotomy developed in one tibia. Percutaneous supramalleolar osteotomy of the tibia is a safe and simple surgical procedure

Background. Until recently, surgical treatments for advanced ankle osteoarthritis have been limited to arthrodesis or ankle replacement. Supramalleolar osteotomy provides a joint-preserving option for patients with eccentric osteoarthritis of the ankle, particularly those with varus or valgus malalignment. Aim. To evaluate radiological and functional outcomes of patients undergoing shortening supramalleolar osteotomy for eccentric (varus or valgus) osteoarthritis of the ankle. Method. Prospective review of patients from 2008 onwards. Osteotomy was the primary surgical procedure in all patients after failure of non-operative measures. Pre-operative standing antero-posterior and Saltzman view radiographs were taken to evaluate degree of malalignment requiring correction. Radiological and clinical outcomes were assessed at 3, 6 and 12 months post-operatively. Radiographs were reviewed for time to union. Patients were assessed on an outpatient basis for ankle range of motion as well as outcomes using AOFAS scores. Results. 33 patients over a 7 year period. Mean follow-up was 25 months (range 22–30). Mean time to radiological union was 8.6 weeks (range 8–10); there were no cases of non-union. There was a statistically significant improvement in functional scoring (P< 0.001); mean AOFAS score improved from 34.8 (range 15–40) pre-operatively to 79.9 (range 74–90) at 12 months post-operatively. There was no significant change in pre- and post-operative range of motion. 2 patients required revision surgery at 12 months; one to arthrodesis and one to ankle replacement. Conclusion. Supramalleolar osteotomy is a viable joint preserving option for patients with eccentric osteoarthritis of the ankle. It preserves motion, redistributes forces away from the affected compartment and corrects malalignment, providing significant symptomatic and functional improvement

Until recently, surgical treatments for advanced ankle osteoarthritis have been limited to arthrodesis or ankle replacement. Supramalleolar osteotomy provides a joint-preserving option for patients with eccentric osteoarthritis of the ankle, particularly those with varus or valgus malalignment. The aim of the study was to evaluate radiological and functional outcomes of patients undergoing shortening supramalleolar osteotomy for eccentric (varus or valgus) osteoarthritis of the ankle. We performed a prospective review of patients from 2008 onwards. Osteotomy was the primary surgical procedure in all patients after failure of non-operative measures. Pre-operative standing antero-posterior and Saltzman view radiographs were taken to evaluate degree of malalignment requiring correction. Radiological and clinical outcomes were assessed at 3, 6 and 12 months post-operatively. Radiographs were reviewed for time to union. Patients were assessed on an outpatient basis for ankle range of motion as well as outcomes using AOFAS scores. 33 patients were reviewed over a 7 year period. Mean follow-up was 25 months (range 22–30). Mean time to radiological union was 8.6 weeks (range 8–10); there were no cases of non-union. There was a statistically significant improvement in functional scoring (P<0.001); mean AOFAS score improved from 34.8 (range 15–40) pre-operatively to 79.9 (range 74–90) at 12 months post-operatively. There was no significant change in pre- and post-operative range of motion. 2 patients required revision surgery at 12 months; one to arthrodesis and one to ankle replacement. Supramalleolar osteotomy is a viable joint preserving option for patients with eccentric osteoarthritis of the ankle. It preserves motion, redistributes forces away from the affected compartment and corrects malalignment, providing significant symptomatic and functional improvement

