Introduction and Objective. Lower limb fractures are amongst the most common surgically managed orthopaedic injuries, with open reduction and internal fixation (ORIF) as the conventional method of treatment of the fibula. In recent years, dedicated intramedullary implants have emerged for fibula fixation in tandem with the move towards minimally invasive surgery in high-risk patients. This is the largest multicentre review to date with the aim of establishing the clinical outcomes following intramedullary nail (IMN) fixation of the fibula and to identify the absolute indication for fibula IMN fixation. Materials and Methods. A retrospective study of adult patients in all UK hospitals, who underwent fibula nail fixation between 01/01/2018 and 31/10/2020 was performed. Primary outcome measures included time to union, infection rate, other post-operative complications associated with the fixation and length of hospital stay. The secondary outcome measure was to identify the indication for fibula nailing. Data tabulation was performed using Microsoft Excel and analysis was performed using SPSS Version 23 (SPSS Statistics). Results. 2 Major Trauma Centres (MTCs) and 9 Trauma Units (TUs) were eligible for inclusion. 102 patients were included and 91% were classified as ankle fractures of 68% (n=69) were Weber B, 24% (n=24) Weber C and 8% (n=9) were either distal tibial fractures with an associated fibula fracture or pilon fractures. The mean age was 64 years of which 45 were male patients and 57 were female. The average BMI was 30.03kg/m. 2. and 44% of patients were ASA 3. 74% of patients had poor pre-op skin condition including swelling and open wounds. The calculated infection rate for fibula nail was 4.9% and metal-work complication rate was 4.9%. The average time to union was 13 weeks and length of inpatient stay was 15 days (SD +/− 12 days). Conclusions. MEFNO has demonstrated that fibula nail is an ideal implant in patients who have a physiologically higher risk of surgery, poor skin condition and a complex fracture pattern. The time to union, complication and infection risks are lower than that reported in literature for ankle ORIFs

Introduction. Fibula shortening with an intact anterior tibiofibular ligament (ATFL) and medial ligament instability causes lateral translation of the talus. Our hypothesis was that the interaction of the AITFL tubercle of the fibular with the tibial incisura would propagate lateral translation due to the size differential. Aim. To assess what degree of shortening of the fibular would cause the lateral translation of the talus. Methodology. Twelve cadaveric ankle specimens were dissected removing all soft tissue except for ligaments. They were fixed on a specially-designed platform within an augmented ankle cage allowing tibial fixation and free movement of the talus. The fibula was progressively shortened in 5mm increments until complete ankle dislocation. The medial clear space was measured with each increment of shortening. Results. The larger AITFL tubercle interaction with the smaller tibial incisura caused a significant increase in lateral translation of the talus. This occurred in most ankles between 5–10mm of fibular shortening. The medial clear space widened following 5mm of shortening in 5 specimens (mean=2.0725, SD=±2.5338). All 12 specimens experienced widening by 10mm fibula shortening (Mean=7.2133mm, SD=±2.2061). All specimens reached complete dislocation by 35mm fibula shortening. Results of ANOVA analysis found the data statistically significant (p<0.0001). Conclusion. This study shows that shortening of the fibula causes a significant lateral translation of the talus provided the ATFL remains intact. Furthermore, the interaction of the fibula notch with the ATFL tubercle of the tibia appears to cause a disproportionate widening of the medial clear space due to its differential in size. Knowledge of the extent of fibula shortening can guide further intervention when presented with a patient experiencing medial clear space widening following treatment of an ankle fracture

The June 2023 Oncology Roundup. 360. looks at: A size-based criteria for flap reconstruction after thigh-adductor soft-tissue sarcoma resection; Surgical treatment of infected massive endoprostheses implanted for musculoskeletal tumours; Free vascularized fibula for proximal humerus oncological reconstruction in children; The national incidence of chondrosarcoma of bone; a review; Bone sarcoma follow-up: when do events happen?; Osteosarcomas in older adults: a report from the Cooperative Osteosarcoma Study Group

Aims. Paediatric triplane fractures and adult trimalleolar ankle fractures both arise from a supination external rotation injury. By relating the experience of adult to paediatric fractures, clarification has been sought on the sequence of injury, ligament involvement, and fracture pattern of triplane fractures. This study explores the similarities between triplane and trimalleolar fractures for each stage of the Lauge-Hansen classification, with the aim of aiding reduction and fixation techniques. Methods. Imaging data of 83 paediatric patients with triplane fractures and 100 adult patients with trimalleolar fractures were collected, and their fracture morphology was compared using fracture maps. Visual fracture maps were assessed, classified, and compared with each other, to establish the progression of injury according to the Lauge-Hansen classification. Results. Four stages of injury in triplane fractures, resembling the adult supination external rotation Lauge-Hansen stages, were observed. Stage I consists of rupture of the anterior syndesmosis or small avulsion of the anterolateral tibia in trimalleolar fractures, and the avulsion of a larger Tillaux fragment in triplanes. Stage II is defined as oblique fracturing of the fibula at the level of the syndesmosis, present in all trimalleolar fractures and in 30% (25/83) of triplane fractures. Stage III is the fracturing of the posterior malleolus. In trimalleolar fractures, the different Haraguchi types can be discerned. In triplane fractures, the delineation of the posterior fragment has a wave-like shape, which is part of the characteristic Y-pattern of triplane fractures, originating from the Tillaux fragment. Stage IV represents a fracture of the medial malleolus, which is highly variable in both the trimalleolar and triplane fractures. Conclusion. The paediatric triplane and adult trimalleolar fractures share common features according to the Lauge-Hansen classification. This highlights that the adolescent injury arises from a combination of ligament traction and a growth plate in the process of closing. With this knowledge, a specific sequence of reduction and optimal screw positions are recommended. Cite this article: Bone Joint J 2024;106-B(9):1008–1014

Aims. The aim of this retrospective cohort study was to assess and investigate the safety and efficacy of using a distal tibial osteotomy compared to proximal osteotomy for limb lengthening in children. Methods. In this study, there were 59 consecutive tibial lengthening and deformity corrections in 57 children using a circular frame. All were performed or supervised by the senior author between January 2013 and June 2019. A total of 25 who underwent a distal tibial osteotomy were analyzed and compared to a group of 34 who had a standard proximal tibial osteotomy. For each patient, the primary diagnosis, time in frame, complications, and lengthening achieved were recorded. From these data, the frame index was calculated (days/cm) and analyzed. Results. All patients ended their treatment with successful lengthening and deformity correction. The frame index for proximal versus distal osteotomies showed no significant difference, with a mean 48.5 days/cm (30 to 85) and 48.9 days/cm (28 to 81), respectively (p = 0.896). In the proximal osteotomy group, two patients suffered complications (one refracture after frame removal and one failure of regenerate maturation with subsequent valgus deformity) compared to zero in the distal osteotomy group. Two patients in each group sustained obstacles that required intervention (one necessitated guided growth, one fibula lengthening, and two required change of wires). There was a similar number of problems (pin-site infections) in each group. Conclusion. Our data show that distal tibial osteotomies can be safely employed in limb lengthening for children using a circular frame, which has implications in planning a surgical strategy; for example, when treating a tibia with shortening and distal deformity, a second osteotomy for proximal lengthening is not required. Cite this article: Bone Joint J 2022;104-B(11):1273–1278

Introduction. The use of vascularised fibula grafts is an accepted method for reconstructing the distal femur following resection of malignant childhood tumours. Limitations relate to the mismatch of the cross-sectional area of the transplanted fibula graft and thel ocal bone, instability of the construct and union difficulties. We present midterm results of a unique staged technique—an immediate defect reconstruction using a double-barrel vascularised fibula graft set in in A-frame configuration and a subsequent intramedullary femoral lengthening. Materials & Methods. We retrospectively included 10 patients (mean age 10 y)with an osteosarcoma of the distal femur, who were treated ac-cording to the above-mentioned surgical technique. All patients were evaluated with regards to consolidation of the transplanted grafts, hypertrophy at the graft-host junctions, leg length discrepancies, lengthening indices, complications as well as functional outcome. Results. The mean defect size after tumour resection was 14.5 cm, the mean length of the harvested fibula graft 22 cm, resulting in a mean (acute) shortening of 4.7 cm (in 8 patients). Consolidation was achieved in all cases, 4 patients required supplementary bone grafting. Hypertrophy at the graft-host junctions was observed in78% of the evaluable junctions. In total 11 intramedullary lengthening procedures in 9 patients had been performed at the last follow up. The mean Muskuloskeletal Society Rating Scale(MSTS) score of the evaluable 9 patients was 85% (57% to 100%)with good or excellent results in 7 patients. Conclusions. A-frame vascularised fibula reconstructions showed encouraging results with respect to defect reconstruction, length as well as function and should therefore be considered a valuable option for reconstruction of the distal femur after osteosarcoma resection. The surgical implementation is demanding though, which is emphasized by the considerable high number of com-plications requiring surgical intervention, even though most were not serious

Introduction. Reconstruction of large defect of tibia following infection is considered as one of the most difficult problem facing the orthopaedic surgeon. Amputation with modern prosthetic fitting is a salvage procedure to treat big defects, which gives a functional result with unpredictable psychological impact. Materials & Methods. Between January 2000 and January 2021, 56 patients (30 males and 26 females) with big defects following infection and post traumatic injury of the tibia were treated. The mean age of the patients at the time of surgery was 20.5 years (4–24 years). The fibula was mobilized medially to fill the defect and was fixed with Ilizarov fixator. The average size of the defects reconstructed was 18.5 cm (17–20 cm). Results. The average time for complete union was 8.6 months (range, 5–9 months). At final follow-up all patients had fully united. We found leg length discrepancy in 52 patients and that was corrected by re-lengthening of the solid new regenerate bone. Conclusions. The Ilizarov method has been shown to be an effective method of treating Tibialization of fibula for reconstruction of big tibial defects

Introduction. The purpose of this study is to evaluate the radiological and clinical outcomes in Northern Ireland of free vascularised fibular bone grafting for the treatment of humeral bone loss secondary to osteomyelitis. Upper limb skeletal bone loss due to osteomyelitis is a devastating and challenging complication to manage for both surgeon and patient. Patients can be left with life altering disability and functional impairment. This limb threatening complication raises the question of salvage versus amputation and the associated risk and benefits of each. Free vascularised fibula grafting is a recognised treatment option for large skeletal defects in long bones but is not without significant risk. The benefit of vascularised over non-vascularised fibula grafts include preservation of blood supply lending itself to improved remodeling and osteointegration. Materials & Methods. Sixteen patients in Northern Ireland had free vascularised fibula grafting. Inclusion criteria included grafting to humeral defects secondary to osteomyelitis. Six patients were included in this study. Patients were contacted to complete DASH (Disabilities of the Arm, Shoulder and Hand) questionnaires as our primary outcome measure. Secondary outcome measures included radiological evaluation of osteointegration and associated operative complications. Complications were assessed via review of Electronic Care Record outpatient and in-patient documents

Background. In fixation of the fibula in ankle fractures, AO advocate using a lag screw and one-third tubular neutralisation plate for simple patterns. Where a lag screw cannot be placed, bridging fixation is required. A local pilot service evaluation previously identified variance in use of locking plates in all patterns with significant cost implications. The FAIR study aimed to evaluate current practice and implant use across the United Kingdom (UK) and review outcomes and complication rates between different fibula fixation methods. Method. The study was supported by CORNET, the North East trainee research collaborative, and BOTA. Data was collected using REDCap from 22 centres in the UK retrospectively for a one-year period between 1. st. January 2019 and 31. st. December 2019 on injury mechanism, fracture characteristics, comorbidities, fixation and complications. Follow-up data was collected to at least two-years from the time surgery. Results. 1448 ankle fractures which involved fixation of the fibula were recorded; one-third tubular plate was used in 866 (59.8%) cases, a locking plate in 463 (32.0%) cases and other methods in 119 (8.2%) cases. There was significant difference between centres (p<0.001) in implant type used. Other factors associated with implant type were age, diabetes, osteoporosis, open fractures, fracture pattern and the presence of comminution. Incidence of lateral wound breakdown was higher in locking plates than one-third tubular plates (p<0.05). There was no significant difference in infection, non-union, fixation failure or removal of metalware. Conclusion. There is significant variation in practice in the UK in implant use for fixation of the fibula in ankle fractures. Potentially unnecessary use of locking plates, where a one-third tubular shows equivalent outcomes, incurs additional cost and may increase the risk of lateral wound breakdown. We would encourage surgeons with high locking plate usage to evaluate their own unit's practice against this data

The aim of this study was to assess the incidence of fibula non-union in patients undergoing distraction osteogenesis, and the incidence of symptoms following this. A consecutive series of 58 patients undergoing distraction osteogenesis at a tertiary centre under a single surgeon were included. Data was collected prospectively. Plain radiographs were reviewed retrospectively by a blinded reviewer. Union was defined as the presence of bridging callous on two views. There were 58 distraction procedures performed. The mean age was 37.2 years (range 16.0 to 80.6). There were 36 males and 22 females. The mean follow-up was 23.4 months (4–70 months). 9 (15.5%) went onto non-union at frame removal. 3 (33.3%) of the 9 fibulas that did not unite developed symptoms. 2 (66.7%) of these required surgery in the form of fibula plating. Both of these patient's symptoms resolved following surgery. 3 (33.3%) of the 9 non-united fibulas also had tibial non-union compared to 1 of the 49 where the fibula united. There was no association between location of fibula osteotomy and development of non-union. 35 fibula osteotomies were performed in the third quarter. Of the fibulas that united, the mean fibula lengthening was 9.25 mm (range 1.2–27.8 mm). In the fibulas that went onto non-union the mean lengthening was 23.66 mm (range 5.1–51.5 mm) (P = 0.004). 54 (93.1%) of the tibias united following osteotomy and distraction, whilst 4 (6.9%) went onto non-union requiring operative treatment. Of the 4 tibias that did not unite, 3 (75%) also had fibula non-union (P = 0.01). Fibula non-union is a relatively common complication following osteotomy in distraction osteogenesis. The length of fibula distraction and tibia non-union are significant risk factors for the development of a fibula non-union. We recommend surgical intervention for those patients who have symptomatic fibula non-unions

We report a variant of tibial hemimelia in a six-year-old boy that did not comply with recognised classification systems. The femur and knee were normal, but the fibula was displaced proximally and there was severe diastasis of the proximal and distal tibiofibular joints to the extent that a grossly deformed foot articulated with the fibula and there was separate soft-tissue cover for the distal tibia and fibula. Although it would have been preferable to create a one-bone leg, amputate the foot and use the fibula as the stump for a below-knee prosthesis, local circumstances resulted in the choice of a disarticulation through the knee. This was undertaken without complications, and six months post-operatively the child was walking comfortably with a prosthesis

