Variations of Putti procedure for reconstruction of congenital absence of tibia. A, Fibula is inserted into hindfoot with foot in severe equinus to lengthen limb. Fibula also has been transferred to intercondylar notch. B, Fibula has been transferred to intercondylar notch, and distal tibiofibular synostosis has been created. C, Type 2 deficiency. Fibula has been synostosed to proximal tibia and inserted into hindfoot with foot positioned in equinus to obtain additional length. End-to-end synostosis is preferred; if side-to-side synostosis is performed, transverse screw can be used for fixation.