Purpose of the study: Frequently described in pediatric orthopedics, supramalleolar osteotomies are theoretically logical in adults, but relatively little studied. Material and methods: Supramalleolar osteotomy was performed for misaligned callus formation or secondary osteoarthrtitis of the ankle joint in fourteen patients in our institution since 1987. Among these fourteen patients, nine were reviewed, of which three underwent surgery for misaligned callus of the distal third of the tibia measuring more than six degrees and asymptomatic at the time of surgery. The six other patients suffered pain with associated tibiotalar osteoarthritis for four. These six patients also underwent surgery. The nine patients were reviewed clinically and radiographially. Results: Mean follow-up was 53 months (range 6–202 months). Mean time to bone healing measured radiographically was 12.2 weeks (range 9–18 weeks). The difference in time to healing between closed and open wedge osteotomies was not significant (p=0.1, Student’s test). The difference in the preoperative AOFAS score compared with the last follow-up score was statistically significant (p=0.01) with an improvement in the AOFAS pain score (p=0.03). Function scores of open and closed wedge osteotomies were not statistically different (p=0.5). In the four patients who presented ankle osteoarthritis at the time of surgery, there was no postoperative progression of the joint degradation. Conversely, in two patients whose joint was free of signs of osteoarthritis at the time of surgery, stage I signs appeared. These two patients were reviewed at 46 and 202 months respectively from the osteotomy which in both cases had been performed to prevent the supposedly deleterious effect of a distal tibial callus misaligned 10°. Conclusion: Open and closed wedge supramalleolar osteotomies are the preferred procedure for distal tibial callus misalignment measuring more than 10° with the reservation that the underlying joints are sufficiently mobile, the advantage of osteotomy over arthrodesis being closely related to this factor. Arthrodesis might however be considered if joint pain predominates the clinical picture

Aims: The purposes of the current retrospective study were to evaluate the outcome of a consecutive series of supramalleolar osteotomies and to identify the inßu-ence of the technique (opening versus closing wedge) on the outcome and the union rate. Methods: In a þve year period, we performed a supramalleolar osteotomy for the correction of distal tibial mechanical malalign-ment of at least 10¡, with concomitant pain and with or without radiographic evidence of arthritic changes, or as an alternative to other common procedures, for the treatment of a small group of patients with degenerative changes of the ankle joint. Results: There were 14 patients (15 feet) with an average follow up of 31.1 months. All osteotomies healed at an average time of 13.6 weeks. The average AOFAS score improved from 53.8 to 87 points, the average Takakura score from 56.7 to 82 and the average pain score from 13.5 to 31.4. In the presence of deformity the average values of TAS and TLS angles were signiþcantly improved. The radiographic degenerative changes in the ankle joint showed no evidence of progression. The choice of technique did not inßuence the clinical- radiographic outcome and the healing time of the osteotomy. Conclusions: Supramalleolar osteotomy is a useful procedure to: a. reconstruct the normal mechanical environment in malunion preventing or decelerating any long term deleterious effects and improving pain and function levels, and b. to shift and redistribute loads in the ankle joint in an effort to protect the articular cartilage from further degenerative process

Aims: The purposes of the current retrospective study were to evaluate the outcome of a consecutive series of supramalleolar osteotomies and to identify the influence of the technique (opening versus closing wedge) on the outcome and the union rate. Methods: In a five year period, we performed a supra-malleolar osteotomy for the correction of distal tibial mechanical malalignment of at least 10°, with concomitant pain and with or without radiographic evidence of arthritic changes, or as an alternative to other common procedures, for the treatment of a small group of patients with degenerative changes of the ankle joint. Results: There were 14 patients (15 feet) with an average follow up of 31.1 months. All osteotomies healed at an average time of 13.6 weeks. The average AOFAS score improved from 53.8 to 87 points, the average Takakura score from 56.7 to 82 and the average pain score from 13.5 to 31.4. In the presence of deformity the average values of TAS and TLS angles were significantly improved. The radiographic degenerative changes in the ankle joint showed no evidence of progression. The choice of technique did not influence the clinical- radiographic outcome and the healing time of the osteotomy. Conclusions: Supramalleolar osteotomy is a useful procedure to: a. reconstruct the normal mechanical environment in malunion preventing or decelerating any long term deleterious effects and improving pain and function levels, and b. to shift and redistribute loads in the ankle joint in an effort to protect the articular cartilage from further degenerative process