1. A hope expressed in 1940, that further cases of spontaneous fracture of the lowest third of the apparently normal fibula would be described, has been fulfilled. The literature is here reviewed. Five further personal cases are added. 2. The clinical and radiographic features, diagnosis, treatment and results are considered in the light of the information so far available. Special note is made of misleading freedom of ankle and tarsal movements and the occasional absence of tenderness. 3. It is established that fractures of the lowest third occur particularly in two groups of subjects: 1) young male runners and skaters; 2) active and hard-pressed women of middle age and over. 4. In male runners and skaters the fracture usually occurs through slender, mainly cortical bone, two inches or more above the tip of the lateral malleolus; in middle-aged women the fracture is usually distal to the interosseous ligament through thicker, mainly cancellous bone, one and a half inches from the tip of the lateral malleolus. 5. The most convenient name for both groups of fractures in the lowest third is low fatigue fracture of the fibula. 6. A review of the literature of fatigue fracture of the uppermost third of the fibula shows that it is very often precipitated by jumping. The most convenient name for it is high fatigue fracture of the fibula. 7. Like all clinical classifications this distinction between low and high fractures has exceptions (a low fracture of one fibula in a runner was followed later by a high fracture of the other; most military fractures were high, but a few may have occurred at other levels). 8. Fatigue fracture of the fibula, high or low, may be bilateral. 9. A fracture similarly situated to the high fatigue fracture of the fibula has been frequent in parachute schools. It is a speculative possibility that military and parachutist fractures of the upper third of the fibula indicate the link between true fatigue fractures (as exemplified by march fractures with minimal trauma often repeated) and purely traumatic fractures (with adequate trauma applied once only)

Introduction and Aim: This project reports on patients treated with malignant fibula pathology at the London Bone Tumor Service with the aim of reporting on the prognosis for such patients. Method and Results: Over a 15-year period, The London Bone Tumor Service has treated 39 patients with malignant fibula pathology: Osteosarcoma (23), Ewing’s sarcoma (16). Proximal fibula pathology was more common (29), distal (five) and diaphyseal (five). Thirty-two patients were treated with wide local excision initially, one below knee amputation, three above knee amputations, two were not fit for surgery and two died while receiving chemotherapy. Two patients required subsequent above knee amputations and one patient a hip disarticulation. Relapse was very common in proximal fibula osteosarcoma. Only 7/23 patients avoided both metastasis and local recurrence. The five-year survival rate of osteosarcoma of the proximal fibula is 33%, distal fibula 100% and diaphyseal 100%. Ewing’s sarcoma of the proximal fibula is 40%, diaphyseal 50% and distal fibula 100%. Conclusion: Despite relatively early presentation of symptoms, the prognosis of proximal fibula osteosarcoma and Ewing’s remains poor. Unlike the prognosis of both distal and diaphyseal pathology, which remains excellent

Introduction. The optimal treatment of elderly patients with unstable ankle fractures is a widely contested and as yet unresolved issue. Whereas the AO technique of anatomical reduction and plate fixation has been shown to give good functional results it is associated with a wound complication rate of up to 40%. This has led some surgeons to believe the risks of operative intervention are too great. The fibula nail is an intra-medullary device with the benefit of requiring minimal soft-tissue dissection. It provides lateral column support over a greater area than the standard plate. The study aims were to assess the clinical and radiographic outcome of a cohort of patients managed with the Fibula Nail (Acumed). Methods. A prospectively collected group of 36 patients with an unstable Weber B or C fracture were managed with a fibula nail. Outcome measures at one-year follow-up were Olerud and Molander ankle scores, radiographic measurements and complications. Results. At one-year follow-up the average Olerud and Molander score was 89/100. Four patients had died and none were lost to follow-up. Twenty-nine patients had normal radiographic measurements, one required a fusion due to fixation failure and two had signs of osteoarthritis. There were two lateral wound infections which both settled without metal work removal. Conclusions. Our case series has demonstrated similar one-year clinical and radiographical results for the fibular nail as previously published with the standard plate and screw technique with few wound complications. The results do indicate the fibula nail has a role in the management of this notoriously difficult fracture. Whether this cohort continues to do well however is unknown and will be the focus of future research

It has been suggested that a supramalleolar osteotomy can return the load distribution in the ankle joint to normal. However, due to the lack of biomechanical data, this supposition remains empirical. The purpose of this biomechanical study was to determine the effect of simulated supramalleolar varus and valgus alignment on the tibiotalar joint pressure, in order to investigate its relationship to the development of osteoarthritis. We also wished to establish the rationale behind corrective osteotomy of the distal tibia. We studied 17 cadaveric lower legs and quantified the changes in pressure and force transfer across the tibiotalar joint for various degrees of varus and valgus deformity in the supramalleolar area. We assumed that a supramalleolar osteotomy which created a varus deformity of the ankle would result in medial overload of the tibiotalar joint. Similarly, we thought that creating a supramalleolar valgus deformity would cause a shift in contact towards the lateral side of the tibiotalar joint. The opposite was observed. The restricting role of the fibula was revealed by carrying out an osteotomy directly above the syndesmosis. In end-stage ankle osteoarthritis with either a valgus or varus deformity, the role of the fibula should be appreciated and its effect addressed where appropriate

Aim. We present the greatest study of patients with proximal fibula resection. Moreover we describe a new classification system for tumour resection of the proximal fibula independent of the tumour dignity. Method. In 57 patients the functional and clinical outcome was evaluated. The follow up ranged between 6 months and 22.2 years (median 7.2 years). Indicationfor surgery was in 10 cases benign tumours and in 47 cases malignant tumours. In 32 patients a resection of the peroneal with resulting peroneal palsy was necessary. Results. In 13 of 45 patients, where a resection of the lateral ligament complex was done, knee instability occurred. Patients with peroneal resection had a significant worse functional outcome than patients without peroneal resection. An ankle foot orthosis was tolerated well by these patients. 3 of 4 patients with pathologic tibia fracture had a local radiation therapy. There was no higher risk of tibia fracture in patients with partial tibia resection. There was a significant better outcome of patients with benign than of patients with malignant tumours. Conclusion. Resection of tumours in the proximal fibula can cause knee instability, peroneal palsy and in case of local radiation therapy a higher risk of delayed wound healing and fracture. Despite the risks of proximal fibula resection good functional results can be achieved

In vitro experiments have shown, that stabilisation of the fibula in complete fractures of the lower leg give more stability compared to a single stabilisation of the tibia. However it is not known how this biomechanical conditions influence the bone healing process. To investigate the effect of fibula stability in tibia fracture healing tibial osteotomies in rats with and without fibula fractures were compared. Male wistar rats (n=18) were operated by a transverse osteotomy of the proximal tibia of the left leg. Fracture was stabilised by intramedullary nailing. In 8 cases an additional closed fibula fracture was performed. The healing period was 21 days. Each whole leg was examined by x-ray. After explantation of the tibia and removing of the nail and the fibula, the tibia was examined by CT-Scan, three-point-bending and histological evaluation. Animals, who had a fibula fracture along with the tibia fracture presented with delayed healing. Density in CT-scan was 30% lower (p=0,0002) in animals with a fibula fracture (405mg/ccm, SD:64) compared to those without a fibula fracture (mean=577mg/ccm, SD:17). In three point bending the bending stiffness was 79% lower (p=0,0006) in animals with a fibula fracture (mean=252Nmm/mm, SD:118) compared to animals without a fibula fracture (mean=1219Nmm/mm, SD:478). The breaking force was 59% lower (p=0,0004) in animals with a fibula fracture (mean=17,5N, SD:6) compared to animals without a fibula fracture (mean=42,4N, SD:14). Complete fractures of the lower leg healed considerably worse than solitary fractures of the tibia. We conclude that the missing of rotational stability of our k-wire fixation of the tibia with a unfixed fibula fracture is one of the reasons for the delay in fracture repair. The results support the in vitro findings of the biomechanical importance of the fibula for the stability of tibia fractures

Background:. The axis of the fibula in the sagittal plane are known as a landmark for the extramedullary guide in order to minimize posterior tibial slope measurement error in the conventional total knee arthroplasty (TKA). However, there are few anatomic studies about them. We also wondered if the fibula in the coronal plane could be reliable landmark for the alignment of the tibia. This study was conducted to confirm whether the fibula is reliable landmark in coronal and sagittal plane. Methods:. We evaluated 60 osteoarthritic knees after TKA using Athena Knee (SoftCube Co, Ltd, Osaka, Japan) 3-D image-matching software. Angle between the axis of the fibula (FA) and the mechanical axis (MA) in the coronal and sagittal plane were measured. Results:. The mean angle between the FA and MA was 0.86 ± 2.0° of varus in the coronal plane (range 6.0° of varus to 4.2° of valgus) and 2.6 ± 2.3° of posterior inclination in the sagittal plane (range 6.8° of posterior inclination to 2.8 of anterior inclination), respectively. The percentage of subjects in which FA was within 3° of the MA was 77% in the coronal plane and 58% in the sagittal plane, respectively. Conclusions:. The FA used as a landmark for the alignment of the tibia in the conventional TKA differed from MA relatively in this study, and not be used safely if the differences are considered

We describe a schwannoma located in the mid-diaphyseal region of the fibula of a 14-year-old boy. Radiologically this was an expansile, lytic, globular and trabeculated lesion. MRI showed a narrow transition zone with a break in the cortex and adjacent tissue oedema. Differential diagnosis included schwannoma, fibrous dysplasia, giant cell tumour and aneurysmal bone cyst. The tumour was excised en bloc, with marginal resection limits, and there has been no recurrence two years after surgery. Histopathological examination confirmed the diagnosis of classic schwannoma. There were typical hypercellular Antoni A zones, less cellular Antoni B zones, and diffuse immunoreactivity to S100 protein. This is the first report of schwannoma involving a long bone in a child

We present two children with massive defects of the tibia and an associated active infection who were treated by medial transport of the fibula using the Ilizarov device. The first child had chronic discharging osteomyelitis which affected the whole tibial shaft. The second had sustained bilateral grade-IIIB open tibial fractures in a motor-car accident. The first child was followed up for three years and the second for two years. Both achieved solid union between the proximal and distal stumps of the tibia and the fibula, with hypertrophy of the fibula. The first child had a normal range of movement at the knee, ankle and foot but there was shortening of 1.5 cm. The second had persistent anterior angulation at the proximal tibiofibular junction and the ankle was stiff in equinus

Purpose. This study compares outcomes in patients with complete congenital fibula absence treated with an amputation protocol to those using an extension prosthesis. Introduction. Complete fibula absence presents with significant lower limb deformity. Parental counselling regarding management is paramount in achieving the optimum functional outcome. Amputation offers a single surgical event with minimal complications and potential excellent functional outcome. Method. 32 patients were identified. 9 patients (2M: 7F, median age at presentation of 22yrs) utilized an extension prosthesis. 23 patients (16M: 7F, median age at presentation of 10 months) underwent 25 amputations during childhood: only two underwent tibial kyphus correction. Mobility was assessed using SIGAM and K scores. Quality of life was assessed using the PedsQL inventory questionnaire; pain by a verbal severity score. Results. 19 Syme and one Boyd amputation in 19 patients were performed early (mean age 15 months). 4 Syme and one trans-tibial amputation in 4 patients took place in older children (mean age 6.6 years). K Scores were significantly higher (mean 4 versus 2) and pain scores lower in the amputation group allowing high impact activity compared to community ambulation with an extension prosthesis. The SIGAM and PedsQL scores were all better in the amputation group, but not significantly so. Conclusion. Childhood amputation for severe limb length inequality and foot deformity in congenital fibula absence offers excellent short term functional outcome with prosthetic support. The tibial kyphus does not need routine correction and facilitates prosthetic suspension. Accommodative extension prostheses offer reasonable long term function but outcome scores are lower

Purpose. This study compares outcomes in patients with complete congenital fibula absence, associated with severe lower limb deformity, treated with an amputation protocol to those using an extension prosthesis. Method. 32 patients were identified. 9 patients (2M: 7F, median age at presentation of 22 yrs) utilized an extension prosthesis. 23 patients (16M: 7F, median age at presentation of 10 months) underwent 25 amputations during childhood: only two underwent tibial kyphus correction to facilitate prosthetic wear. Mobility was assessed using the SIGAM and K scores. Quality of life was assessed using the PedsQL inventory questionnaire; pain by a verbal severity score. Patients undergoing amputation were further subdivided by age, below and above 2 yrs at the time of surgery. Results. 19 Syme and one Boyd amputation in 19 patients were performed early (mean age 15 months). 4 Syme and one trans-tibial amputation in 4 patients took place in older children (mean age 6.6 years). K Scores were significantly higher (mean 4 versus 2) and pain scores lower in the amputation group allowing high impact activity compared to community ambulation with an extension prosthesis. The SIGAM and PedsQL scores were all better in the amputation group, but not significantly so. There was no significant difference in the scores based on the time of amputation. Conclusion. Complete fibula absence can present with significant lower limb deformity. Parental counselling regarding management is paramount in achieving the optimum functional outcome. Childhood amputation for severe limb length inequality and foot deformity in congenital fibula absence offers excellent short term functional outcome with prosthetic support. The tibial kyphus deformity does not need routine correction and facilitates prosthetic suspension. Accommodative extension prosthesis does offer reasonable long term function but outcome scores are lower

Introduction: Extent of fibular resection dramatically alters limb function. Aim of our study was to evaluate the functional outcome following resections for 23 malignant tumors of fibula. Methods: 23 biopsy proven malignant tumors of fibula were included in the study. There were 11 cases of Ewings sarcoma (PNET), 8 osteosarcomas, 2 malignant fibrous histiocytoma and 1 each of synovial sarcoma and chondrosarcoma. Following chemotherapy (wherever indicated) limb salvage surgery was done in all cases. There were 9 proximal, 6 middle and 9 cases of distal third of fibula. Type I resection was done in all proximal and 4 tumors of middle third fibula. Type II fibular resection with reconstruction of ankle joint was done in 10 cases. Reversal of contralateral fibula to reconstruct the ankle was done in 7 cases. Allograft was used in 3 patients. Results: Average follow up was for 4.5 years (2 to 7 years). 17 patients (68%) were alive after 4 years of surgery. Local recurrence was seen in 3 cases and these were treated by above knee amputation. 3 patients died within 1 year of surgery. 82% of survivors had a good to excellent functional outcome according to the MSTS functional evaluation criteria and 65% were able to bear full weight and had unlimited activity. Recurrence was commonest in patients with PNET. All patients undergoing reversed fibular grafting showed good functional outcome. Discussion and Conclusion: Results of limb salvage in malignant fibular lesions is infrequently reported. Site of fibular lesion is critical in salvage surgery and need for further reconstruction. Good results are obtained with reversed contralateral fibular reconstruction of the ankle

