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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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.

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.

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.

Aims. The aim of this study was to analyze the complications and outcomes of treatment in a series of previously untreated patients with a primary aneurysmal bone cyst (ABC) who had been treated by percutaneous sclerosant therapy using polidocanol. Methods. Between January 2010 and December 2016, 56 patients were treated primarily with serial intralesional sclerosant injections. Their mean age was 20 years (1 to 54). The sites involved were clavicle (n = 3), humeri (n = 11), radius (n = 1), ulna (n = 3), hand (n = 2), pelvis (n = 12), femur (n = 7), tibia (n = 13), fibula (n = 3), and foot (n = 1). After histopathological confirmation of the diagnosis, 3% polidocanol (hydroxypolyaethoxydodecan) was injected into the lesion under image intensifier guidance. Patients were evaluated clinically and radiologically every six to eight weeks. In the absence of clinical and/or radiological response, a repeat sclerosant injection was given after eight to 12 weeks and repeated at similar intervals if necessary. Results. There were no complications of treatment. One patient was lost to follow-up. Overall, 46/55 (84%) of lesions healed after one or more injections of polidocanol: 24/55 (44%) patients healed with a single injection, and 43/55 (78%) within two injections. Of these 46, four (9%) patients developed local recurrence, two of whom healed with a repeat sclerosant injection. Thus, 44/55 (80%) patients of primary ABC healed with sclerotherapy. The mean follow-up was 62 months (20 to 111). The local recurrence free survival (LRFS) with percutaneous sclerosant therapy with polidocanol was 100%, 98% (95% confidence interval (CI) 85 to 100) and 93% (95% CI 78 to 98) at two, three, and five years, respectively. Conclusion. Percutaneous sclerotherapy using polidocanol is a safe, effective, minimally invasive and inexpensive method of treating a primary ABC of the limbs or pelvis. Cite this article: Bone Joint J 2020;102-B(2):186–190

Aims. Cone beam CT allows cross-sectional imaging of the tibiofibular syndesmosis while the patient bears weight. This may facilitate more accurate and reliable investigation of injuries to, and reconstruction of, the syndesmosis but normal ranges of measurements are required first. The purpose of this study was to establish: 1) the normal reference measurements of the syndesmosis; 2) if side-to-side variations exist in syndesmotic anatomy; 3) if age affects syndesmotic anatomy; and 4) if the syndesmotic anatomy differs between male and female patients in weight-bearing cone beam CT views. Patients and Methods. A retrospective analysis was undertaken of 50 male and 50 female patients (200 feet) aged 18 years or more, who underwent bilateral, simultaneous imaging of their lower legs while standing in an upright, weight-bearing position in a pedCAT machine between June 2013 and July 2017. At the time of imaging, the mean age of male patients was 47.1 years (18 to 72) and the mean age of female patients was 57.8 years (18 to 83). We employed a previously described technique to obtain six lengths and one angle, as well as calculating three further measurements, to provide information on the relationship between the fibula and tibia with respect to translation and rotation. Results. The upper limit of lateral translation in un-injured patients was 5.27 mm, so values higher than this may be indicative of syndesmotic injury. Anteroposterior translation lay within the ranges 0.31 mm to 2.59 mm, and -1.48 mm to 3.44 mm, respectively. There was no difference between right and left legs. Increasing age was associated with a reduction in lateral translation. The fibulae of men were significantly more laterally translated but data were inconsistent for rotation and anteroposterior translation. Conclusion. We have established normal ranges for measurements in cross-sectional syndesmotic anatomy during weight-bearing and also established that no differences exist between right and left legs in patients without syndesmotic injury. Age and gender do, however, affect the anatomy of the syndesmosis, which should be taken into account at time of assessment. Cite this article: Bone Joint J 2019;101-B:348–352

The posterior malleolus component of a fracture of the ankle is important, yet often overlooked. Pre-operative CT scans to identify and classify the pattern of the fracture are not used enough. Posterior malleolus fractures are not difficult to fix. After reduction and fixation of the posterior malleolus, the articular surface of the tibia is restored; the fibula is out to length; the syndesmosis is more stable and the patient can rehabilitate faster. There is therefore considerable merit in fixing most posterior malleolus fractures. An early post-operative CT scan to ensure that accurate reduction has been achieved should also be considered. Cite this article: Bone Joint J 2017;99-B:1413–19

