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PubMed This is a summary of 15 peer-reviewed journal articles Updated
Pediatric Orthopedics

The Surgical Journey: Reconstruction and Lengthening

At a Glance

Surgical treatment for fibular hemimelia involves a multi-step process. Surgeons first stabilize the ankle using the SHORDT or SUPERankle procedure, followed by limb lengthening (distraction osteogenesis) using external frames or internal nails. The recovery phase requires rigorous daily physical therapy and pin care.

Choosing surgical reconstruction and limb lengthening is a commitment to a “surgical marathon.” The goal is not just to make the leg longer, but to build a stable, strong foundation that allows your child to walk, run, and jump on their own foot [1][2].

Step 1: Building a Stable Foundation

Before any lengthening can happen, the ankle must be stable and the foot must be flat (plantigrade) [1]. This initial reconstruction surgery usually occurs around 18 to 24 months of age [3]. Surgeons use two primary “reconstruction” methods:

  • The SHORDT Procedure: Used for ankles that tilt outward only when walking (dynamic valgus). The surgeon “shortens” the tibia bone, which effectively “lengthens” the short fibula, giving the ankle the side-support it needs [2].
  • The SUPERankle Procedure: Used for more severe, “fixed” deformities. The surgeon performs precise bone cuts (osteotomies) to realign the ankle and foot bones without lengthening the tendons, which preserves the child’s muscle strength [2][4].
  • Removing the “Bowstring”: A key part of these surgeries is removing the fibular anlage, a tough tissue band that acts like a bowstring pulling the ankle into a tilt [1][5]. Removing it helps prevent the deformity from returning as the child grows [6].

Step 2: The Mechanics of Lengthening

Once the ankle is stable, the lengthening phase begins. This involves distraction osteogenesis: the surgeon carefully cuts the bone and then slowly pulls the two halves apart (usually about 1 millimeter per day), allowing new bone to grow in the gap [7].

  • External Fixators (Frames): These are metal rings or bars on the outside of the leg, connected to the bone by pins. They are excellent for complex corrections in young children but require daily pin-site care to prevent infection [8][9].
  • Internal Nails (e.g., PRECICE): These are telescopic rods placed entirely inside the bone and lengthened using an external magnet. Because they must fit inside the bone marrow canal, they are typically only an option once the child is around 8 years of age or older [10][11].

Life During the “Distraction” Phase

The distraction phase requires tremendous physical and emotional endurance from the whole family. The active pulling phase lasts several months, followed by several more months of waiting for the new bone to harden (consolidation) [7].

  • Physical Therapy: This is non-negotiable. To prevent joint stiffness, children often need physical therapy up to 5 days a week [7][2].
  • Psychological Toll: The daily frame adjustments and physical limitations can be emotionally draining for a child. Preparing for this psychological reality is just as important as the physical prep.
  • Monitoring Bone Growth: The new “regenerate” bone is fragile at first. If the frame is removed too early or the child falls, a regenerate fracture can occur [12][13].
  • Pin Care: For external fixators, managing pin tract infections with daily cleaning and occasional antibiotics is a standard part of the process [9][11].

While the process is long, the result of modern reconstruction is a limb that is stable, equal in length, and fully functional for a lifetime of activity [14][15].

Common questions in this guide

What is the first step in fibular hemimelia lengthening surgery?
Before any lengthening can occur, surgeons must stabilize the ankle and ensure the foot is flat. This is achieved through reconstruction surgeries, such as the SHORDT or SUPERankle procedures, typically performed when the child is 18 to 24 months old.
What is the difference between the SHORDT and SUPERankle procedures?
The SHORDT procedure is used when the ankle only tilts outward during walking, whereas the SUPERankle procedure corrects more severe, fixed deformities. Both procedures aim to build a stable foundation before limb lengthening begins.
How does limb lengthening work for fibular hemimelia?
Surgeons use a process called distraction osteogenesis. The bone is carefully cut and slowly pulled apart using an external frame or internal nail, usually about one millimeter per day. This gradual stretching allows new bone to naturally grow and fill the gap.
When can an internal lengthening nail be used instead of an external frame?
Internal lengthening nails, like the PRECICE system, must fit inside the bone's marrow canal. Because of this size requirement, they are typically only an option once a child is around 8 years of age or older. Younger children usually require external fixators.
What is the recovery like during the limb lengthening phase?
The lengthening phase requires a significant daily time commitment. This includes rigorous physical therapy up to five days a week to prevent joint stiffness, and daily cleaning to prevent pin infections if an external frame is used.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Based on my child's current ankle stability, are they a better candidate for the SHORDT procedure or the SUPERankle procedure?
  2. 2.What specific physical therapy protocols do you recommend during the 'distraction' phase to prevent my child's knee and ankle from getting stiff?
  3. 3.At what age or bone size do you typically transition from using external fixator frames to internal lengthening nails like the PRECICE system?
  4. 4.If a regenerate fracture occurs after the frame is removed, what is the typical 'plan B' for treatment?