Torsional deformities of the tibia are common in children, but in the majority both the torsion and the associated disturbance of gait resolve without intervention. There are, however, a significant number of children and adults with neuromuscular disease who present with pathological tibial torsion, which may require surgical correction. We conducted a prospective study in two centres, to investigate the outcome of supramalleolar derotation osteotomy of the tibia, using internal fixation with the AO-ASIF T plate. A range of outcome variables was collected, prospectively, for 57 patients (91 osteotomies), including thigh foot angle, foot progression angle, post-operative complications and serial radiographs. Correction of thigh foot angle and foot progression angle was satisfactory in all patients. Three major complications were recorded; one aseptic nonunion, one fracture through the osteotomy site after removal of the plate and one distal tibial growth arrest. We found that supramalleolar derotation osteotomy of the tibia, with AO-ASIF T plate fixation is an effective method for the correction of torsional deformities of the tibia and the associated disturbances of gait in children and adults with neuromuscular disease, with a 5.3% risk of major complications

We report the results of supramalleolar varus osteotomy on seven ankles (in six patients) for haemophilic arthropathy and secondary valgus deformity. The operation reduced pain and the frequency of intra-articular bleeding while preserving joint function for a mean of nine years. The procedure is an attractive alternative to the more commonly used surgical option of arthrodesis

We undertook a prospective study to analyse the outcome of 48 malunited pronation-external rotation fractures of the ankle in 48 patients (25 females and 23 males) with a mean age of 45 years (21 to 69), treated by realignment osteotomies. The interval between the injury and reconstruction was a mean of 20.2 months (3 to 98).

In all patients, valgus malalignment of the distal tibia and malunion of the fibula were corrected. In some patients, additional osteotomies were performed. Patients were reviewed regularly, and the mean follow-up was 7.1 years (2 to 15).

Good or excellent results were obtained in 42 patients (87.5%) with the benefit being maintained over time. Congruent ankles without a tilted talus (Takakura stage 0 and 1) were obtained in all but five cases. One patient required total ankle replacement.

The development of lateral tibial torsion in the paralysed lower limb is well documented, but its pathogenesis is poorly understood. This paper attempts to provide an explanation for its development when it is associated with a varus or equinovarus deformity of the hindfoot. Correction of the lateral tibial torsion by supramalleolar derotation tibial osteotomy and reorientation of the ankle mortise appear to unlock the talus from the laterally rotated position, correcting a mobile hindfoot varus deformity and altering soft-tissue tensions about the ankle so that the correction achieved is maintained. In the presence of a fixed hindfoot deformity, supramalleolar derotation tibial osteotomy is useful as a first-stage procedure before corrective osteotomies of the foot. The operation described is technically simple and carries a low morbidity. Twenty supramalleolar derotation tibial osteotomies in 18 patients have been performed with satisfactory results and few complications.

It has been suggested that a supramalleolar osteotomy can return the load distribution in the ankle joint to normal. However, due to the lack of biomechanical data, this supposition remains empirical. The purpose of this biomechanical study was to determine the effect of simulated supramalleolar varus and valgus alignment on the tibiotalar joint pressure, in order to investigate its relationship to the development of osteoarthritis. We also wished to establish the rationale behind corrective osteotomy of the distal tibia. We studied 17 cadaveric lower legs and quantified the changes in pressure and force transfer across the tibiotalar joint for various degrees of varus and valgus deformity in the supramalleolar area. We assumed that a supramalleolar osteotomy which created a varus deformity of the ankle would result in medial overload of the tibiotalar joint. Similarly, we thought that creating a supramalleolar valgus deformity would cause a shift in contact towards the lateral side of the tibiotalar joint. The opposite was observed. The restricting role of the fibula was revealed by carrying out an osteotomy directly above the syndesmosis. In end-stage ankle osteoarthritis with either a valgus or varus deformity, the role of the fibula should be appreciated and its effect addressed where appropriate