Introduction. Different techniques for fixation of lateral malleolus have been described. We report our results of using fibula rod for unstable ankle fractures in level one major trauma centre. Methods. We reviewed the results of 40 ankle fractures (14 open and 26 closed) with significant soft tissue injuries and open fractures that were treated with a fibula rod between 2012 and 2015. The median age of patients was 60 (17–98 years). Results. Satisfactory fracture reduction was achieved in all of these patients Two patients had loss of syndesmosis fixation. All fibula fractures healed but 3 medial malleolus non unions occurred which did not need further surgery. 1 patient developed post-operative deep infection and had removal of metalwork. The median physical component Short-Form 12 (PSF12), Olerud and Molander score (OMS), and American Academy of Orthopaedic Surgeons Foot and Ankle outcome scores (AOFAS) were 40 (19 to 52), 57 (0 to 85) and 75 (20 to 95), respectively. The median PSF12, OMS and AOFAS were 33, 35 and 47 for open fractures and 42, 60 and 78 for closed fractures respectively. Conclusion. Using the fibula rod resulted in good radiological and satisfactory functional outcomes with minimal complications. In spite of lower scores in the open fracture group, only one patient needed removal of metal work for deep infection. We recommend using the fibula rod in unstable ankle fracture in patients with significant soft tissue injuries and consider its use in open injuries

Purpose: Reconstruction using a revascularised fibula has advantages in terms of remodelling the transplant to the stress forces and of better resistance against infections. Osteosynthesis offers mechanical advantages (stabilisaton facilitating primary and stress fracture healing) but with the risk of preventing hypertrophy of the fibula which is not exposed to the stress forces. Material and methods: Our series of 25 vascularised fibular transfers (maximum follow-up 15 years) concerned post-trauma tissue loss (11 cases) and tumour resections (14 cases). For this study of remodelling, we retained only oncological reconstructions because in the event of trauma sequelae, many factors can interfer (infection, preservation of the homolateral fibula with tibial tissue loss). None of the patients were lost to follow-up and remodelling was assessed at two years or more. Results: There was one failure requiring leg amputation (infected nonunion of the distal tibia on a radiated osteo-sarcoma). All the other fibulae healed. Three metaphyseal resections of the distal femur were assembled with a lateral plate using the fibula as a medial strut under compression. This type of assembly favours remodelling and excellent results were obtained in three cases. Five arthrodeses of the knee were performed using a fibula with a femorotibial nail. Healing was slow and the fibula thickened little, particularly when it was simply apposed on the tutor (three cases) rather than encased under compression (two cases). For five proximal humeri, use of a thin plate in three cases (forearm plate) was sufficient to allow healing without inhibiting remodelling. Discussion: For the lower limb, good remodelling is obtained with an assembly allowing compression of the fibula placed medially to the shaft alignment. For metaphyseal loss, we advise a lateral plate with a fibular strut medially. For arthrodesis, a nail is probably more prudent. The position of the lateral tutor decreases the stress on the fibula and is recommended less than the medial strut position. For the humerus, synthesis is required but may be minimal to allow optimal remodelling. Conclusion: Vascularised fibula transfer is a reliable technique which can be recommended for major resections (mean 160 mm) in active subjects. Axial compression forces applied to the graft and use of light osteosynthesis appear to favour healing and remodelling

Aims:Vascularized fibula has been widely used in limb salvage surgery to reconstruct large bone defects. Aim of this study is the analysis of the complications related both to the donor and the recipient site in a series of patients affected by bone tumors. Material and methods: In the period from 1988 to 2002, 114 patients ranging in age between 4 and 64 years underwent bone reconstruction by mean of a vascularized fibula graft. There were 64 men and 50 women and all them were affected by malignant neoplasm. The upper limb was involved in 25 cases and the lower extremity in 89 cases. The length of resection ranged between 7 and 28 cm, the follow up between 6 and 166 months. Results: Several complications have been noted either at the donor or at the recipient site. The most common complications affecting the donor leg, have been the retraction of flexor tendons (6), the valgus deformity of the ankle (3) the retraction of extensor hallucis longus (1) and a transient palsy of the peroneal nerve (1). The most frequent complications observed at the recipient site has been a fracture of the graft (15) followed by non union (12), infection (5 cases), failure of plate (5), skin necrosis (4), transient palsy of the peroneal nerve (3) and joint stiffness. Because of complications, a total failure of the procedure occurred in 4 cases. Conclusions: Although the vascularized fibula graft is the recommended procedure in dealing with challenging reconstruction of large diaphyseal defects, this option is not free of complications. However, in our experience, when conservative treatment of complications was not successful, further surgery was able to lead to recovery in the majority of cases

Ninety-seven limbs, in eighty-one patients, with a diagnosis of congenital deficiency of the fibula have been reviewed. A classification was devised to distinguish the minimal hypoplasia of the fibula (Type I) from the well-known complete absence (Type II). Congenital anomalies of the femur were present in 76 per cent of patients with Type I deficiency and in 59 per cent with Type II. The shortening of the limb was by 13 per cent in Type I and by 19 per cent in Type II, and the percentage shortening was fairly constant during growth. A detailed description of the spectrum of other congenital anomalies was found to be characteristic: for example, the ball and socket formation of the ankle, tarsal coalition and anomalies of the foot. The treatment aimed simply to equalise leg length in Type I deficiency, while amputation of the foot and the fitting of a prosthesis were necessary in Type II to obtain satisfactory function

Competence of the extensor mechanism is the major determinant of functional outcome after resection of the proximal tibia and tumor prosthesis implantation. Restoration of a compromised active extension of the knee and an extension lag still remains a difficult challenge. Various techniques have been proposed in the past twenty years including direct attachment of the patellar ligament to the prosthesis, transposition of the medial gastrocnemius muscle possibly associated with other muscle flaps, transposition of the fibula and combination of these techniques. Transposition of the fibula was first reported by Kotz in 1983 but not sufficiently described, so that surgeons who want to plane and manage such a procedure can have some difficulties. We present our technique of fibula transposition and report the functional results about seven patients treated for high-grade sarcomas of the proximal tibia. Fibula transposition is carried out only if the entire fibula and its soft-tissues can be preserved. Resection of the tumor and reconstruction is carried out using the same anteromedial approach. After implantation of the prosthesis, the fibula and its muscles are mobilized anteriorly in a ‘baionnette’ shape obtained by performing a two-level osteotomy. The peroneal nerve and the anterior tibial vessels are previously identified and released to prevent tension on these structures during transposition. Care must be taken to preserve as much as possible the muscular insertions on the fibula so that probability of bone fusion increases. The biceps tendon and the lateral collateral ligament inserted in the fibular head are sutured to the patellar ligament. The knee is immobilized in a knee-ankle orthosis for 6 weeks. We have performed this technique in seven cases. A medial gastrocnemius muscle flap was associated in 3 cases to cover the prosthesis. Fusion was achieved in all cases. Full active extension was obtained in all cases with an extensor strength rated 5/5. All patients were ambulatory without external support at the last follow up

1 . Dislocation of the upper end of the fibula is probably less unusual than the paucity of the published reports suggests. 2. Dislocation may be anterior or posterior, anterior dislocation occurring about twice as often as posterior. Rarely the fibula moves proximally. 3. In most cases a closed manipulation suffices for reduction, and a full and rapid return of normal function follows. 4. Five cases are described. In one case operative reduction was required

Various kinds of bone have been used as a donor for vascularised bone grafts (VGF) to the upper extremities; among them the fibula has been widely used because of its structural characteristics and low donor site morbidity. Vascularised fibular graft is indicated in patients with large bone defects, bone tumour resection, established or infected non-union, congenital pseudarthrosis, avascular necrosis or bone defects surrounded by scarred, infected and poorly vascularised soft tissue or failure of conventional techniques. Between 1994 and 2003 nine patients were treated with vascularised fibular graft (VFG) and five for reconstruction of upper extremities defects, following trauma of the forearm with failure of conventional treatments. Four were male and one were female; the mean age was 32 years; the reconstructed sites were four radius and one ulna. The mean lengths of the bone defect was 9 cm. All patients were evaluated pre-operatively with angiography and/or magnetic resonance imaging. Two patients had a concomitant arthrodesis of the wrist. The bone graft was stabilised with plates (AO/LCP), screws, K-wires and the forearm was immobilised in plaster or with external fixation for several months. Cancellous iliac bone graft was packed about the proximal and distal junctions. In two recent cases autologous platelet gel was added at the sites of fixation. Bone healing was assessed clinically by the absence of pain and mobility on stress, and radiologically. Patients’ satisfaction and function results were assessed by the DASH questionnaire. After an average duration of follow-up of 48 months (from December 1996 to December 2003), all but one of the patients had radiographic evidence of osseous union of both bone junctions. All wounds healed primarily and no patient had problems related to the donor leg. Three patients had returned to their pre-injury occupation. Vascularised fibula transfer is a valuable technique for the reconstruction of extensive long-bone defects in the upper extremities. The fibula allows a transfer of a bone that is structurally similar to the radius and is of sufficient length for the reconstruction of most skeletal defects in the forearm. In these serious forearm injuries, rapidity of fracture healing is not the primary issue, but rather control of infection and bone stability. The only disadvantage of VFG is that it is more costly; because more technical expertise is required for the microvascular work and the operating time is extended. The reliability and the value of vascularised fibula transfer will increase, with further experience, careful patient selection and appropriate pre and post-operative technical details

Statement of purpose. To determine whether the amount of fibula resection in fibula osteotomy influences outcome in deformity correction surgery. Methods. Retrospective case note and imaging review was performed on a cohort of 45 patients from November 2005 to July 2009 treated with lengthening and/or correction for leg deformity in either an adult or paediatric limb reconstruction centre. Method, extent and level of original fibular resection was recorded, as well as type of fixator, distraction regime and total gap at osteotomy site after distraction. Outcome was measured as premature, expected or non-union and subsequent need for reintervention. Results. Fibula osteotomies were made in 45 patients with a mean age of 23 (median 16, range 6–65). 14 subsequently underwent lengthening only, 15 correction of deformity only and 16 a combination of the two. 32 cases used the Ilizarov frame, four the Taylor-Spatial frame and 9 the Sheffield ring fixator. The mean extent of fibular resection was 3.6 mm (range 0.5–17 mm), with saw osteotomy used more frequently than drill or osteotome. Mean latency from surgery to distractions starting was 6 days. Premature union preventing further distraction/correction occurred in four cases, three of which required repeat osteotomy and one which resolved after increasing the rate of distractions. 37 osteotomies went on to unite, with four non-unions. These non-unions were asymptomatic and did not require further intervention. Conclusion. The extent of fibular resection does not appear to directly influence outcome in terms of symptomatic fibular non-union requiring intervention. Care needs to be taken in the paediatric population to guard against premature union requiring repeat osteotomy

Introduction: Malignant tumours of the fibula are rare and can be difficult to treat. We discuss the management and outcome of 52 patients who presented with malignant tumours of the fibula over a 15-year period between 1983 and 1998. Methods: Data was collected prospectively and reviewed from the Bone Tumour database, medical records and by clinical review. Consecutive patients were studied and survival was calculated using the Kaplan-Meier curve. Patients: The tumour type was Osteosarcoma (23 patients), Ewing’s sarcoma (16), Chondrosarcoma (11 – of which 10 low grade) and Malignant Fibrous Histiocytoma (2). We concentrate on the two most common frankly malignant groups: Osteosarcoma and Ewing’s. The male:female ratio of patients with Osteosarcoma was 11:12 and with Ewing’s Sarcoma was 11:5. Mean age for Osteosarcoma was 21.5 years and for Ewing’s Sarcoma was 14.2. The most common site of tumour was in the proximal fibula in both Osteosarcoma (19 / 23) and Ewing’s Sarcoma (10 / 16). The stage of disease at presentation was IIa or IIb in the majority of patients, with seven patients presenting with metastases. Management: The current investigative procedures are Radiographs, Magnetic Resonance Imaging, Radioisotope Bone Scans, Computerised Tomography of the chest and needle biopsy whereas in the past CT of the lesion and open biopsy were common. Chemotherapy was administered as per protocol at the time of diagnosis and radiotherapy was given in selected cases. Surgery was performed on all but 3 patients, who were unfit and died. This consisted of local en bloc resection in 86.3% and above knee amputation in 6.8%. Outcome: Whereas all the diaphyseal and distal lesions were completely excised, 9 out of 26 proximal lesions had a marginal excision, 4 of which had open biopsies. The common peroneal nerve was sacrificed in 50% of cases and this had no link to survival. The overall 5-year survival was 33% for Osteosarcoma and 40% for Ewing’s Sarcoma, with proximal lesions doing much worse than diaphyseal and distal lesions. Patients who had marginal excisions all died within 2.5 years

We have carried out prosthetic reconstruction in six patients with malignant or aggressively benign bone tumours of the distal tibia or fibula. The diagnoses were osteosarcoma in four patients, parosteal osteosarcoma in one and recurrent giant-cell tumour in one. Five tumours were in the distal tibia and one in the distal fibula. The mean duration of follow-up was 5.3 years (2.0 to 7.1). Reconstruction was achieved using custom-made, hinged prostheses which replaced the distal tibia and the ankle. The mean range of ankle movement after operation was 31° and the joints were stable. The average functional score according to the system of the International Society of Limb Salvage was 24.2 and five of the patients had a good outcome. Complications occurred in two with wound infection and talar collapse. All patients were free from neoplastic disease at the latest follow-up. Prosthetic reconstruction may be used for the treatment of malignant tumours of the distal tibia and fibula in selected patients

