Weinstein Lovell and Winters Pediatric Orthopaedics 7e

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CHAPTER 30  |  The Child with a Limb Deficiency

FIGURE 30-2. A–C : Clinical photos and AP radiograph of the tibia exhibiting bony overgrowth and ulcer formation.

should be used first unless a bony spike is felt. If revision sur- gery is necessary, a capping procedure should be ­considered. In the case of a primary amputation, it is advisable to use available parts from the amputated portion of the limb to cap the end of the bone, if conditions permit. The most com- mon procedure is the use of the proximal fibula to cap the tibia (Figs. 30-3A–E). As in any revision, adequate resection of the bone is essential to provide a healthy soft-tissue enve- lope. Harvest of the proximal fibula involves detaching the

lateral collateral ligament of the knee, which can theoretically lead to lateral knee instability. However, there have been no reports of lateral knee instability after proximal fibular resec- tion for biologic capping, and the literature regarding knee instability after proximal fibular resection for tumors is mixed (50–54). Given that the literature is unclear on the need for lateral ligamentous reconstruction, it seems reasonable to test intraoperative knee instability and repair or reconstruct the ligament if necessary.

FIGURE 30-3. A–D : Intraoperative pho- tos demonstrating proximal fibular harvest and subsequent insertion of the proximal fibula in the medullary canal of the tibia (modified Marquardt procedure). E : AP radio- graphic appearance of the tibia 6 weeks after the procedure.