The Knud Jansen lecture. The operative treatment of congenital limb malformation--part III.

Longitudinal deficiency tibia, total or partial Orthopaedic-surgical t reatment cannot be avoided if a child with this condition is to walk. If possible the operat ion is carried out at the suckling age, so that walking can start according to the child's development . If, in the case of longitudinal deficiency tibia total , the femoral condyles and the knee capsule are normal , and if the child is to be operated on not later than in his second year of life, the Brown (1965) procedure—that is the construction of a knee joint between the femoral condyles and the head of the fibula—is indicated. Dur ing a second operating session the distal end of the fibula is fused with the astragalus or calcaneus according to Blauth (1978) in preference to disarticulation of the ankle joint. F r o m the third year of life, disarticulation of the knee joint is the me thod of choice if the tibia is totally lacking and a normal femur is present. If the distal femur is hypoplastic, there may be a m o r e or less serious disturbance of the growth and , after a knee disarticulation, a cone shaped, eventually mid-thigh and poor load carrying s tump end . In such a case, especially if malformations of the upper limbs are present, fusion be tween the condyles of the femur and the head of the fibula is recommended; also between the distal end of the fibula and the astragalus or calcaneus, if necessary with ensuing partial amputa t ion of the foot (Marquardt , 1981). Advantages in comparison with knee disarticulation are the better end bearing capacity and the self-supporting and rotationstable fixation of the orthoprosthesis with Velcro closures which a child with a hand or arm disability may manage more easily than a knee disarticulation prosthesis (Fig. 1, left).