Summary

This case series reviews the outcomes and challenges associated with ACL reconstruction in 6 adolescent patients known for fibular hemimelia.

Abstract

Background

Fibular Hemimelia (FH), a congenital deficiency in the fibular bone, is the most common long bone
deficiency with an estimated incidence of between 1:135,000 and 1:50,000 births [2]. Furthermore,
some FH patients are known for knee cruciate ligament hypoplasia or deficiency that can lead to
further damage in knee structures [2]. In fact, the ACL and PCL are deficient in up to 95% and 60%
of FH patients respectively, leading to knee instability and increasing their risk for knee injuries [3].
The purpose of this case series is to assess the outcomes and challenges associated with cruciate
ligament reconstruction in patients with FH.

Methods

Six patients aged from 15 to 22 years known for fibular hemimelia who underwent a cruciate
ligament reconstruction were included in this study. The operative protocols were reviewed to
identify the anatomical abnormalities and specific surgical characteristics. Patient outcomes were
assessed using passive and active range of motion, Lachman test grades and PEDI-IKDC grades.

Results

All 6 patients included in this study underwent successful cruciate ligament reconstruction surgery.
The knee stabilizing procedure was indicated in five patients prior to a limb lengthening procedure
and in one patient to improve knee stability for sports. Four patients had a hypoplastic ACL and 2
patients had an absent ACL. Five ACL reconstructions were performed using an Achilles tendon
allograft. A tibialis anterior allograft was used for the ACL and an Achilles tendon allograft was
used for the patient who required both ACL and PCL reconstruction. Only one patient underwent
concomitant PCL reconstruction. All patients underwent a notchplasty to allow for cruciate ligament
reconstruction. Three out of six patients required partial meniscectomy for associated meniscal tears.
Postoperatively, no patient reported knee instability. All patients completed a course of
physiotherapy and regained full ROM. All postoperative Lachman test grades post-surgery were 1A.

Discussion

This study demonstrates the efficacy of ACL reconstruction in FH patients who require a knee
stabilization procedure prior to limb lengthening procedures or to improve their knee function and
allow them to play sports. Cruciate ligament reconstruction can allow patients to partake in
high-level sports or improve their function in normal day to day activities, as well as avoiding future
secondary sequelae of congenitally hypoplastic or absent cruciate ligaments.

References:
1. Achterman C, Kalamchi A. Congenital deficiency of the fibula. J Bone Joint Surg Br. 1979 May;61-B(2):133-7. doi: 10.1302/0301-620X.61B2.438260. PMID: 438260.
2. Paley D. Surgical reconstruction for fibular hemimelia. J Child Orthop. 2016 Dec;10(6):557-583. doi: 10.1007/s11832-016-0790-0. Epub 2016 Dec 1. PMID: 27909861; PMCID: PMC5145840.
3. Roux MO, Carlioz H. Clinical examination and investigation of the cruciate ligaments in children with fibular hemimelia. J Pediatr Orthop. 1999 Mar-Apr;19(2):247-51. doi: 10.1097/00004694-199903000-00022. PMID: 10088698.