Fibula autograft reconstruction, both vascularised (v) and non-vascularised (nv), has been established as a standard method in limb salvage surgery of bone and soft tissue tumours of the extremities. This study retrospectively analyses the results of fibula autograft procedures in general and in relation to vascular reconstruction or simple bone grafting. Since the implementation of the Vienna Tumour Registry in 1969, 26 vascularised and 27 non-vascularised fibula transfers have been performed at our institution in 53 patients, 26 males and 27 females with an average age of 21 years (range 4 to 62 years). Indications included osteosarcoma in 18, Ewing’s Sarcoma in 15, adamantinoma in 5, leiomyosarcoma in 3 and others in 12. Thirty patients were operated for reconstruction of the tibia (8v/22 nv), 7 for the femur (6v/1nv), 7 for defects of the forearm (4v/3nv), 5 for metarsal defects (all v), 3 for the humerus (1v/2nv) and one patient was treated for a pelvic defect (nv). Average follow-up was 63 months (range 2 to 259 months). 43 patients showed successful primary bony union of the autograft. In 12 cases pseudarthrosis indicated further surgical revision, 9 of these patients were primarily reconstructed by use of a nv autograft. 4 patients, 2 with v and 2 with nv reconstruction, suffered a fracture of the transplant and were operated for secondary osteosynthesis. 10 patients with v bone graft developed wound healing disturbances which led to surgery, 2 patients with nv grafts suffered such complications. In 2 patients recurrent infection of a nv and a v fibula transfer led to the implantation of a modular tumour prostheses or amputation, retrospectively. Function of all patients with primary bone healing was rated satisfactory. The use of fibula autograft in limb-salvage surgery under oncological conditions allows biological reconstruction with good functional outcome, especially when primary bone healing is achieved. Vascularised bone grafting seems to have a better outcome in terms of primary bone healing than simple fibula bone grafting, and thus represents a feasible choice in the reconstruction of bone defects from tumour resection

In oncological resections there is a higher risk of infection around the foot and ankle. An infection here can be difficult to treat and easily lead to an amputation due to the limited amount of soft tissue coverage of the region. In three patients an infection developed after resection of a bone tumour in the foot and ankle. In the first case, female 34 years, an epitheloid hemangioepithelioma was excised from the anterior part of the calcaneus, cuboid and lateral os cuneiform. An iliac crest graft was initially used to fill the defect, but got infected. The antibiotic loaded bone cement spacer cured the infection and filled the dead space but was painful. A free vascularised fibula with skin-flap was used successfully to fill the defect and take away the pain. At three-year follow-up there is no pain and full weight bearing, with a nice hypertrophy of the graft. In the second case, a 14-year old girl, there was an Aneu-rismal Bone Cyst (ABC) of the distal tibia with a deep infection after ethibloc injection. The vacuum assisted closure cleaned the wound but a defect resulted. It was successfully filled with an ipsilateral free vascularised fibula with skin-flap. Follow-up shows full function and nice hypertrophy at 24 months. In the third case, male 65 years, a chondrosarcoma grade one (after biopsy) in the cuboid was curetted out. It proved grade two in the definitive histology and furthermore it got infected. The cuboid was excised and a cement spacer was placed. The soft tissues were insufficient to close it properly. A free vascularised fibula with skin-flap was used. The vascularity of the graft was insufficient and the skin-flap did not survive. A vacuum assisted closure was done. He can bear weight and has no pain. The fibula graft is shows some hypertrophy and a fistula persists for 18 months now. We conclude that vascularised free fibula with skinflap can successfully prevent amputation in case of infection in oncological resection of foot and ankle. The fibula reconstructs the bone defect and the skin-flap the soft tissue defect

Ten adults were studied two to seven years after resection of a fibula for use as a free vascularised bone graft. Six had no symptoms in the donor leg, four had some aching, weakness or paraesthesia and three had definite weakness of the long toe flexors and extensors. All knees and ankles were clinically and radiologically stable, but the distal fibular remnant was osteoporotic in nine patients. Gait analysis of the donor leg and the contralateral normal leg showed definite differences, which could be attributed to weakness of the deep muscles caused by loss of their normal origin and to the change in load transmission through the fibula

We report four patients with unilateral bowing of the lower leg, affecting only the fibula. The bone is too long with anterolateral curvature of the distal third. Because of its regressive course and the absence of cutaneous involvement, this newly described entity can be distinguished from other forms of bowing of the leg

In our cadaver study plating the fibula in addition to nailing the tibia decreased the mean rotation across the tibial osteotomy site compared to nailing the tibia alone. Although this is statistically significant (p=0.0034) it may not be clinically relevant as the mean values for ROM were 19.10 and 17.96 degrees respectively. Plating the fibula resulted in no statistically significant difference in the mean vertical displacement, angulation or neutral zone. Therefore, we may conclude that plating the fibula in a combined distal third tibia and fibula fracture does not enhance the stability of tibial IM nailing. The purpose of this study was to determine if combined distal third tibia and fibula fractures are more stable when fibular fixation is added to the standard tibial IM rodding. In combined distal third tibia and fibula fractures, plating the fibula does not enhance stability of intramedullary tibial nailing. No additional incision or soft tissue stripping is required for plating of the fractured fibula. The average range of motion in rotation was 19.1° for tibial and fibular fixation combined, and 18.0 ° for tibial fixation alone with a difference of 1.1°, which was clinically significant ( p=0.0034). The mean differences in vertical displacement, angulation, and neutral zone were not statistically significant. Five matched pairs of embalmed cadaveric lower limbs were dissected and stripped of soft tissue. Each tibia received a 9mm solid titanium nail that was locked proximally and distally. Fibular fixation consisted of a seven- hole LCDCP. A 1.5 cm section of tibia and a 1.0 cm section of fibula were removed. Testing was accomplished with an MTS machine. Vertical displacement was tested with an axial load to 500 N, rotation was tested with an internal and external torque of 5 Nm, and angulation was calculated from the vertical displacement data. All displacement data was measured across the osteotomy site. The mean range of motion in rotation was the only statistically significant finding. However, considering the average range of motion with and without fibular plating of 17.96° and 19.10° respectively, this finding is likely not clinically relevant. Funding: Tibial nails, bolts, fibular plates and screws provided by Synthes (Paoli, PA, USA)

The upper three-quarters of the fibula is commonly used as a non-vascularised autograft. Subsequent to this isolated weakness of extensor hallucis longus may occur. We have studied 26 patients in whom the upper and middle thirds of the fibula had been harvested as a graft through Henry’s posterolateral approach. Isolated weakness of extensor hallucis longus was found after operation in ten patients but not in the remainder. EMG and nerve-conduction studies confirmed injury of the nerve to extensor hallucis longus in those with weakness. We dissected 40 cadaver limbs and found that those in which the nerve to extensor hallucis longus ran close to the fibular periosteum were at risk. The injury is mostly incomplete and recovery occurs within four to six months

We discuss the management and outcome of 52 patients who presented with malignant tumours of the fibula over a 15-year period between1983 and 1998. The tumour type was Osteosarcoma (23 patients), Ewing’s sarcoma (16), Chondrosarcoma (11 – of which 10 low grade) and Malignant Fibrous Histiocytoma (2). We concentrate on the two most common frankly malignant groups: Osteosarcoma and Ewing’s. The male:female ratio of patients with Osteosarcoma was 11:12 and with Ewing’s Sarcoma was 11:5. Mean age for Osteosarcoma was 21. 5 years and for Ewing’s Sarcoma was 14. 2. The most common site of tumour was in the proximal fibula in both Osteosarcoma (19 / 23) and Ewing’s Sarcoma (10 / 16). The stage of disease at presentation was IIa or IIb in the majority of patients, with seven patients presenting with metastases. The current investigative procedures are Radiographs, Magnetic Resonance Imaging, Radioisotope Bone Scans, Computerised Tomography of the chest and needle biopsy whereas in the past CT of the lesion and open biopsy were common. Chemotherapy was administered as per protocol at the time of diagnosis and radiotherapy was given in selected cases. Surgery was performed on all but 3 patients, who were unfit and died. This consisted of local en bloc resection in 86. 3% and above knee amputation in 6. 8%. Whereas all the diaphyseal and distal lesions were completely excised, 9 out of 26 proximal lesions had a marginal excision, 4 of which had open biopsies. The common peroneal nerve was sacrificed in 50% of cases and this had no link to survival. The overall 5-year survival was 33% for Osteosarcoma and 40% for Ewing’s Sarcoma, with proximal lesions doing much worse than diaphyseal and distal lesions. Patients who had marginal excisions all died within 2. 5 years

Purpose: Therapeutic options for shaft reconstruction are allografts, shaft prosthesis, and autografts, which may be vascularised or not. The purpose of this work was to assess mid-term results and complications after upper limb reconstructions using a vascularised fibula in children and adolescents undergoing surgery for tumour resection. Material and methods: A vascularised fibular graft was used for reconstruction in ten patients who underwent surgery for resection of upper limb tumours between 1994 and 2000. The patients were seven boys and three girls, aged seven to seventeen years. the vascularised fibula was used for reconstruction after tumour resection in the same operation for eight patients and to salvage a proximal humeral prosthesis in two patients. The eight single-procedure reconstructions concerned four resections of the humeral shaft and four resections of the radius. Tumour histology was: classical osteosarcoma (n=7), low-grade osteosarcoma (n=1), Ewing tumour (n= 1) and aggressive enchondroma (n=1). Six patients were on chemotherapy at the time of the fibular transfer. Graft lengths varied from nine to 21 cm (mean 14 cm). Plate fixation was used in most cases. All patients wore a cast for six to twelve weeks after surgery. Results: Results were analysed retrospectively after 3.9 years follow-up (range 1 – 7 years). Mean time to bone healing was three months (range 1.5 – 5 months). Five of the six humeral shaft reconstructions fractured due to trauma, requiring revision surgery in four cases. All patients who were reoperated achieved bone healing rapidly. One radius had to be revised to add supplementary bone. The mean functional score (MSTS) was 25.5/30 (range 21 – 30). One patient died from lung metastasis and the others exhibited complete tumour remission. Discussion: Vascularised fibula reconstruction of the upper limb provides good radiological results, particularly for the radius. For the humerus, the results are better for younger children because the bone can grow in thickness. Certain mechanical complications may occur if normal sports activities are resumed too early. Functional outcome after these shaft reconstructions is nearly normal

We assessed three children who had limb salvage surgery for sarcomata of the proximal fibula. Their ages ranged from 6 to 13 years. MRI showed involvement of the anterior, lateral and deep posterior compartments. Incisional biopsy showed two osteoblastic osteosarcomata and one Ewing’s sarcoma. Preoperative angiogram confirmed that the tibialis posterior artery was the main blood supply to the foot. The surgical technique was as described by Malawer (1984): via an anterolateral incision, the anterior, lateral and deep posterior compartments were excised en bloc with the proximal fibula. The peroneal artery was sacrificed in all three patients, and the common peroneal nerve and tibialis anterior artery in two. In the patient with Ewing’s sarcoma, the tibialis anterior muscle, artery and nerve did not require excision. What remained were the tibialis posterior nerve and artery, gastrocnemius, flexor digitorum longus and most of soleus. The lateral gastrocnemius was rotated forward to fill the defect. The collateral ligament of the knee was reconstructed by suturing the lateral collateral ligament and biceps femoris to the proximal tibia. All three patients had neo-adjuvant chemotherapy. Tumour necrosis ranged from 90% to 100%. At follow-up at 2, 4 and 9 years, there was no recurrence. The Musculoskeletal Tumour Society evaluation was used and all patients scored more than 80% and were happy with the cosmetic result. Although two of the three patients required an orthotic because of weak dorsiflexion, the functional result was good

1. An account is given of fifty stress fractures of the fibula which occurred in athletes. 2. The characteristic symptoms, signs and radiological appearances are described, with details of treatment and prognosis. 3. The mechanism of the injury has been suggested on clinical grounds and supported by experimental methods

A high stress fracture of the fibula which occurred in 48 out of a class of 120 recruits doing a difficult jumping exercise is described. No more were seen when the exercise was stopped. The importance of this report is that it confirms the theory that different muscular activities cause different stress fractures

Free, vascularised fibular grafting is well described in limb salvage surgery. The mechanical properties of the fibula make it ideal for replacement of bony defects after tumour resection and it can be sacrificed with minimal morbidity. We review the outcome of a consecutive series of 24 patients. Between 1993 and 2002 we performed free vascularised fibular grafts in 24 patients as part of a limb salvage procedure following tumour excision. Pre-operatively patients were staged using the Musculoskeletal Tumour Society (MSTS) system. Post-operatively patients were followed up with radiographs and clinical examination. From the radiographs graft hypertrophy and time to bony union was documented. Functional outcome was assessed using the MSTS scoring system. Complications were recorded. There were 15 women and 9 men with a mean age of 26 years (6–52). Mean follow up was 51 months (12–106). There were 19 malignant tumours, all stage 2b, and 5 giant cell tumours. The mean length of graft was 12.5 cm. (4.5–25). 16 grafts were used in the upper limb and 8 in the lower limb. Arthrodesis was performed in 8 cases and intercalary reconstruction in 16 cases. Fixation of grafts was achieved with a plate and screws in 21, a blade plate in 2 and an IM nail in 1. In 6 cases the resected tumour bone was reinserted as autograft after extracorporeal irradiation. In all but one patient the tumour margins were clear. Primary bony union was achieved in 22 patients (92%) at a mean of 35 weeks (12–78). Graft hypertrophy was seen in 7/29 cases (24%). Complications included 2 wound breakdowns, 3 stress fractures, 1 muscle contracture, 1 malunion and 1 painful plate. Overall 8 patients (33%) required second operation. 2 patients died of recurrent disease and one has metastases. The mean MSTS functional score was 87% (80–93). Free vascularised fibula grafts offer a reliable method of reconstruction after excision of bone tumours. The complication rate appears high and some patients require a revision procedure. However, the problems are relatively easy to correct, bony union is achieved in the majority and functional outcome is good

Introduction Free, vascularised fibular grafting is well described in limb salvage surgery. The mechanical properties of the fibula make it ideal for replacement of bony defects after tumour resection and it can be sacrificed with minimal morbidity. We review the outcome of a consecutive series of 24 patients. Methods Between 1993 and 2002 we performed free vascularised fibular grafts in 24 patients as part of a limb salvage procedure following tumour excision. Pre-operatively patients were staged using the Musculoskeletal Tumour Society (MSTS) system. Post-operatively patients were followed-up with radiographs and clinical examination. From the radiographs graft hypertrophy and time to bony union was documented. Functional outcome was assessed using the MSTS scoring system. Complications were recorded. There were 15 women and nine men with a mean age of 26 years (6 to 52). Mean follow-up was 51 months (12 to 106). There were 19 malignant tumours, all stage 2b, and five giant cell tumours. The mean length of graft was 12.5 cm (4.5 to25). Sixteen grafts were used in the upper limb and eight in the lower limb. Arthrodesis was performed in eight cases and intercalary reconstruction in 16 cases. Fixation of grafts was achieved with a plate and screws in 21, a blade plate in two and an IM nail in one. In six cases the resected tumour bone was reinserted as autograft after extracorporeal irradiation. Results In all but one patient the tumour margins were clear. Primary bony union was achieved in 22 patients (92%) at a mean of 35 weeks (12 to 78). Graft hypertrophy was seen in 7/29 cases (24%). Complications included two wound breakdowns, three stress fractures, one muscle contracture, one malunion and one painful plate. Overall eight patients (33%) required second operation. Two patients died of recurrent disease and one has metastases. The mean MSTS functional score was 87% (80 to 93). Conclusions Free vascularised fibula grafts offer a reliable method of reconstruction after excision of bone tumours. The complication rate appears high and some patients require a revision procedure. However, the problems are relatively easy to correct, bony union is achieved in the majority and functional outcome is good