We report the results of a retrospective review of patients that underwent distal tibial deformity correction with transphyseal or supramalleolar osteotomy with or without tibial lengthening. The aims of the procedures performed were to obtain equal leg length, restore the alignment of the ankle joint and tibio—fibular relationship. Supramalleolar osteotomy enables deformity correction, can be combined with lengthening and is appropriate where the tibio—fibular relationship is normal. When the tibio—fibular relationship is abnormal, as is often the case with bone dysplasias, differential tibio—fibular lengthening can be performed. If physeal arrest has occurred, for example after sepsis, deformity correction can be achieved with a transphyseal osteotomy allowing correction and ensuring epiphysiodesis. When the fibular length is excessive, transphyseal osteotomy can be combined with a fibular shortening. Our review encompassed 12 patients over a period of 10 years with 5 having deformity after previous meningococcal septicaemia, 4 with fibular hemimelia, 2 with a history of previous trauma and 1 with deformity occurring after a compartment syndrome as a consequence of snake bite. Seven transphyseal osteotomies were performed in 5 patients (2 bilateral), 4 with deformity secondary to meningococcal septicaemia and 1 with deformity secondary to previous trauma. After 1 transphyseal osteotomy there was recurrent distal tibial deformity (14%) which occurred within 1 year requiring a later supramalleolar dome osteotomy. Of the other 6 transphyseal osteotomies all healed with no residual leg—length inequality or deformity. Seven patients underwent supramalleolar osteotomies with all healing and recurrent deformity occurring in 1 patient (14%). Future lengthening is required in 2 patients and 1 patient will undergo a subtalar joint arthrodesis for a painful valgus hindfoot. Distal tibial deformity correction is challenging but our results show that providing the stated principles are adhered to, successful management with an acceptable recurrent deformity rate is possible

The October 2013 Children’s orthopaedics Roundup. 360. looks at: Half a century of Pavlik treatment; Step away from the child!: trends in fracture management; Posterolateral rotatory elbow instability in children; Osteochondral lesions undiagnosed in patellar dislocations; Oral bisphosphonates in osteogenesis imperfecta; Crossed or parallel pins in supracondylar fractures?; Not too late nor too early: getting epiphysiodesis right; Fixation of supramalleolar osteotomies

Fibular Hemimelia is not just a fibular anomaly but there is entire limb involvement with varied expression in each segment. Factors which we have considered in treatment are the amount of fibula present, percentage of shortening, tibial and leg deformity and foot deformity. Residual or recurrent foot deformity is the prime reason for unsatisfactory results, so we have used Paley's classification which takes into consideration foot deformity. Our series is of 29 cases, Paley type I-7, Type II-6, Type III-16 and none of type IV. Tibial lengthening (+/−) bow correction was performed in 28 cases. Supramalleolar osteotomy was done in 4 cases. In foot, soft tissue release only was done in 6 cases and soft tissue release with osteotomy (subtalar or calcaneal) was done in 14 cases. Amputation was done in 2 cases. Age ranged from 11 months to 16 years. Mean follow up was 4.2 years. Mean lengthening was 3.5 cm. Desires lengthening was achieved in 21/29 cases and plantigrade foot was achieved in 16/29 cases. Complications faced were recurrence of foot deformity, knee valgus, knee fixed flexion deformity, knee subluxation and pin tract problems. Less than 3 rays and more than 25 cm of limb length discrepancy were poor prognostic factors. We had 7 excellent, 16 good and 6 poor results. To conclude, it is difficult to achieve the aim of plantigrade foot and limb length equality in all cases but radical surgery with foot correction and tibial lengthening can give good results

Aim. The treatment of relapsed clubfeet presents a significant challenge. The Ilizarov method of gradual correction has been shown to provide satisfactory outcome. Since 2001 we have employed a newer differential soft tissue distraction using an Ilizarov frame in relapsed feet based on the Ponseti principles. The aim of our study was to analyse the outcome of this treatment. Material and Methods. All feet treated with soft tissue distraction only were studied. The feet were assessed using international clubfoot study group evaluation, pedobarography, and gait analysis, X-rays and ASK (activity scale for kids) questionnaire. Results. Out of 35 feet, 16 children with 27 feet attended for follow-up. The indications for surgery were failed multiple surgeries in 19 feet and failed Ponseti in 8 feet. The average age at operation was 5 years and the median follow-up was 5 years. The average duration of the frame was 5 months. Using international club foot scoring evaluation 25 feet scored ‘good’ and 2 scored ‘fair’. The pedobarography and gait analysis showed improvement when compared to the pre-operative assessment. The ASK functional questionnaire showed all 16 children were able to be independent most of the time. Grade 1 infection was noted in all cases. There were no physeal disruptions, growth arrest or joint subluxations. Five feet needed tibialis anterior transfer, 2 underwent supramalleolar osteotomy, 1 needed percutaneous tendo achilles lengthening and 1 needed scar revision as further surgical procedures. The deformity has recurred in 1 foot and is waiting for bony correction. Conclusion. We conclude that the Ponseti principles of soft tissue differential distraction with Ilizarov frame give reasonable results

