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