Questions For You

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References

References (15)
  1. 1

    Ankle Reconstruction in Fibular Hemimelia: New Approach.

    Hefny H, Elmoatasem EM, Mahran M, et al.

    HSS journal : the musculoskeletal journal of Hospital for Special Surgery 2017; (13(2)):178-185 doi:10.1007/s11420-016-9524-6.

    PMID: 28690469
  2. 2

    Surgical reconstruction for fibular hemimelia.

    Paley D

    Journal of children's orthopaedics 2016; (10(6)):557-583 doi:10.1007/s11832-016-0790-0.

    PMID: 27909861
  3. 3

    Outcomes of Simultaneous Lengthening and ACL Reconstruction in Fibular Hemimelia: A Retrospective Case Series.

    Reeves B, Roper B, Salton R, et al.

    The Iowa orthopaedic journal 2024; (44(1)):93-98.

    PMID: 38919371
  4. 4

    Correction of Ankle Malalignment in Severe Fibular Hemimelia.

    Shadi M, Janusz P, Kotwicki T

    Journal of pediatric orthopedics 2025; (45(4)):e366-e377 doi:10.1097/BPO.0000000000002876.

    PMID: 39676695
  5. 5

    Embryology of the lower limb demonstrates that congenital absent fibula is a radiologic misnomer.

    Hootnick DR, Levinsohn EM

    Anatomical record (Hoboken, N.J. : 2007) 2022; (305(1)):8-17 doi:10.1002/ar.24628.

    PMID: 33773063
  6. 6

    Prevention of recurrence of tibia and ankle deformities after bone lengthening in children with type II fibular hemimelia.

    Popkov A, Aranovich A, Popkov D

    International orthopaedics 2015; (39(7)):1365-70 doi:10.1007/s00264-015-2752-4.

    PMID: 25832175
  7. 7

    Limb lengthening: slower distraction rates may expedite patient joint recovery.

    Tang H, Heydemann JA, McHorse KJ, et al.

    Journal of applied physiology (Bethesda, Md. : 1985) 2025; (139(6)):1649-1654 doi:10.1152/japplphysiol.00623.2025.

    PMID: 41263148
  8. 8

    Use of Hexapod External Fixation in Limb Lengthening in Patients with Disproportionate Short Stature: A Systematic Review of the Last 20 Years.

    Testa G, Marchetti M, Sapienza M, et al.

    Journal of clinical medicine 2025; (14(4)) doi:10.3390/jcm14041091.

    PMID: 40004622
  9. 9

    Aesthetic lower limb lengthening techniques: a systematic review of efficacy, complications, and patient satisfaction.

    Giorgino R, Cornacchini J, Sillmann YM, et al.

    Journal of orthopaedic surgery and research 2025; (20(1)):415 doi:10.1186/s13018-025-05808-x.

    PMID: 40275369
  10. 10

    Meta-analysis of complications and functional outcomes in cosmetic limb lengthening.

    Bulut H, Altin O, Salduz I, Salduz A

    Journal of orthopaedics 2025; (65()):41-45 doi:10.1016/j.jor.2024.12.012.

    PMID: 39801900
  11. 11

    Motorized Internal Limb-Lengthening (MILL) Techniques Are Superior to Alternative Limb-Lengthening Techniques: A Systematic Review and Meta-Analysis of the Literature.

    Sheridan GA, Falk DP, Fragomen AT, Rozbruch SR

    JB & JS open access 2020; (5(4)) doi:10.2106/JBJS.OA.20.00115.

    PMID: 38090621
  12. 12

    Risk Factors for Complications in Reconstructing Congenital Femoral Deficiency.

    Shahcheraghi GH, Javid M, Nemati A

    The Journal of the American Academy of Orthopaedic Surgeons 2025; (33(9)):e511-e521 doi:10.5435/JAAOS-D-24-00090.

    PMID: 39693525
  13. 13

    Clinical Results and Complications of Lower Limb Lengthening for Fibular Hemimelia: A Report of Eight Cases.

    Mishima K, Kitoh H, Iwata K, et al.

    Medicine 2016; (95(21)):e3787 doi:10.1097/MD.0000000000003787.

    PMID: 27227952
  14. 14

    Lengthening Reconstruction Surgery for Fibular Hemimelia: A Review.

    Fuller CB, Shannon CE, Paley D

    Children (Basel, Switzerland) 2021; (8(6)) doi:10.3390/children8060467.

    PMID: 34199455
  15. 15

    Use of Paley Classification and SUPERankle Procedure in the Management of Fibular Hemimelia.

    Kulkarni RM, Arora N, Saxena S, et al.

    Journal of pediatric orthopedics 2019; (39(9)):e708-e717 doi:10.1097/BPO.0000000000001012.

    PMID: 31503232

This page provides educational information about surgical reconstruction and lengthening for fibular hemimelia. Always consult your child's pediatric orthopedic surgeon for personalized medical advice and surgical planning.

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