Following resection of primary malignant bone tumours of the humerus, limb salvage can be performed by vascularized fibula graft for reconstruction of large segmental defects. In 12 patients with malignant bone tumour of the proximal humerus, tumour was resected and the bone defect reconstructed by vascularized fibula graft. Median age of the patients was 23 years. Median follow up was 114 months. In 10 patients humeral head had to be resected and was replaced by fibular transplant including head and shaft of the ipsilateral fibula. Humeral head could be left in place in 2 patients. Median length of transplant was 17.2 cm. Radiographic union could be seen after 8 months in median. In 7 patients partial necrosis of the fibular head occurred, in 4 patients fracture of the transplant happened following trauma. In these 4 cases revision surgery was required. Partial necrosis of the head of fibula had no significant influence on shoulder function. One patient died of disease, the others are disease free. Enneking Index was 61% in median at time of last follow up. At donor side 3 cases of transient peroneal palsy could be seen. We conclude that vascularized fibula graft is a successful surgical procedure for upper limb salvage especially for preservation of joint function also in long term follow up

Segmental excision of long-bone sarcomas can require complex reconstruction, often resulting in the use of prosthetic replacements at a young age. The use of vascularised free fibula grafting (VFFG) is well established as a reconstruction modality in sarcoma surgery. Aims. To analyse the experience of two European sarcoma centres and their use of vascularised free fibula grafting as a primary and revision procedure in limb salvage for diaphyseal long-bone defects in sarcoma surgery. Methods. A retrospective analysis was carried out of 70 consecutive patients undergoing VFFG between 1996 and 2009 under the Oxford Sarcoma Service (Nuffield Orthopaedic Centre) and the Dutch Orthopaedic Tumour Society (Leiden University Hospital). Clinical and radiological assessments were made and functional outcome scores collected. Results. 70 patients, 42 male, with a mean age of 20 years (3–61) received a VFFG (a primary procedure in 76%) and underwent mean follow up of 82 months (11–181). 83% of grafts were located in the lower extremity with 71% resulting from reconstruction of malignant tumours. VFFGs with a mean length of 17.4 cm (6–25) were used to reconstruct defects with a mean length of 13.5 cm (8–21). 92% of VFFGs achieved union at mean of 59 weeks (16–250). Predictors for non-union included defects greater than 12cm, malignant disease processes and an immature skeleton. 65% of patients had at least one complication with 51% requiring at least one revision procedure, although only 3 required removal of the graft (2 endoprosthetic replacements and 1 amputation). Mean MSTS score at final follow-up was 26.7 (20–30). Conclusion. The vascularised free fibula graft has been proven to provide a stable reconstruction of bony defects after tumor resection and results in a functional extremity, however it is accompanied by a high risk of complications and revision surgery

1. The cases of four children who presented with bowing or pseudarthrosis of the fibula only, are described. 2. There is a gradation in the severity and significance of this condition. There may be fibular bowing without fibular pseudarthrosis; fibular pseudarthrosis without ankle deformity; fibular pseudarthrosis with deformity but without the late development of tibial pseudarthrosis; or fibular pseudarthrosis with the late development of tibial pseudarthrosis. 3. Proper management is dependent on a knowledge of this range of conditions

An alternative to Syme's amputation for congenital absence of the fibula is described in this paper. Nine children have had the ankle reconstructed using the Gruca technique with a very satisfactory result in eight. This procedure is not suitable for every patient and in most unilateral cases the operation can only be regarded as an interim procedure because of progressive leg-length inequality. The decision to remove the foot may be delayed and it allows childhood to be spent without resort to prostheses. However, the procedure can be considered as the definitive operation in cases of bilateral deformity

The aim of this abstract is to show that when dealing with an infected non-union, all possibilities of treatment must be considered in order to choose the best treatment plan for each patient. This case shows the evolution of an infected non-union following type III open fractures which, after the used of several methods that failed, had to be solved with amputation. We present a case report of a 41 years old man, with a type IIIA open fracture of the right tibia and fibula. Initially, he was treated with an external fixator, which was removed and plate implanted. After this, he who presented to us with an infected non-union. He was submitted to surgery, the plate was removed and a circular external fixator was used. Six months later, the external fixator was removed and a reamed intramedullary nail was implanted with bone graft from iliac crest. One year later, the facture site was still mobile, so he was submitted to fixation with internal plate. As this last method also failed, a bellow knee amputation was performed, 4 years after the initial event. After several attempts with several distinctive methods, the infected non-union had to be solved with the sacrifice of the limb. The treatment of infected non-union is one of the most difficult in Orthopedic Surgery. There are several procedure that can be used. When all these fail, amputation and consequent limb prosthetic substitution, might allow the patient to return to the society

Large benign lytic lesions of the proximal femur present a significant risk of pathological fractures. We report our experience of treating 9 consecutive patients with such defects treated with curettage and fibula strut grafting without supplementary osteosynthesis to evaluate the outcome of this type of reconstruction. The mean age at the time of diagnosis was 13 years (8–21). Follow up ranged from 2 to 215 months (median 15). Histological diagnosis was fibrous dysplasia in 10 patients and unicameral cyst in 2. All the patients were at risk of pathological fracture. None of the patients developed pathological fracture after surgery and the lesions consolidated fully within one year. Local recurrence occurred in one patient (8%). Minor donor site complications occurred four patients. All the patients were able to fully weight usually within 3 months of surgery. At the time of review all but one patient were completely asymptomatic and fully weight bearing. The only symptomatic patient was the patient with local recurrence which has recently been treated. We conclude that fibula strut graft is a good method of reconstruction of cystic defects in the proximal femut. It prevents pathological fracture, allows mechanical reinforcement of the lesion and delivers biological tissue allowing early consolidation of the defect

Congenital pseudarthrosis of the lower limb is not uncommon, with an incidence of approximately 1 in 150,000. In contrast, isolated congenital pseudarthrosis of the fibula without tibial involvement is a very rare. There were only 11 cases of true isolated congenital pseudarthrosis of the fibula described in the English literature till 1999. We describe 3 patients diagnosed and treated in our institution. The current management is also discussed, highlighting the unique treatment options in this rare condition

The aim of surgery in the treatment of tumours of the distal radius is to achieve satisfactory clearance whilst best preserving function of the hand and wrist. Since 1992 a technique of distal radial tumour excision with reconstruction by autologous free fibula strut grafting has been employed in the treatment of thirteen patients at our unit. The procedure employs fixation of the non-vascularised fibula shaft to the proximal radius by step-cuts and a dynamic compression plate. The fibula head substitutes for the distal limit of the radius and articulates with the carpus. We have treated 10 cases of primary or recurrent giant cell tumour and cases of osteosarcoma, chondrosarcoma and Ewings’ sarcoma by this technique. The patients were reviewed at a mean of 50 months post surgery, with assessment of their functional outcome and measurement of the range of wrist movement and grip strength. The patient with Ewings tumour had died of meta-static disease 62 months post grafting. Three patients treated for giant cell tumour had required further surgery, two of these had forearm amputation for malignant transformation. In comparison to the unoperated wrist, range of movement was well preserved. The power of grip strength was 57% of the contralateral wrist and hand. These results compare well with published rates of recurrence of benign giant cell tumour treated by other methods. This technique would seem to offer an acceptable functional result without compromise of the tumour prognosis

Purpose. Analyze the results of reconstruction of post osteomyelitic bone defect using non-vascularised fibula graft in children and correlation of results with magnitude of defect. Methods. 11 boys and 15 girls (mean age 6.8±2.33 years) were prospectively enrolled in the study. All had primary acute hematogeneous osteomyelitis with diaphyseal sequestration and active discharging sinuses. 7 femur, 12 tibia, 3 humerus, 3 radius and 1 ulna were the bone involved. As first step a radical debridement and sequestrectomy was performed. Second step was considered after a ‘dry’ period judged clinically and by normalized CRP. A subperiosteal resection of fibula was done and used as graft to fill in the diaphyseal defect. Graft was stabilized using intramedullary ‘K’ wires and supported by post-operative casts. Weight-bearing was started on radiological evidence of union. Results. mean follow up was 3.02±0.74 years with mean union time of 38.76±12.02 weeks. Delayed union (n=4) was seen at sites with large discrepancy between diameter of native bone and graft (like proximal tibial metaphysis). These cases united with plate fixation and bone grafting. There was weak positive correlation between union time and preoperative bone defect (+0.699). Subgroup analysis showed that there no significant difference between union times of patients with defect <4cms (mean of 31.7±11.5 weeks) and defect >4<6cms (mean 36.6±9 weeks), however the union time of patients with defect >6cms was significantly more (51±6.7 weeks). Conclusion. Non-vascularised fibula graft gives predictable results in children with post-osteomyelitic bone defects. Delayed unions are expected if the size of bone defect is >6cms or there is large discrepancy between the diameters of native and grafted bone

We report eight patients with prominent cystic changes in the head of the fibula. Seven of these had osteoarthritis of the adjacent knee, and five had evidence of local deposition of calcium pyrophosphate dihydrate crystals. A radiographic survey of 470 knees in 254 patients with osteoarthritis suggested that such cysts are rare, but should be considered in the differential diagnosis of such changes before expensive or invasive investigations are performed

Introduction: Megaprosthetic failures around the knee and especially those who are infection-related are difficult to manage. Although most of these cases are effectively managed with a two-stage prosthetic revision, selected cases eventually require sacrifice of the knee joint. The authors present their experience with knee-arthrodesis using a vascularized fibula and allograft reinforcement. Materials and Methods: Between 1998 and 2002, eight patients with failed knee prosthesis were referred for resection-arthrodesis; all patients had at least two previous revision attempts using a spacer or a new implant. Knee-arthrodesis included resection of the distal femur and proximal tibia and reconstruction with a free micro-vascularized fibular graft and allograft reinforcement. Fibular grafts were harvested with a large musculocutaneous flap to facilitate soft-tissue coverage and monitor flap viability. Following surgery, patients were kept non-weight-bearing for 3 months. Radiographs were performed 6 and 12 weeks postoperatively to establish fibular graft incorporation. If healing had progressed satisfactorily, weight-bearing was gradually allowed. Results: At the most recent follow-up’ all eight patients had a stable and painless reconstruction, associated with radiological evidence of solid fibular graft union. The latter was typically observed between 6 to 12 weeks from surgery. Complications included one emergent surgery for anastamotic rupture in one patient and surgical debridement with skin grafting of musculocutaneous flap necrosis in another patient. Conclusions: Knee-arthrodesis using microvascularized fibula and allograft reinforcement is a safe and reliable salvage procedure in end-stage failures of megaprosthetic knee implants

We describe a technique of lengthening osteotomy of the fibula for the late treatment of symptomatic malaligned or malunited fractures of the ankle. Good results at two to three years were achieved in five of six cases despite delays of up to four years from the original injury. The method can prevent progressive instability and degenerative arthritis

Failure of union of the tibia with a large defect is difficult to treat, especially in the presence of sepsis and adherent scars. Conventional methods of fixation and bone grafting are not easily applicable. Experiments on Macaca monkeys showed that a vascularised pedicle graft of the shaft of the ipsilateral fibula could be fixed across a defect in the tibia and remain viable, even if it was isolated from surrounding soft tissues. Transfer of part of the shaft of the ipsilateral fibula on a vascular and muscle pedicle was carried out in 11 patients with large tibial defects and sepsis. There was one failure because of severe infection, but the other 10 patients gained sound union in about four months. The tibia was then protected by a caliper for the 18 months of full reconstitution. The bone infection healed and there was no evidence of avascular necrosis. Although the salvaged limbs were scarred, stiff and ugly, none of the patients suffered from pain, recurrent oedema or persistent infection

1. In congenital absence of the fibula, the fibrous strip that replaces the bone, abnormal insertions of fibular muscles, and disturbances in the formation and growth of the tarsal bones all go to cause the valgus deformity of the foot and the complete or partial dislocation of the talo-tibial joint. 2. Conservative treatment is justified only for children less than a year old and then only as preparation for operation. 3. Between the second and seventh year of life operations upon the soft tissues are indicated, to eliminate the contractures occurring on the posterior and lateral sides, to restore the proper position of the foot in line with the axis of the tibia, and to restore the normal shape of the foot and muscular equilibrium. At the same time favourable conditions are created for operative reconstruction of the lateral malleolus. 4. Arthrodesis of the talo-tibial joint or reconstruction of the lateral malleolus by a bone graft with the aim of stabilising the foot in the axis of tibia is not advisable in the growing limb. 5. The results obtained in three cases described support the conclusion that the bifurcation operation recommended by Gruca produces a new lateral malleolus with an epiphysis that grows at the same rate as the remainder of the lower epiphysis of the tibia, does not affect the rate of growth of the tibial epiphysis, prevents the recurrence of the deformity, and preserves the mobility of the talo-tibial joint. 6. In early cases this reconstructive operation may be done at the same time as soft-tissue deformities are corrected and subluxation reduced. 7. It is probable that the bifurcation operation should be done on children aged between two and seven years in order to give the limb the best chance to develop normally

1. A case is described of fatigue fractures occurring in the lowest thirds of the right tibia and fibula simultaneously. 2. The fibular fracture was a runner's fracture. 3. The tibial fracture was ascribed to the application of a below-knee walking plaster to treat the fibular lesion. 4. Both fractures were slow in uniting. 5. The fractures occurred in a rapidly growing youth but no clinical evidence of an endocrine dysfunction was found

We report the results of a three-year study of bifocal fractures of the tibia and fibula, excluding segmental shaft fractures. In our whole series, these formed 4.7% of all tibial diaphyseal fractures. We describe three groups: bifocal fractures of both the proximal and the distal joint surfaces, fractures of the shaft and tibial plateau, and fractures of the shaft and ankle. These groups of fractures had different characteristics and prognoses. We discuss treatment protocols for each of these three groups

