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Adult Outcomes Following Amputation or Lengthening for Fibular Deficiency
Janet L. Walker, MD1; Dwana Knapp, MSW1; Christin Minter, MA1; Jennette L. Boakes, MD2; Juan Carlos Salazar, PhD3; James O. Sanders, MD4; John P. Lubicky, MD5; David M. Drvaric, MD6; Jon R. Davids, MD7
1 Shriners Hospitals for Children, 1900 Richmond Road, Lexington, KY 40502
2 Shriners Hospitals for Children, 2425 Stockton Boulevard, Sacramento, CA 95817
3 Escuela de Estadística, Universidad Nacional de Colombia, Sede Medellín, Calle 59A, #63-020, Bloque 43, Oficina 109, Medellín, Colombia
4 Shriners Hospitals for Children, 1645 West 8th Street, Erie, PA 16505
5 Indiana University School of Medicine, Riley Hospital for Children, 702 Barnhill Drive, ROC 4250, Indianapolis, IN 46202
6 Shriners Hospitals for Children, 516 Carew Street, Springfield, MA 01104
7 Shriners Hospitals for Children, 950 West Faris Road, Greenville, SC 29605
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Shriners Hospitals for Children and Kosair Charities, Inc. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at Shriners Hospitals for Children (Lexington, Kentucky; Northern California [Sacramento, California]; Erie, Pennsylvania; Chicago, Illinois; Springfield, Massachusetts; and Greenville, South Carolina)

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Apr 01;91(4):797-804. doi: 10.2106/JBJS.G.01297
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Background: Fibular deficiency results in a small, unstable foot and ankle as well as a limb-length discrepancy. The purpose of this study was to assess outcomes in adults who, as children, had had amputation or limb-lengthening, commonly used treatments for fibular deficiency.

Methods: Retrospective review of existing data collected since 1950 at six pediatric orthopaedic centers identified 248 patients with fibular deficiency who were twenty-one years of age or older at the time of the review. Excluding patients with other anomalies and other treatments (with the excluded group including six who had had lengthening and then amputation), we identified ninety-eight patients who had had amputation or limb-lengthening for the treatment of isolated unilateral fibular deficiency. Sixty-two patients (with thirty-six amputations and twenty-six lengthening procedures) completed several questionnaires, including one asking general demographic questions, the Beck Depression Inventory-II, the Quality of Life Questionnaire, and the American Academy of Orthopaedic Surgeons Lower Limb Questionnaire including the Short Form-36. A group of twenty-eight control subjects completed the Beck Depression Inventory-II and the Quality of Life Questionnaire.

Results: There were forty men and twenty-two women. The average age at the time of the interview was thirty-three years. There were more amputations in those with fewer rays and less fibular preservation. Lengthening resulted in more surgical procedures (6.3 compared with 2.4 in patients treated with amputation) and more days in the hospital (184 compared with sixty-three) (both p < 0.0001). However, when we compared treatment outcomes we did not find differences between groups with regard to education, employment, income, public assistance or disability payments, pain or use of pain medicine, sports participation, activity restriction, comfort wearing shorts, dislike of limb appearance, or satisfaction with treatment. No patient who had been treated for fibular deficiency reported signs of depression. The only significant difference between treatment groups shown by the Quality of Life Questionnaire was in the scores on the Job Satisfiers content scale, with the amputees scoring better than the patients treated with lengthening (p = 0.015). The American Academy of Orthopaedic Surgeons Lower Limb Module did not demonstrate differences in health-related quality of life or physical function.

Conclusions: The patients who were treated with lengthening had started out with more residual foot rays and more fibular preservation than the amputees. They also required more surgical intervention than did those with an amputation. While patients with an amputation spent less of their childhood undergoing treatment, they were found to have a better outcome in terms of only one of seventeen quality-of-life parameters. Both groups of patients who had had treatment of fibular deficiency were functioning at high levels, with an average to above-average quality of life compared with that of the normal adult population.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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