Regarding a limb with PFFD, fibular dimelia and mirror foot deformity

Embryonic Vascular Dysgenesis: The Origin of Proximal Femoral Focal Deficiency

BACKGROUND

Proximal Femoral Focal Deficiency (PFFD) is the most proximal manifestation of a syndrome involving Congenitally Shortened lower Limbs (CSL), which also affects the fibula and midline metatarsals. This pattern of congenital human long bone deficiencies corresponds, in a time dependent manner, to the failed ingrowth pathways of new blood vessels of the growing embryonic limb. The distal femoral condyles are, in contrast, served by an alternative vascular supply from around the knee joint, and so remain resistant to the CSL deficiency.

AIM

We hypothesize that embryonic vascular dysgenesis causes PFFD, as well as the cardinal features of the Femoral, Fibular and midline Metatarsal deficiencies (FFM) syndrome.

RESULTS

Arteriography of CSL with PFFD reveals diminution or failed formation of the Femoral Artery (FA), which corresponds to downstream skeletal reductions. It may also reveal preservation of the primitive Axial Artery (AA) of the embryonic limb. The combination of missing and retained primitive vessels inform the time, place, and nature of the etiologic vascular events. This suggests that PFFD is the visible expression of a normally prefigured cartilaginous scaffold of the femur, which develops in conformity with the available pattern of blood vessels present. The teratogen thalidomide, known to affect the forming embryonic vasculature, also produces PFFD indistinguishable from the naturally occurring entity.

CONCLUSION

The entire spectrum of PFFD, including phocomelia, fibular, and metatarsal dystrophisms, should thus be regarded as downstream skeletal results of embryonic arterial dysgeneses.

A Seven Toes Foot: Case Series as an Isolated Dysplasia With Variety of Appearance

A seven toes foot is an extremely rare foot disorder. It may appear as part of a complex limb dysplasia or as an isolated deformity. We present five children with a seven toes foot. Supernumerary bones of the foot were found either as isolated duplicated great and little toe either affecting proximal bones, including the metatarsals or midtarsal bones, characterized as mirror foot. Radiological examination with X-rays was adequate for the evaluation of the affected foot. All patients had dysplasia isolated to the foot. Spine dysplasia was found in one child, and a hypoplastic unilateral little finger in another. The affected foot had a plantigrade shape without leg length discrepancy (LLD). The aesthetic of the enlarged foot with the problems of shoe wear was the main concern of the dysplasia. Surgical treatment was provided after the walking age. Surgery was demanded to provide a cosmetically acceptable foot. Removal of the supernumerary rays, either the medial or the central rays, was performed after the radiological evaluation. Our results were satisfactory, and none of our patients required additional interventions, although a mild varus position of the great toe was still observed in one patient.

Proximal Femoral Focal Deficiency/Congenital Femoral Deficiency: Evaluation and Management

Proximal focal femoral deficiency is a congenital transverse deficiency in which the femur is globally smaller with a typical proximal deformity at the hip that may include distal involvement of knees, leg, and feet. Congenital femoral deficiency (CFD) describes a broader spectrum of longitudinal deficiency inclusive of proximal focal femoral deficiency. CFD may also include lateral distal femoral hypoplasia, knee cruciate ligament deficiency, rotational instability, patellar dislocation, fibular hemimelia, ray absence, and contralateral limb involvement. Treatment intends to maximize function by limb equalization and deformity correction ranging from nonsurgical management using prosthetics to amputation and may include lengthening, shortening, and complex limb reconstruction. Management decisions depend on overall severity and the patient and family's preferences and priorities. Owing to its complexity, CFD is best treated by clinicians with considerable deformity treatment experience who can help guide decision making and embark on a treatment course that will maximize the functional outcome.