Fig. 6.

a Radiographs of a 3-year-old girl with unilateral tibial hemimelia, Paley type 2B tibial hemimelia + metatarsals/toes. The obvious delta tibia is seen with two secondary ossific nuclei. The foot has seven metatarsals and eight toes. The foot is in equino-varus. The ankle and knee joint are maloriented. The proximal fibula is relatively overgrown and sits proximal to the distal femoral physis. b Clinical photograph of same girl. c Arthrogram of knee and ankle showing joint malorientation and dysplasia. d AP (left) and lateral (right) radiographs with TSF in place and osteotomy lengthening and deformity correction of the tibia. The foot deformity correction is partially through the distal tibial reorientation. Note there is no osteotomy of the fibula and that it is only fixed to the distal tibial ring using one distal tibio–fibular wire and half pin. e AP (left) and lateral (right) radiographs following 8 cm of tibial lengthening and deformity correction with distal fibular transport. The frame was modified connecting the distal tibiofibular wire and fibular half pin to the proximal ring. This frees the ankle joint for distraction correction of the remaining foot deformity. Note that the proximal fibula has been pulled down almost to station. f Two years after removal of the external fixator the tibia is well consolidated. The fibula is already showing significant relative proximal and distal overgrowth. The distal fibular epiphysiodesis screw’s head is migrated into the epiphysis and screw shaft is broken rendering it mostly ineffective at this juncture. The foot varus deformity is slowly recurring. This will require another differential lengthening surgery in a year or two. g Clinical photos showing knee and ankle range of motion two years after lengthening. h This girl is very active despite recurrent leg length difference and mild foot deformity. Note how she plays with the other girls while she wears a shoe lift. She is the tall girl in the middle