Aims. The aim of this study was to utilize a national paediatric inpatient database to determine whether obesity influences the operative management and inpatient outcomes of paediatric limb fractures. Patients and Methods. The Kids’ Inpatient Database (KID) was used to evaluate children between birth and 17 years of age, from 1997 and 2012, who had undergone open and closed treatment of humeral, radial and ulna, femoral, tibial, and ankle fractures. Demographics, hospital charges, lengths of stay (LOS), and complications were analyzed. Results. Obesity was significantly associated with increased rates of open reduction and internal fixation (ORIF) for: distal humeral (odds ratio (OR) = 2.139, 95% confidence interval (CI) 1.92 to 3.44; p < 0.001); distal radius and ulna fractures (OR = 1.436, 95% CI 1.14 to 2.16; p < 0.05); distal femoral (OR = 2.051, 95% CI 1.69 to 3.60; p < 0.05); tibial and fibula shaft (OR = 2.101, 95% CI 2.10 to 3.50; p < 0.001); and ankle (OR = 1.733, 95% CI 1.70 to 2.39; p < 0.001). Older age was significantly associated with ORIF for all fractures (p < 0.05). LOS, hospital charges, and complications were significantly increased in obese patients following ORIF for upper and lower limb fractures (p < 0.05). Conclusion. Obese paediatric patients are more likely to undergo ORIF in both upper and lower limb fractures and have more inpatient complications. These findings may assist in informing obese paediatric fracture patients and their families regarding the increased risk for open operative fixation and associated outcomes. Cite this article: Bone Joint J 2019;101-B:491–496

Anatomical atlases document safe corridors for placement of wires when using fine-wire circular external fixation. The furthest posterolateral corridor described in the distal tibia is through the fibula. This limits the crossing angle and stability of the frame. In this paper we describe a new, safe Retro-Fibular Wire corridor, which provides greater crossing angles and increased stability. In a cadaver study, 20 formalin-treated legs were divided into two groups. Wires were inserted into the distal quarter of the tibia using two possible corridors and standard techniques of dissection identified the distance of the wires from neurovascular structures. In both groups the posterior tibial neurovascular bundle was avoided. In group A the peroneal artery was at risk. In group B this injury was avoided. Comparison of the groups showed a significant difference (p < 0.001). We recommend the Retro-Fibular wire technique whereby wires are inserted into the tibia mid-way between the posteromedial border of the fibula and the tendo Achillis, at 30° to 45° to the sagittal plane, and introduced from a posterolateral to an anteromedial position. Subsequently, when using this technique in 30 patients, we have had no neurovascular complications or problems relating to tethering of the peroneal tendons

We have quantitatively documented the insertion geometry of the main stabilising structures of the posterolateral corner of the knee in 34 human cadavers. The lateral collateral ligament inserted posterior (4.6 mm, . sd. 2) and proximal (1.3 mm, . sd. 3.6) to the lateral epicondyle of the femur and posterior (8.1 mm, . sd. 3.2) to the anterior point of the head of the fibula. On the femur, the popliteus tendon inserted distally (11 mm, . sd. 0.8) and either anterior or posterior (mean 0.84 mm anterior, . sd. 4) to the lateral collateral ligament. The popliteofibular ligament inserted distal (1.3 mm, . sd. 1.2) and anterior (0.5 mm, . sd. 2.0) to the tip of the styloid process of the fibula. The ligaments had a consistent pattern of insertion and, despite the variation between specimens, the standard deviations were less than the typical size of drill hole used in reconstruction of the posterolateral corner. The data provided in this study can be used in the anatomical repair and reconstruction of this region of the knee

Aims

The sacroiliac joint (SIJ) is the only mechanical connection between the axial skeleton and lower limbs. Following iliosacral resection, there is debate on whether reconstruction of the joint is necessary. There is a paucity of data comparing the outcomes of patients undergoing reconstruction and those who are not formally reconstructed.

Aims

The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients.

