Introduction: The purpose of this cadaver study was to test feasibility and safety of a new technique for harvesting the FDL tendon through a plantar incision placed directly overlying the FDL division and to define the relevant surgical anatomy.

Materials and Methods: In eight cadaver feet the FDL tendon was exposed in the midfoot through a plantar incision. The FDL tendon was divided and pulled proximally through a wound in the hindfoot. All the tissues superficial to the FDL tendon were then reflected to check for any inadvertent damage to adjacent neurovascular structures.

Results: The FDL division lies midway between the back of the heel and the base of the second toe and about 3.7 cm medial to the lateral border of the foot. The medial and the lateral plantar neurovascular bundles are respectively about 0.43 cm and 0.86 cm away from the FDL division.

Conclusions: The FDL tendon can be harvested through a plantar incision. The adjacent neurovascular structures remained undamaged. Plantar surface anatomy guides placement of the plantar incision so that the incision can overlie directly over the FDL division.

Introduction: Screws placed in the fibula do not have a satisfactory purchase during internal fixation of an osteoporotic ankle fracture. Tibia-pro-fibula screws that extend from the fibula into the distal tibial metaphysis provide additional purchase. The purpose of this study is to investigate if purchase of these screws can be enhanced further by injecting calcium sulfate and calcium phosphate composite graft in the drill holes prior to insertion of the screws.

Methods: Bone density was quantified using DEXA scan in paired cadaver legs. One leg from each pair was randomly selected for injection of composite graft into screw holes before insertion of the screws. Two screws were inserted through the fibula into the distal tibial metaphysis in each leg, at the level of the syndesmosis under fluoroscopy in a standardized fashion using a jig.

The screws were pulled out using a materials testing machine. Stiffness, force, displacement, and energy required were recorded.

Results: After testing 4 pairs of cadaver legs, a statistically significant difference was noted in displacement, failure load, and failure energy between augmented and non-augmented screws, with the augmented screws being considerably stronger. Of the two screws the distal, when compared to the proximal one, required more displacement, higher force and energy to fail whether augmented with composite graft or not.

Conclusion: Screws augmented with composite graft provide significantly greater purchase in an osteoporotic distal tibial metaphysis than non-augmented screws.

Clinical relevance: Use of composite graft to augment purchase of the screws inserted in the distal tibial metaphysis may enhance the stability of the internal fixation of an osteoporotic ankle fracture. This will enable early weight-bearing mobilization and return to function which is important in elderly patients.