Purpose. To define the orthopaedic problems associated with pseudoachondroplasia (PSACH) and their functional impact. Methods. We reviewed the medical records of 12 consecutive patients presenting to our unit. Radiographic analysis of deformity included assessment of mechanical axis and dysplasia at hip, knee and ankle measured by acetabular index (AI), Reimer's migration percentage (MP), neck-shaft angle, distal lateral femoral (aDFLA) and proximal (mMPTA) and distal tibial angles. The paediatric/adolescent PODCI questionnaires and the SF36 were used to assess quality of life issues. Results. 12 patients (9 female) were reviewed at median age 18yrs (range 12-43yrs). Most symptoms related to walking tolerance, joint discomfort and deformity: 9 patients had genu varum, 7 tibial torsion, 2 patella instability and 3 significant low back pain. All patients had hip dysplasia. 10 had medial displacement of the mechanical axis, with a mean mDFLA 105 deg (88 -128) and mMPTA 75deg (51-90). 2 patients have been treated only with growth hormone; 10 patients have undergone a total of 9 distal femoral, 19 proximal tibial and 2 supramalleolar osteotomies. 6 procedures were performed using an external fixator. 7 limb segments have been treated by guided growth and in all these cases alignment has improved. One patient has had bilateral hip arthroplasties (age 29), a second patient has had bilateral patellectomies. These 10 patients have undergone a mean 3.8 operative procedures on a mean 2.4 occasions. Patients scored less well than their peer groups in all domains of the PODCI assessment. All have maintained some independent mobility. Conclusions. PSACH is a severe skeletal dysplasia with deformity at all levels of the lower limb affecting patient satisfaction and quality of life. Knee deformities are those which most frequently require surgical intervention. Significance. The genetic defect in PSACH differs from that in achondroplasia, joint degeneration is more common and maintenance of limb alignment is essential

Acquired pilon deformities are often a combination of axial deviation, translation, rotational defects and leg length discrepancy. Correction of a deformity pattern with a percutaneous rectilinear supramalleolar osteotomy and an external fixation by Ilizarov apparatus aims to reduce misalignment progressively, simultaneously and minimally invasively. From 1994 to 2004, 27 patients were treated for pilon tri-planar deformity of the leg. The mean age was 27 years (range 16 to 49 years); 15 were males and 12 females. Type and level of the deformity were determined by preoperative X-rays. For the procedure, two rings of Ilizarov apparatus are positioned in the segment of the limb proximal to the osteotomy: one at the level of the proximal tibial metaphysis and the other 3–4 cm beyond the osteotomy. A third ring is positioned at the level of the tibial pilon, parallel to the articular edge of the ankle. In order to maintain stability of the ankle, a half ring or horseshoeshaped component should be placed on the calcaneus and metatarsals with opposing olive wires. The positions of the mobile joints between the rings depend on the location of the correction axis. Closed metaphyseal osteotomy is performed in order to correct tri-planar deformities in a progressive way, through angulations and translation in an oblique plane. The half ring on the foot maintains distraction in the ankle, which is necessary to reduce articular compression and to avoid soft tissue damage and muscular contractures in this region. In all cases we achieved correction of the angular or rotational deformities. Bleeding was never over 100 ml. We have not observed any soft tissue damage. Controlled weight-bearing was practised on the first day postoperatively, and the mean hospitalisation time was 4 days. Time required to reach the correction was in a range of 3–6 weeks. In 20 patients the total leg discrepancy was in a range of 1.5–6 cm. We reported no case of infection nor union. The devices were removed after a mean time of 11 weeks (range 8–15 weeks). Corrections of tri-planar deformity of the pilon by the Ilizarov apparatus are progressive and minimally invasive. In addition, it is possible to treat misalignment and lengthening by a single operation. With the apparatus layout combining foot fixation and ankle distraction soft tissue and secondary deformities can be corrected and finally a rapid recovery of weight bearing is possible