Our Purpose is to present the results of treatment of 35 (thirty five) comminuted fractures of the diaphyses of Tibia and Fibula with combination of Orthofix External Fixator and Sarmiento Brace. In Syros General Hospital, during the last 8 (eight) years, 35 (thirty five) comminuted fractures of the Diaphyses of Tibia and Fibula were treated. Twenty were closed and 15 (fifteen) compound. Five were type 1, 8 (eight) type 2 and 2 type 3 Gustilo. Our Method : After a good surgical cleaning all fractures were reduced and stabilized with Orthofix External Fixator. We used two pins above and two pins below the fracture. According to the union of the fracture, we allowed partial weight bearing with dynamization. In three months the External Fixator was removed and a Sarmiento Brace was put. With the Brace we allowed full weight bearing until the fracture was united. Results: All fractures united. It took five months for the close and six months for the compound. There was no displacement in any fracture. In four fractures we had pin infection that was cured with antibiotics and lack of weight bearing for 15 days. Conclusion : Comminuted fractures of Tibia are a challenge for every Orthopaedic Surgeon. We believe that the combination of those two methods that are simple and safe solve the treatment of those difficult fractures

Purpose of the study: Transfer of a vascularised fibular is an option after tumour resection to save the limb. Material and methods: Thirty-eight consecutive cases of malignant bone tumours located in the shaft of long bones of the lower limb were treated with a free transfer of a vascularised fibula. There were 30 femoral localisations and 8 tibial localisations, 32 first-intention transfers and six transfers after failure of an allograft. Mean age at transfer was 11.8 years (range 4.33–22.57). Adapted chemotherapy was associated. The Musculo-skeletal Tumour Society score was noted for the functional assessment. Healing was considered achieved when there was a bone bridge between the transplant and the recipient bone associated with disappearance of the osteotomy line. Outcome was expressed as mean or percentage with the 95% confidence interval. P< 0.05 was considered significant. Results: Mean follow-up for the 38 patients was 7.56 years (range 0.37–18.4). The mean MSTS was 27.2 (range 20–30).. This mean score was significantly higher (S t = 2.11> 2.04) for vascularised fibular transfer surgery immediately after tumour resection (27.4) than after revision surgery (25.4). The healing rate was 89%. The rate of healing failure of the vascularised free transfer was significantly greater (p=0.005< 0.05) after revision (33%) than after immediate transfer (6%). The rate of good results in the Boer classification was significantly higher for tibial than femoral reconstructions (p=0.006< 0.05), for immediate surgery than revision surgery (p=0.005< 0.05), and for Ewing tumours than for osteosarcoma (p=0.0019< 0.05). Discussion: Free transfer of a vascularised fibula is a reliable reconstruction technique for bone shaft loss of the lower limb after resection of a malignant bone tumour in children. This is a mutilating surgery with frequent complications but which can save the limb. This reconstruction surgery should be done at the same time as the resection. Healing of the vascularised fibular transplant is more difficult to achieve for femoral reconstructions than tibial reconstruction and there are more complications in the femoral localisation. Femoral reconstructions using a vascularised fibular transplant should be associated with an allograft

Forty-three patients with unilateral congenital short tibia with partial or complete absence of the fibula are reviewed. The factors influencing the degree of leg shortening at maturity are considered. Serial radiographic measurements of leg length in fourteen patients covering an average observation period of 9-3 years support the hypothesis that the relative difference in growth between the two limbs remains remarkably constant. By estimating the percentage difference between the normal and abnormal leg lengths on the first measurable radiograph it is therefore possible to predict the likely shortening at maturity. This method of prediction allows the surgeon to make the decision to proceed to Syme's amputation or to the use of an extension prosthesis at about one year of age when the child starts to walk

Bone shape variability within a specific population has been seldom investigated and used to optimize implant design. There is insufficient anatomical fitting of the existing prebend periarticular plates for the distal fibula. We developed a methodology for design of orthopaedic implants that fit a maximum percentage of the target population, both in terms of geometry and biomechanical stability. In co-operation with an implant manufacturer and different academic institutions, a virtual bone database has been developed that contains anatomical data of more than 1000 CT datasets with the implemented possibility to generate idealized implant fits for different anatomical sites. This program (Stryker Virtual Bone Database (VBD) is able to generate statistical anatomical shapes for different populations like age groups or ethnical groups. Based on this, an implant for the distal fibula has been developed (VariAx Distal Lateral Fibula Locking Plate) for distal fibula fracture treatment. Aim of this study was to develop and validate an implant that is optimized for the specific anatomical area. It should be precontoured and still fit to the majority of patients sustaining a distal fibular fracture. Another objective was to create a distally tapered design as there is less soft tissue cover in that anatomic area. Materials & Methods. ProE CAD system was used in combination with the Bone Database (VBDB) to evaluate the bone shape of the target population plate shape. Several bones (from CT scans) have been used in a first validation process in comparison with an implant already available on the market (SPS Fibula Plate). Additionally, the results have been verified with a bone fitting study which was conducted in collaboration with the Maurice E. Müller Institute (MEM) in Bern/Switzerland. In a second step, the finished implant design was validated against statistical bone shapes of populations of different ethical origin. Results. The comparison of the new Plate's shape with real bone data confirmed that the neutral form does cope with the anatomic situation laterally which means that no systematic pre-bending of the plate is required. Comparing with a conventional implant, the new implant could have been implanted unbend in 6 of 7 cases of virtual matching with real patient datasets compared to none with the conventional implant. The validation of statistical datasets of different ethnical origin (Caucasian, Asian) showed no statistical difference of implant mismatch. Conclusion. Based on these results, the new Plate can be considered an efficient solution to treat distal fibula fractures without or only limited time consuming intra-operative bending. Although technically now possible, different plate designs for Caucasians and Asians are not required

100 fibula fractures sustained at or below the syndesmosis were studied retrospectively. They were consecutive trauma clinic referrals with an initial conservative treatment plan. All initial radiographs studied were taken prior to application of below knee plaster splintage. Weber A and B classification was n=47 and 53 respectfully. Serial radiographs showed that none of the 100 ankles developed further displacement during their treatment. There was 5.6 and 6.6 individual radiographs and 4.2 and 4.3 clinic reviews for Weber A and B respectfully. We conclude that Weber A and B fractures without talar shift are stable injuries. Once the decision has been made to treat them conservatively, no further radiographs need be requested. This will result in reduction to two clinic reviews and one single initial anteroposterior and lateral radiograph. Significant cost savings to the health service and reduction in ionising radiation exposure to the patient will result

Congenital pseudarthrosis of the tibia (CPT) is a rare but well recognised condition. Obtaining union of the pseudarthrosis in these children is often difficult and may require several surgical procedures. The treatment has changed significantly since the review by Hardinge in 1972, but controversies continue as to the best form of surgical treatment. This paper reviews these controversies.

Cite this article: Bone Joint J 2013;95-B:1027–34.

Aims

The use of frozen tumour-bearing autograft combined with a vascularized fibular graft (VFG) represents a new technique for biological reconstruction of massive bone defect. We have compared the clinical outcomes between this technique and Capanna reconstruction.

Autografts produced by recycling of tumor-bearing bone have been used for bridging intercalary bone defects but they are known to act as massive allografts after recycling procedures due to devitalisation. Recycled bone is superior to massive allografts since it allows anatomical reconstruction. Vascularised fibular grafts are inserted into recycled bone segments to provide biological support and to promote healing. Twelve patients with a mean age of 13.3 years (6–31), who had undergone curative resection of malignant bone tumor followed by biological reconstruction comprised of recycled bone combined with vascularised fibula, were followed up for a mean period of 16.8 (6–46). The tumor was located in distal femur in 7 patients, proximal femur in 2, proximal tibia in 2 and mid-diaphyseal tibia in 1. Cryopreservation with liquid nitrogen was employed for all patients. Contralateral single strut vascularised fibular grafts were used in all except one patient for whom bilateral fibula grafts were harvested to span a longer defect. Plates were used for fixation in 11 patients, and intramedullary nailing in one case. Mean length of bony defect was 16.1 cm (9.0–25.0). Mean fibular graft length was 17.5 cm (10.0–23.0 cm). Complete union and full weight bearing was achieved in 6 patients, and mean time to detect the commencement of union was 6 months (4–8). Incomplete union was detected in 4 patients and no union in 2. Five patients were complicated by implant failure, 1 with deep infection and 1 with drop foot. In order to fill large defects after resection of bone tumors, recyled bone combined with vascularised fibular graft is an effective reconstructive tool. Union rate of this technique is quite satisfactory with good functional results

Purpose: The bifoliated vascularised fibula graft is an attractive alternative for reconstruction of large bone segments. The purpose of this work was to evaluate mid-term results and the usefulness of two surgical techniques: skin island flap monitoring and the arterio-venous loop. Material and methods: This retrospective analysis included fourteen patients (eleven men and three women) treated between 1992 and 2002. Mean age was 30 years (10–54). Indications were complications of open fractures in nine patients, major bone loss in two, septic nonunion in four, and aseptic nonunion in three. Reconstruction was performed after bone tumour resection in five patients involving immediate reconstruction after failure of an infected massive allograft in four of them. Localisations were: tibia (n=6), femur (n=5), humerus (n=2), and pelvis (n=1). Average bone loss was 10 cm (7–15 cm). Minimal pinning, cerclage or screwing was used to stabilise the flap completed by internal fixation in four patients and external fixation in ten. A monitoring skin island was used for twelve patients (the island was technically impossible in two patients). Vascular anastomoses were performed in seven patients using an arteriovenous loop, performed as a preliminary measure in six. Results: Mean follow-up was 35 months. One patient died early from tumour progression. Among the seven patients who had an arteriovenous loop, one required revision for a vascular complication. For the seven “classical” bypasses, there were three intraoperative or early complications requiring revision of the anastomoses. Nonunion developed despite early revision in the four patients whose monitoring skin island suffered. Consolidation was achieved without revision in all patients who skin island did not suffer; time to bone healing was eleven months for seven of them. Conclusion: Bone healing was related to the quality of graft vacularisation. Clinical observation of the monitoring island was the best way to identify vascular complications early and initiate treatment. Use of a preliminary arteriovenous loop decreased the risk of vascular insufficiency inherent with long bypasses and shortened operative time

This text has been removed at the authors' request.

Between 1989 and 1994 we used a vascularised ipsilateral fibular graft in 24 patients with segmental tibial defects. We report 12 patients with a minimum follow-up of two years. The graft was either transposed medially or inverted on its vascular pedicle. Full weight-bearing was achieved at between four and seven months. We had few complications and consider that the use of this method is a valuable option in reconstruction of the tibia.

Fibular plating comprises a major component in the treatment of Pilon fractures with open reduction and internal fixation. However, its necessity when Pilon fractures are treated by hybrid fixation has been questioned. A retrospective clinical study with 65 high energy pilon fractures treated by circular fixators between 1996 and 2001 was undertaken, in order to clarify this technical detail. The mean age was 35 years (range 21 to 69 years). The fractures were classified according to the systems of Ruedi -Allgower (9 II, 56 III) and Ovadia-Beals (9 II, 21 III, 13 IV, 22 V). Hybrid fixation (tension wire fixation at the fracture site augmented by screws) was performed in 39 fractures. The lateral malleolus was internally fixed in 39(60%) patients. In 48(74%) patients the fixation was extended to the calcaneus for 6 weeks. The metaphyseal defect (25 fractures, 38.5%) was treated by grafting in fourteen, acute shortening in six, and bone transport in five fractures. Clinical and radiological results were evaluated.

Mean follow up was 3 years (range 1 to 10 years). On the basis of Ruedi-Allgower system, there was a negative correlation between the end result and fibular fixation in all the fractures types (p< 0.001). However, if Ovadia Beals system was used, fibular fixation was associated with better results in type II and III, but with inferior results in type IV and V.

We conclude that in fractures with metaphyseal defect, fibular fixation does not allow acute shortening and makes bone transport more difficult leading to poor results. Ovadia – Beals classification considers the metaphyseal defect and the fracture comminution and should be chosen for the selection of the technique. Fibular plating is desirable for types II and III but it should be avoided or at least not preceded for types IV and V.

A 14-year-old girl with a congenitally deformed and shortened right leg and foot is described. The patient could not bear weight on the deformed limb and had to hop on the left leg. The deformed foot faced backwards and had nine toes. The right leg was shorter than the left by 26 centimetres. Radiologically, the lower end of the right femur was ill-developed and there was no knee joint. There were two fibulae and the tibia and the patella were absent. A through-knee disarticulation was done and a prosthesis fitted later. The amputated leg and foot were dissected. Many of the muscles in the leg and foot were duplicated. There were two calcanei, one talus, one navicular, two cuboids and four cuneiforms. Ther were nine metatarsals, and all the toes had three phalanges except for one which had two.

Introduction: Treatment of high energy unstable lower leg fractures requires a fixation system that will provide skeletal stability, promote bone healing without residual deformity and allow wound care. The Taylor Spatial Frame is a device which provides excellent skeletal stability, allows immediate weight bearing and provides an opportunity for correction of residual deformity without return to the operating theatre.

Method: 9 patients (10 limbs), all male, mean age 12.6 (5.2–16.5 years old) were treated at Bristol Royal Hospital for Children for high energy tibial fractures between 2005 and 2008. There were 6 open fractures (3 fractures Gustilo IIIA and 3 IIIB) and 4 closed fractures. Of the 4 closed fractures, 3 required fasciotomies for compartment syndrome. The case notes and radiographs of all patients were retrospectively reviewed to assess outcomes.

Results: 2 patients were stabilized primarily with TSF, 1 had plaster backslab before applying TSF, 7 were treated primarily with unilateral external fixation prior to applying TSF. TSF was applied on average 7.3 days after initial injury. All fractures were reduced at the first visit to the operating theatre. In 6 cases malalignment developed and residual deformity corrections were performed via TSF programming, in 1 case frame was adjusted at the second visit to theatre to facilitate wound closure and then fracture reduced. Time of treatment with TSF was on average 107 days. Sound bone union and satisfactory wound healing was achieved in all cases. All tibiae were united without significant residual deformity or leg length discrepancy. There was one complication – muscle tethering at proximal fine wire fixation requiring adjustment of TSF with insertion of half pins.

Discussion: In this study group the results of TSF fixation were excellent. The commonest device used in this patient group is unilateral external fixation. Whilst this gives predictable results and allows good wound care there are limitations to the use of this technique. The TSF has two particular advantages that we believe make it more suitable than unilateral external fixation. The intrinsic stability of the ring structure allows immediate post-operative weight bearing and the programmable strut adjustments allow easy non-operative correction of residual deformity.

Aims: Fibular plating comprises a major component in the treatment of Pilon fractures with ORIF. However its necessity in fractures treated by EX.FIX has been questioned. In order to clarify this technical detail we carried out a retrospective study with Pilon fractures treated by circular þxators. Methods: Between 1992–2001, 65 pilon fractures were treated with circular þxators. Fractures were classiþed according to the systems of Ruedi Ð All-gower (9 II, 56 III) and Ovadia-Beals (9 II, 21 III, 13 IV, 22 V). Tension wire þxation at the fracture site was augmented by screws in 39 fractures. The lateral malleolus was internally þxed in 39(60%) patients. In 48(74%) patients the þxation was extended to the calcaneus for 6 weeks. The metaphyseal defect (25 fractures, 38.5%) was treated by grafting in fourteen, acute shortening in six, and bone transport in þve fractures. Clinical and radiological results were evaluated. Results: Mean follow up was 3 years (1 to 10 years). On the basis of Ruedi-All-gower system, there was found negative correlation of the end result and þbular þxation in all the fractures types. However if Ovadia Beals system was used, þbular þxation was associated with better results in types II and III, but with inferior results in types IV and V. Conclusions: Ovadia Ð Beals classiþcation considers the metaphyseal defect and fracture comminution and should be chosen for the selection of the technique. In fractures with metaphyseal defect, þbular þxation does not allow acute shortening and makes bone transport more difþcult leading to poor results. Fibular plating is desirable for types II and III but it should be avoided or at least not preceded for types IV and V.

Purpose: Reconstruction after resection of malignant bone tumours remains a major challenge. Free vascularised fibular grafts may be a useful alternative in this indication.

Material: Thirty children (nine girls, twenty-one boys) were treated between 1993 and 2000. Mean age was eleven years. Tumour histology was: osteogenic osteo-sarcoma (n=20), Ewing tumour (n=5), justacortical osteosarcoma (n=3), synovialosarcoma (n=1), and chondrosarcoma (n=1). Tumours were located in the femur (n=17), the tibia (n=6), the humerus (n=5), the radius (n=1), and the distal fibular (n=1). The length of resection varied from 100 mm to 260 mm (mean 160 mm). Internal fixation was used in 27 cases and external fixation in three. The adjacent epiphysis was preserved in 22 cases and initial arthrodesis was performed in eight.

Method: Patients were followed clinically and radiographically. A bone scintigram was obtained in all patients at least once during the postoperative period. Radiological assessment was based on the hypertrophy index of the graft using the method described by DeBoer and Wood. Functional outcome was assessed using the Enneking criteria.

Results: Mean follow-up was 51 months (range 2 – 9 years). Early amputation was required in two patients due to local ocological complications. One patient died at eight months follow-up due to lung metastasis. Among the remaining 27 patients, primary bone healing was achieved in 22. The five other patients exhibited clear signs of non-vascularisation. Successful healing was achieved in four of these patients after a complementary autologous graft. All cases of stress fracture healed after simple immobilisation.

The twenty-two patients who achieved primary bone healing developed a hypertrophic graft (mean 61%, range 22 – 190%). Graft hypertrophy was not observed in the five cases requiring a secondary graft after the scintigram demonstrated lack of vascularisation. Hypertrophy of the vascularised fibular graft was more marked for lower limb reconstructions than for upper limb reconstructions..

Functional outcome was satisfactory in all cases. On the 30-point Enneking scale as modified, our patients achieved a mean 26 points (range 19 – 30).

Discussion: Outcome was directly related to patency of the vascular anastomoses. Bone scintigraphy, performed one month after reconstruction surgery, was an important element for assessing prognosis. In case of unsuccessful vascularisation, a complementary cortico-cancellous graft should be used. Early weight-bearing is advisable using adequate protective devices. Dynamic osteosynthesis systems should be helpful in improving graft hypertrophy.

Objective and Purpose: Pilon fractures are complex fractures of the tibial articular surface usually associated with high energy trauma and major soft tissue injury. We investigated the effectiveness of Ilizarov external fixator in such cases. At our hospital, we obtain excellent results performing reconstruction using vascularised fibular grafts for the infectious non-union.

Methods and Materials: We examined 21 cases treated with the Ilizarov apparatus for the fresh pilon fracture from 1999. There were 13 males and 8 females, with an average of 44 years. The AO classification was A2 type in 2 cases, B1 in 4, C1 in 3, C2 in 3, and C3 in 9, with open fractures of Gustilo type?Uor ?Va in 7 cases. 11 cases were treated by the Ilizarov technique only. 10 cases were treated by the additional limited open reduction with screw, K-wire and fibular plating. The average time between injury and surgery was 4 days. We examined 6 cases treated with the vascularised fibular graft for the infectious non-union cases after internal fixation. Age at the surgery was from 19 to 70 (mean 46).

Results: All fractures were united and removed at an average of 10 weeks (range 8–12 weeks). Complications included 5 cases of superficial pin tract infections. There is no deep infections and no pseudarthrosies.

Conclusion: The use of Ilizarov fixator is a safer method of treatment of pilon fractures, especially for the severe soft tissue injury and we don ft delay surgery for soft tissue considerations.

Abstract. Objectives. The syndesmosis joint, located between the tibia and fibula, is critical to maintaining the stability and function of the ankle joint. Damage to the ligaments that support this joint can lead to ankle instability, chronic pain, and a range of other debilitating conditions. Understanding the kinematics of a healthy joint is critical to better quantify the effects of instability and pathology. However, measuring this movement is challenging due to the anatomical structure of the syndesmosis joint. Biplane Video Xray (BVX) combined with Magnetic Resonance Imaging (MRI) allows direct measurement of the bones but the accuracy of this technique is unknown. The primary objective is to quantify this accuracy for measuring tibia and fibula bone poses by comparing with a gold standard implanted bead method. Methods. Written informed consent was given by one participant who had five tantalum beads implanted into their distal tibia and three into their distal fibula from a previous study. Three-dimensional (3D) models of the tibia and fibula were segmented (Simpleware Scan IP, Synopsis) from an MRI scan (Magnetom 3T Prisma, Siemens). The beads were segmented from a previous CT and co-registered with the MRI bone models to calculate their positions. BVX (125 FPS, 1.25ms pulse width) was recorded whilst the participant performed level gait across a raised platform. The beads were tracked, and the bone position of the tibia and fibula were calculated at each frame (DSX Suite, C-Motion Inc.). The beads were digitally removed from the X-rays (MATLAB, MathWorks) allowing for blinded image-registration of the MRI models to the radiographs. The mean difference and standard deviation (STD) between bead-generated and image-registered bone poses were calculated for all degrees of freedom (DOF) for both bones. Results. The absolute mean tibia and fibula bone position differences (Table 1) between the bead and BVX poses were found to be less than 0.5 mm for both bones. The bone rotation differences were found to be less than 1° for all axes except for the fibula Z axis rotation which was found to be 1.46°. One study. 1. has reported the kinematics of the syndesmosis joint and reported maximum ranges of motion of 9.3°and translations of 3.3mm for the fibula. The results show that the accuracy of the methodology is sufficient to quantify these small movements. Conclusions. BVX combined with MRI can be used to accurately measure the syndesmosis joint. Future work will look at quantifying the accuracy of the talus to provide further understanding of normal ankle kinematics and to quantify the kinematics across a healthy population to act as a comparator for future patient studies. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction. A significant burden of disease exists with respect to critical sized bone defects; outcomes are unpredictable and often poor. There is no absolute agreement on what constitutes a “critically-sized” bone defect however it is widely considered as one that would not heal spontaneously despite surgical stabilisation, thus requiring re-operation. The aetiology of such defects is varied. High-energy trauma with soft tissue loss and periosteal stripping, bone infection and tumour resection all require extensive debridement and the critical-sized defects generated require careful consideration and strategic management. Current management practice of these defects lacks consensus. Existing literature tells us that tibial defects 25mm or great have a poor natural history; however, there is no universally agreed management strategy and there remains a significant evidence gap. Drawing its origins from musculoskeletal oncology, the Capanna technique describes a hybrid mode of reconstruction. Mass allograft is combined with a vascularised fibula autograft, allowing the patient to benefit from the favourable characteristics of two popular reconstruction techniques. Allograft confers initial mechanical stability with autograft contributing osteogenic, inductive and conductive capacity to encourage union. Secondarily its inherent vascularity affords the construct the ability to withstand deleterious effects of stressors such as infection that may threaten union. The strengths of this hybrid construct we believe can be used within the context of critical-sized bone defects within tibial trauma to the same success as seen within tumour reconstruction. Methodology. Utilising the Capanna technique in trauma requires modification to the original procedure. In tumour surgery pre-operative cross-sectional imaging is a pre-requisite. This allows surgeons to assess margins, plan resections and order allograft to match the defect. In trauma this is not possible. We therefore propose a two-stage approach to address critical-sized tibial defects in open fractures. After initial debridement, external fixation and soft tissue management via a combined orthoplastics approach, CT imaging is performed to assess the defect geometry, with a polymethylmethacrylate (PMMA) spacer placed at index procedure to maintain soft tissue tension, alignment and deliver local antibiotics. Once comfortable that no further debridement is required and the risk of infection is appropriate then 3D printing technology can be used to mill custom jigs. Appropriate tibial allograft is ordered based on CT measurements. A pedicled fibula graft is raised through a lateral approach. The peroneal vessels are mobilised to the tibioperoneal trunk and passed medially into the bone void. The cadaveric bone is prepared using the custom jig on the back table and posterolateral troughs made to allow insertion of the fibula, permitting some hypertrophic expansion. A separate medial incision allows attachment of the custom jig to host tibia allowing for reciprocal cuts to match the allograft. The fibula is implanted into the allograft, ensuring nil tension on the pedicle and, after docking the graft, the hybrid construct is secured with multi-planar locking plates to provide rotational stability. The medial window allows plate placement safely away from the vascular pedicle. Results. We present a 50-year-old healthy male with a Gustilo & Anderson 3B proximal tibial fracture, open posteromedially with associated shear fragment, treated using the Capanna technique. Presenting following a fall climbing additional injuries included a closed ipsilateral calcaneal and medial malleolar fracture, both treated operatively. Our patient underwent reconstruction of his tibia with the above staged technique. Two debridements were carried out due to a 48-hour delay in presentation due to remote geographical location of recovery. Debridements were carried out in accordance with BOAST guidelines; a spanning knee external fixator applied and a small area of skin loss on the proximal medial calf reconstructed with a split thickness skin graft. A revision cement spacer was inserted into the metaphyseal defect measuring 84mm. At definitive surgery the external fixator was removed and graft fixation was extended to include the intra-articular fragments. No intra-operative complications were encountered during surgeries. The patient returned to theatre on day 13 with a medial sided haematoma. 20ml of haemoserous fluid was evacuated, a DAIR procedure performed and antibiotic-loaded bioceramics applied locally. Samples grew Staphylococcus aureus and antibiotic treatment was rationalised to Co-Trimoxazole 960mg BD and Rifampicin 450mg BD. The patient has completed a six-week course of Rifampicin and continues on suppressive Co-Trimoxazole monotherapy until planned metalwork removal. There is no evidence of ongoing active infection and radiological evidence of early union. The patient is independently walking four miles to the gym daily and we believe, thus far, despite accepted complications, we have demonstrated a relative early success. Conclusions. A variety of techniques exist for the management of critical-sized bone defects within the tibia. All of these come with a variety of drawbacks and limitations. Whilst acceptance of a limb length discrepancy is one option, intercalary defects of greater than 5 to 7cm typically require reconstruction. In patients in whom fine wire fixators and distraction osteogenesis are deemed inappropriate, or are unwilling to tolerate the frequent re-operations and potential donor site morbidity of the Masqualet technique, the Capanna technique offers a novel solution. Through using tibial allograft to address the size mismatch between vascularised fibula and tibia, the possible complication of fatigue fracture of an isolated fibula autograft is potentially avoidable in patients who have high functional demands. The Capanna technique has demonstrated satisfactory results within tumour reconstruction. Papers report that by combining the structural strength of allograft with the osteoconductive and osteoinductive properties of a vascularised autograft that limb salvage rates of greater than 80% and union rates of greater than 90% are achievable. If these results can indeed be replicated in the management of critical-sized bone defects in tibial trauma we potentially have a treatment strategy that can excel over the more widely practiced current techniques

Abstract. Background. Extracorporeal radiation therapy (ECRT) has been reported as an oncologically safe and effective reconstruction technique for limb salvage in diaphyseal sarcomas with promising functional results. Factors affecting the ECRT graft-host bone incorporation have not been fully investigated. Methods. In our series of 51 patients of primary bone tumors treated with ECRT, we improvised this technique by using a modified V-shaped osteotomy, additional plates and intra-medullary fibula across the diaphyseal osteotomy in an attempt to increase the stability of fixation, augment graft strength and enhance union at the osteotomy sites. We analyzed our patients for various factors that affected union time and union rate at the osteotomy sites. Results. On univariate analysis, age <20 years, metaphyseal osteotomy site, V-shaped diaphyseal osteotomy, extramedullary plate fixation and use of additional plate at diaphyseal ostetomy had a significantly faster time to union while gender, tumor type, resection length, chemotherapy and use of intra-medullary fibula did not influence union time. In multivariate analysis, metaphyseal ostoeotomy, V-shaped diaphyseal osteotomy and use of additional plate at diaphyseal ostetomy were the independent factors with favourable time to union. Although the rate of union was higher with V-shaped diaphyseal osteotomy and use of additional plate and intra-medullary fibula at diaphyseal ostetomy, this difference could not be established statistically. None of the analyzed factors apparently affected the union rate in univariate analysis. Conclusion. Judicious choice of osteosynthesis and augmentation of ECRT graft can enhance incorporation with reduced complications and good functional outcome

It is still difficult to determine an appropriate hinge position to prevent fracture in the lateral cortex of tibia in the process of making an open wedge during biplane open wedge high tibial osteotomy. The objective of this study was to present a biomechanical basis for determining the hinge position as varus deformity. T Three-dimensional lower extremity models were constructed using Mimics. The tibial wedge started at 40 mm distal to the medial tibial plateau, and osteotomy for three hinge positions was performed toward the head of the fibula, 5 mm proximal from the head of the fibula, and 5 mm distal from the head of the fibula. The three tibial models were made with varus deformity of 5, 10, 15 degrees with heterogeneous material properties. These properties were set to heterogeneous material properties which converted from Hounsfield's unit to Young's modulus by applying empirical equation in existing studies. For a loading condition, displacement at the posterior cut plane was applied referring to Hernigou's table considering varus deformity angle. All computational analyses were performed to calculate von-mises stresses on the tibial wedges. The maximum stress increased to an average of 213±9% when the varus angle was 10 degrees compared to 5 degrees and increased to an average of 154±8.9% when the varus angle was 15 degrees compared to 10 degrees. In addition, the maximum stress of the distal position was 19 times higher than that of the mid position and 5 times higher than that of the proximal position on average. Conclusion:. For varus deformity angles, the maximum stress of the tibial wedge tended to increase as the varus deformity angle increased. For hinge position of tibial wedge, maximum stress was the lowest in the mid position, while the highest in the distal position. *This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (NRF-2022R1A2C1009995)