We analyzed the radiographic results of patients treated surgically for flatfoot deformity and who underwent medial cuneiform opening wedge osteotomy as part of the operative procedure. The aim of this study was to confirm the utility of the cuneiform osteotomy as part of the correction of hindfoot and ankle deformity. All patients requiring operative management of flatfoot deformity between January 2002 and December 2007 were prospectively entered in a database. We selected all patients who underwent medial cuneiform opening wedge osteotomy. We measured standardized and validated radiographic parameters on pre and post-operative weight bearing radiographs of the foot. All radiographs were assessed using the digital imaging software package (Siemens). The following measurements were used: lateral talus-1st metatarsal angle; medial cuneiform to floor distance (mm), talar declination angle, calcaneal-talar angle, calcaneal pitch angle, 1st metatarsal declination angle, talonavicular coverage angle, and anteroposterior talus-1st metatarsal angle. Other variables including concomitant surgical procedures, healing of the osteotomy, malunion, and adjacent joint arthritis were also noted. There were 86 patients with a mean age of 36 years (range 9–80). 15 patients had bilateral surgery. The aetiology of the deformity was flexible flat-foot in 48, rupture of the posterior tibial tendon in 41, rigid flatfoot deformity with a fixed forefoot supination deformity in 7, and fixed forefoot varus with metatarsus elevatus in 5. In addition to an opening wedge medial cuneiform osteotomy, a lateral column lengthening calcaneus osteotomy was performed in 80, a gastrocnemius recession in 76, a supramalleolar osteotomy in 2, a triple arthrodesis in 4, a subtalar arthroerisis in 13, excision of an accessory navicular in 6, a tendon transfer in 15 and medial-slide calcaneal osteotomy in 8 patients. The mean lateral talus-1st metatarsal angle improved from 23° to 1°; the mean medial cuneiform to floor distance improved from 20mm to 34mm; the mean talar declination angle improved from 39° to 27°; the mean calcaneal-talar angle improved from 64° to 55°; the calcaneal pitch angle improved from 14° to 23°; the mean 1st metatarsal declination angle improved from 17° to 26°; the mean talonavicular coverage angle improved from 45° to 18°; and the mean anteroposterior talus-1st metatarsal angle improved from 19° to 0° Radiographical analysis confirms that the medial cuneiform opening wedge osteotomy is a reliable and valuable surgical tool in the correction of the forefoot which is associated with flatfoot deformity and that arthrodesis of the 1st metatarsocuneiform joint may not be required to obtain correction of the elevated 1st metatarsal

Introduction: Tibial pilon acquired deformities are often a combination of axial deviation, translation, rotational defects and leg length discrepancy. Correction of deformity pattern with a percutaneous rectilinear supramalleolar osteotomy and an external fixation by Ilizarov apparatus aims to reduce misalignment progressively, simultaneously and mini-invasively. Method: From 1994 to 2004, 29 patients have been treated for pilon tri-planar deformity of the leg. The mean age was 26 years (range 16 to 49 years), 15 were males and 14 females. Type and level of the deformity were determined by preoperational X-ray pictures. Two rings of Ilizarov apparatus are positioned in the segment of the limb proximal to the osteotomy: one at the level of the proximal tibial metaphysis and the other 3–4 cm further the osteotomy. A third ring is positioned at the level of the tibial pilon, parallel to the articular edge of the ankle. In order to maintain stability of the ankle, a half ring or horseshoe-shaped component should be placed on the calcaneus and metatarsals with opposing olive wires. The positions of the mobile joints between the rings will depend on the location of the correction axis. The closed metaphiseal osteotomy is performed in order to correct triplanar deformities in a progressive way, through angulations and translation in an oblique plane. The half ring on the foot allows maintaining the ankle distracted, which is necessary to reduce articular compression and to avoid soft tissue damages and muscular contractures in this region. Correction of translational deformities, axial deviation, and rotational deformities we performed in two stages. The axial deviation and translational deformity should be corrected in the first stage, and the rotational deformity is corrected during the second stage. Results: In all cases we achieved correction of the angular or rotational deformities. Bleeding was never over 100 ml. We have not observed any soft tissue damages. Controlled weight-bearing was practiced in first day postoperatively, and the mean hospitalization time was 4 days. Time required to reach the correction was in a range of 3–6 weeks. In 20 patients the entire of the leg discrepancy was in a range of 1,5–6 cm. We reported no case of infection or non union. The devices have been removed after a mean time of 11 weeks (range 8–15 weeks). Conclusion: Corrections of triplanar deformity of the pilon by the Ilizarov apparatus are progressive and mini–invasive. Also, it allows treating misalignment and lengthening by a single operation. The apparatus layout combining foot fixation and ankle distraction permits to correct soft tissues, secondary deformities, and finally a rapid weight bearing recovery

Introduction. Congenital deficiency of the fibula frequently presents as spectrum of musculoskeletal anomalies involving the ipsilateral hip, femur, knee, tibia/fibula, ankle and foot. Until recently the treatment of choice for sever type-II fibular hemimelia has been Syme’s or Boyd’s amputation. The present technique of limb lengthening with distraction osteogenesis have proved to be a valid alternative. The study shows that simultaneous treatment of tibial and foot deformities allows the patient to obtain a plantigrade foot and to avoid the prosthetic choice of treatment. Materials and methods. 12 patients with 15 involved extremities underwent tibial lengthening and correction of the foot deformities for congenital tipe II fibular hemimelia with Ilizarov apparatus. There were 10 boys and 2 girls, range 7 years 3 month to 16 years 2 month (mean 10 years 7 month). The mean follow up time was 28 months ( range 15–63 month). Most of the patients had hypoplasia of the lateral femoral condyle and femoral shortening and simultaneous lengthening of femur in 9 cases was performed. Valgus-procurvatum deformity of tibia was present in all cases, absent lateral rays were present in 8 feet, foot coalition in 5 feet. Results. Lengthening of the tibia was performed at one level in 4 cases In the other 11 it was performed simultaneously with a proximal osteotomy of tibia to correct thevalgus and with a supramalleolar osteotomy to obtain axial realignment of ankle. Correction of the foot deformities was performed by closed method in 5 cases with overcorrecton in varus-adduction and plaster cast. Subtalar osteotomy in the presence of coalition was performed in 5 cases, osteotomy of calcaneus for equinus in3, and in 2 cases osteotomy through rigid subtalar joint. Osteotomy of midfoot for abducted and equines forefoot was performed in 3 cases. In two difficult rigid cases ankle arthrodesis was needed to stabilise the foot. Prophylactic anlage excision with soft tissue release and Achilles-tendon lengthening in 13 cases. Good results were achieved in 12 cases. 2 were successful and one poor because the patient refused continuing treatment with external fixator. There were 5 major and 16 minor complications. Complications involving delayed consolidation, bending or deformation of regenerated bone, early consolidation were observed in 4 cases. Complications involving soft tissue were observed in 9 cases, There were no permanent neurological and vascular injures. Conclusions. The Ilizarov technique provides a means of achieving simultaneous lengthening of the femur and tibia, angular and rotational deformities correction in children with congenital type II fibular hemimelia. This method should be combined with simultaneous ankle and foot reconstruction for correction of eqininovalgus deformity associated instability and subluxation of ankle. This method should be combined with simultaneous ankle and foot reconstruction for correction of eqininovalgus deformity associated instability and subluxation of ankle. Various types of osteotomy of the hind and mid food give the possibility to achieve the stable result of correction