The June 2024 Trauma Roundup. 360. looks at: Skin antisepsis before surgical fixation of limb fractures; Comparative analysis of intramedullary nail versus plate fixation for fibula fracture in supination external rotation type IV ankle injury; Early weightbearing versus late weightbearing after intramedullary nailing for distal femoral fracture (AO/OTA 33) in elderly patients: a multicentre propensity-matched study; Long-term outcomes with spinal versus general anaesthesia for hip fracture surgery; Operative versus nonoperative management of unstable medial malleolus fractures: a randomized clinical trial; Impact of smoking status on fracture-related infection characteristics and outcomes; Reassessing empirical antimicrobial choices in fracture-related infections; Development and validation of the Nottingham Trauma Frailty Index (NTFI) for older trauma patients

Introduction. Fibula contributes to weight bearing and serves as a lateral buttress to the talus. Fibular shortening leads to ankle valgus, distal tibial epiphyseal wedging and ankle instability. Trauma, infection and skeletal dyplasias are the common causes of fibular shortening in children. Aim was to review this cohort who underwent fibular lengthening and ankle reconstruction. Materials and Methods. Retrospective review from a prospective database of clinical and radiographic data of all children who underwent fibular lengthening for correction of ankle valgus. Distraction osteogenesis with external fixator was performed for all cases. Results. Eight children with 10 fibulae (average age: 10 years) were followed up for an average of 75.6 months. In older children, corrective tibial osteotomy was performed in addition to fibular lengthening. TSF frame mounted with mini-rail fixator was used in seven children who required adjuvant tibial correction and mini-rail was used for bilateral fibular lengthening in one. Remodelling of the wedged distal tibial epiphysis was noted in 75%. Talar tilt and mLDTA improved in 66.7% and fibular station in 85.7% limbs. Seven year old girl required re-lengthening. Two children developed fibular non-union. Proximal fibular migration was observed in one child, in whom the tibial wire did not engage the fibula. Conclusions. Restoration of tibial mechanical axis and lateral talar buttress is necessary to correct ankle valgus. Stabilisation of fibula to the tibia is prudent during distraction. Younger children may require re-lengthening. Remodelling of the triangular tibial epiphysis can be achieved when done early

The December 2023 Oncology Roundup. 360. looks at: A single osteotomy technique for frozen autograft; Complications, function, and survival of tumour-devitalized autografts used in patients with limb-sparing surgery; Is liquid nitrogen recycled bone and vascular fibula the biological reconstruction of choice?; Solitary pulmonary metastases at first recurrence of osteosarcoma; Is a radiological score able to predict resection-grade chondrosarcoma in primary intraosseous lesions of the long bones?; Open versus core needle biopsy in lower-limb sarcoma – current practice patterns and patient outcomes; Natural history of intraosseous low-grade chondroid lesions of the proximal humerus; Local treatment modalities and event-free survival in patients with localized Ewing’s sarcoma; Awaiting biopsy results in solitary pathological proximal femoral fractures

The August 2024 Oncology Roundup. 360. looks at: What factors are associated with osteoarthritis after cementation for benign aggressive bone tumour of the knee joint: a systematic review and meta-analysis; Recycled bone grafts treated with extracorporeal irradiation or liquid nitrogen freezing after malignant tumour resection; Intercalary resection of the tibia for primary bone tumours: are vascularized fibula autografts with or without allografts a durable reconstruction?; 3D-printed modular prostheses for the reconstruction of intercalary bone defects after joint-sparing limb salvage surgery for femoral diaphyseal tumours; Factors influencing the outcome of patients with primary Ewing’s sarcoma of the sacrum; The significance of surveillance imaging in children with Ewing’s sarcoma and osteosarcoma; Resection margin and soft-tissue sarcomas of the extremities treated with limb-sparing surgery and postoperative radiotherapy

The February 2024 Shoulder & Elbow Roundup. 360. looks at: Does indomethacin prevent heterotopic ossification following elbow fracture fixation?; Arthroscopic capsular shift in atraumatic shoulder joint instability; Ultrasound-guided lavage with corticosteroid injection versus sham; Combined surgical and exercise-based interventions following primary traumatic anterior shoulder dislocation: a systematic review and meta-analysis; Are vascularized fibula autografts a long-lasting reconstruction after intercalary resection of the humerus for primary bone tumours?; Anatomical versus reverse total shoulder arthroplasty with limited forward elevation; Tension band or plate fixation for simple displaced olecranon fractures?; Is long-term follow-up and monitoring in shoulder and elbow arthroplasty needed?

Open tibial fractures can be difficult to manage, with a range of factors that could affect treatment and outcome. We present a large cohort of patients, and analyse which factors have significant associations with infection outcome. Elucidation will allow clinicians to strive for treatment optimisation, and patients to be advised on likely complications. Open tibia fractures treated at a major trauma centre between 2015-2021 were included. Mean age at injury was 55.4 (range 13-102). Infection status was categorized into no infection, superficial infection, and osteomyelitis. Age, mode of injury, polytrauma, fibula status, Gustilo-Anderson (GA) classification, wound contamination, time from injury to: first procedure/definitive plastics procedure/definitive fixation, type of definitive fixation, smoking and diabetic status, and BMI, were collected. Multicollinearity was calculated, with highly correlated factors removed. Multinomial logistic regression was performed. Chi Squared testing, with Post Hoc Bonferroni correction was performed for complex categorical factors. Two hundred forty-four patients with open tibial fractures were included. Forty-five developed superficial infection (18.4%), and thirty-nine developed osteomyelitis (16.0%). Polytrauma, fibula status, and type of definitive fixation were excluded from the multivariate model due to strong multicollinearity with other variables. With reference to the non-infected outcome; superficial infection patients had higher BMI (p<0.01), higher GA grade (p<0.01), osteomyelitis patients had longer time to definitive fixation (p=0.049) and time to definitive plastics procedure (p=0.013), higher GA grade (p<0.01), and positive wound contamination(p=0.015). Poc hoc analysis showed “no infection” was positively associated with GA-I (p=0.029) and GA-II (p<0.01), and negatively associated with GA-IIIC (p<0.01). Osteomyelitis was positively associated with GA-IIIc (p<0.01). This study investigated the associations between the injury and presentation factors that may affect infection outcome. The variables highlighted are the factors clinicians should give extra consideration to when treating cases, and take preventative measures to optimize treatment and mitigate infection risk

Abstract. Objectives. This abstract provides an update on the Open Ankle Models being developed at the University of Bath. The goal of this project is to create three fully open-source finite element (FE) ankle models, including bones, ligaments, and cartilages, appropriate musculoskeletal loading and boundary conditions, and heterogeneous material property distribution for a standardised representation of ankle biomechanics and pre-clinical ankle joint analysis. Methods. A computed tomography (CT) scan data (pixel size of 0.815 mm, and slice thickness of 1 mm) was used to develop the 3D geometry of the bones (tibia, talus, calcaneus, fibula, and navicular). Each bone was given the properties of a heterogeneous elastic material based on the CT greyscale. The density values for each bone element were calculated using a linear empirical relation, ρ= 0.0405 + (0.000918) HU and then power law equations were utilised to get the Young's Modulus value for each bone element [1]. At the bone junction, a thickness of cartilage ranging from 0.5–1 mm, and was modelled as a linear material (E=10 MPa, ν=0.4 [2]). All ligament insertions and positions were represented by four parallel spring elements, and the ligament stiffness and material attributes were applied in accordance with the published literature [2]. The ankle model was subjected to static loading (balance standing position). Four noded tetrahedral elements were used for the discretization of bones and cartilages. All degrees of freedom were restricted at the proximal ends of the tibia and fibula. The ground reaction forces were applied at the underneath of the calcaneus bone. The interaction between the cartilages and bones was modelled using an augmented contact algorithm with a sliding elastic contact between each cartilage. A tied elastic contact was used between the cartilages and the bone. FEbio 2.1.0 (University of Utah, USA) was used to construct the open-source ankle model. Results. When the double-legged stance phase loading condition was taken into consideration, stress at the antero-medial tibial wall (ranged from 1 to 7 MPa) was found to be similar to the prior work [2], indicating bulk of the load transfer was through this region. The maximum principal strain was predicted at the different regions on bones around the ankle joint. The proximal surface of the talus, and tibial distal surface were shown to have the highest maximum principal strains followed by antero-medial walls of the tibia bone, at the proximal location. Conclusions. The present open 3D FE model of the ankle will assist researchers in better understanding ankle biomechanics, precisely predicting load transfer, and examining the ankle to address unmet clinical needs for this joint. The results of the current investigation are realistic in terms of load transfer and stress-strain distribution across the ankle joint and well comparable to those reported in the literature [2]. However, sensitivity and ankle instability simulations will be performed in future work to investigate the model's reliability and robustness. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction. Intramedullary nailing is gaining popularity for treatment of distal tibial fractures due to short operative time and minimum surgical trauma to soft tissues. Distal tibial fractures are commonly associated with concurrent fibular fractures at, above or below the level of tibial fractures. So far there is no consensus for fixation of fibular fractures. Materials and Methods. Fractures of fibula at or below the level of fracture of tibia were taken into consideration. Fractures of fibula above the tibial level were excluded because they do not add to stability of fracture fixation. Retrospective study was done and distal tibia-fibula fractures were separated into 2 groups based on whether fibula was fixed or not. Measures of angulation were obtained from radiographs taken immediately after the surgery, a second time 3 months later, and at 6-month follow-up. Results. 35 fracture of distal tibia and fibula were included in study. Fibula was not fixed in 21 cases while 14 fibular fixations were carried out either using short plates(8) or intramedullary pins(6). No significant differences were observed for malalignment in fracture of fibula at the level of tibial fractures. However for fractures of fibula at a level lower than its tibial counterpart, fixation of fibula significantly reduced malalignment. Conclusion. Fixation of fibula has a definite role in reducing malunion in cases where fibula was fractured below the level of tibial fracture. Fixation of fibula may increase overall stability of fixation of tibia and reduce malunion

Abstract. Objectives. The aim of this study was to develop an open-source finite element model of the ankle for identification of the best clinical treatment to restore stability to the ankle after injury. Methods. The ankle geometry was defined from the Visible Human Project Female CT dataset available from the National Library of Medicine, and segmented using Dragonfly software (Object Research Systems, 2020). The finite element model was created with FEBio (University of Utah, 2021) using the dynamic nonlinear implicit solver. Linear isotropic material properties were assigned to the bones (E=7300MPa, ν=0.3, ρ=1730kg/m. 3. ) and cartilage (E=10MPa, ν=0.4, ρ=1100kg/m. 3. ). Spring elements were used to represent the ligaments and material properties were taken from Mondal et al. [1]. Lagrangian contact was defined between the cartilaginous surfaces with μ=0.003. A standing load case was modelled, assuming even distribution of load between the feet. A reaction force of 344.3N was applied to the base of the foot, a muscle force of 252.2N, and the proximal ends of the tibia and fibula were fully constrained. Results. The von Mises stresses closely matched those reported by Mondal et al. for the fibula (Present study: 1.00MPa, Mondal: 1.30MPa) and the talus (Present study: 2.20MPa, Mondal: 2.39MPa). However stresses within the tibia were underpredicted (Present study: 1.08MPa, Mondal: 5.86MPa). This was because the present study modelled a shorter tibial length because of a limitation in the CT slices available, which reduced the bending force. Conclusions. This first step in producing an open source ankle model for the orthopaedics community has shown the potential of the model to generate results comparable with those found in the literature. Future work is underway to examine the robustness of the model under different loading and explore alternative open-source CT datasets. [1] Mondal, S., & Ghosh, R. (2017). J Orthopaedics, 14(3), 329–335. . https://doi.org/10.1016/j.jor.2017.05.003

Background. Ankle fractures are often associated with ligamentous injuries of the distal tibiofibular syndesmosis, the deltoid ligament and are predictive of ankle instability, early joint degeneration and long-term ankle dysfunction. Detection of ligamentous injuries and the need for treatment remain subject of ongoing debate. In the classic article of Boden it was made clear that injuries of the syndesmotic ligaments were of no importance in the absence of a deltoid ligament rupture. Even in the presence of a deltoid ligament rupture, the interosseous membrane withstood lateralization of the fibula in fractures up to 4.5mm above the ankle joint. Generally, syndesmotic ligamentous injuries are treated operatively by temporary fixation performed with positioning screws. But do syndesmotic injuries need to be treated operatively at all?. Methods. The purpose of this biomechanical cadaveric study was to investigate the relative movements of the tibia and fibula, under normal physiological conditions and after sequential sectioning of the syndesmotic ligaments. Ten fresh-frozen below-knee human cadaveric specimens were tested under normal physiological loading conditions. Axial loads of 50 Newton (N) and 700N were provided in an intact state and after sequential sectioning of the following ligaments: anterior-inferior tibiofibular (AITFL), posterior-inferior tibiofibular (PITFL), interosseous (IOL), and whole deltoid (DL). In each condition the specimens were tested in neutral position, 10 degrees of dorsiflexion, 30 degrees of plantar flexion, 10 degrees of inversion, 5 degrees of eversion, and externally rotated up to 10Nm torque. Finally, after sectioning of the deltoid ligament, we triangulated Boden's classic findings with modern instruments. We hypothesized that only after sectioning of the deltoid ligament; the lateralization of the talus will push the fibula away from the tibia. Results. During dorsiflexion and external rotation the ankle syndesmosis widened, and the fibula externally rotated after sequential sectioning of the syndesmotic ligaments. After the AITFL was sectioned the fibula starts rotating externally. However, the external rotation of the fibula significantly reduced when the external rotation torque was combined with axial loading up to 700N as compared to the external rotation torque alone. The most relative moments between the tibia and fibula were observed after the deltoid ligament was sectioned. Conclusion. Significant increases in movements of the fibula relative to the tibia occur when an external rotation torque is provided. However, axial pressure seemed to limit external rotation because of the bony congruence of the tibiotalar surface. The AITFL is necessary to prevent the fibula to rotate externally when the foot is rotating externally. The deltoid ligament is the main stabilizer of the ankle mortise