Aims

Giant cell tumour of bone (GCTB) is a locally aggressive lesion that is difficult to treat as salvaging the joint can be associated with a high rate of local recurrence (LR). We evaluated the risk factors for tumour relapse after treatment of a GCTB of the limbs.

A vascularised fibular strut graft was used for anterior spinal fusion in 16 patients with spinal kyphosis. The procedure was abandoned in three because of difficulty in establishing a vascular anastomosis and in one because the grafted fibula dislodged two days after operation. One patient died after five days. Of the 11 remaining patients, there were seven males and four females. Their ages at the time of operation averaged 30.9 years (12 to 71). The number of vertebrae fused averaged 6.7 (5 to 9) and the length of fibula grafted averaged 10.9 cm (6.5 to 18). Average follow-up was 54 months (27 to 84). Bone union occurred at both ends of the grafted fibula in all 11 patients, with an average time to union of 5.5 months (3 to 8). We did not see a fracture of the grafted fibula. Two patients had postoperative complications; the graft dislodged in one and laryngeal oedema occurred two days after operation in the other. A vascularised fibular strut graft provides a biomechanically stable and long-standing support in spinal fusion because the weak phase of creeping substitution does not take place in the graft

Aims

The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes.

Aims. The aim of the study was to investigate the controversial issue of whether the pelvic ring should be reconstructed following resection of the sarcomas of the ilium. Patients and Methods. From our database, we identified 64 patients who underwent excision of a tumour involving the ilium between 1976 and 2015. A total of 35 underwent complete resection, of whom 24 were reconstructed with a non-vascularised fibula graft, and four with extracorporeal irradiation and reimplantation. A total of 29 patients had a partial resection. The mean follow-up was 9.2 years (1.1 to 25.6). Functional outcomes were assessed using the Toronto Extremity Salvation Score (TESS) at final follow-up. In all, 32 patients (50%) had a chondrosarcoma. Results. The mean TESS for all patients was 71.6% (17% to 100%). The mean TESS for those who underwent total resection with reconstruction was 72.0% (17% to 100%) and without reconstruction it was 53.3% (20% to 90%) and for those who underwent partial resection it was 76.3% (31.3% to 100%). The rate of local recurrence was 42.2% and this was more common in those treated by partial resection (p = 0.048). The risk of local recurrence was related to the margin achieved at resection. Conclusions. Given the high rate of local recurrence following excision of a tumour from the ilium, obtaining wide surgical margins should be a priority even if this requires more aggressive surgery. In young patients, where late recurrence may occur, more radical complete resection should be considered. When total resection of the ilium is considered, reconstruction should also be considered as it confers a higher functional outcome than total resection without reconstruction. Cite this article: Bone Joint J 2017;99-B:538–43

There is a disparity in sport-related injuries between sexes, with females sustaining non-contact musculoskeletal injuries at a higher rate. Anterior cruciate ligament ruptures are between two and eight times more common than in males, and females also have a higher incidence of ankle sprains, patellofemoral pain, and bone stress injuries. The sequelae of such injuries can be devastating to an athlete, resulting in time out of sport, surgery, and the early onset of osteoarthritis. It is important to identify the causes of this disparity and introduce prevention programmes to reduce the incidence of these injuries. A natural difference reflects the effect of reproductive hormones in females, which have receptors in certain musculoskeletal tissues. Relaxin increases ligamentous laxity. Oestrogen decreases the synthesis of collagen and progesterone does the opposite. Insufficient diet and intensive training can lead to menstrual irregularities, which are common in female athletes and result in injury, whereas oral contraception may have a protective effect against certain injuries. It is important for coaches, physiotherapists, nutritionists, doctors, and athletes to be aware of these issues and to implement preventive measures. This annotation explores the relationship between the menstrual cycle and orthopaedic sports injuries in pre-menopausal females, and proposes recommendations to mitigate the risk of sustaining these injuries.

Cite this article: Bone Joint J 2023;105-B(7):723–728.

Aims

The preoperative grading of chondrosarcomas of bone that accurately predicts surgical management is difficult for surgeons, radiologists, and pathologists. There are often discrepancies in grade between the initial biopsy and the final histology. Recent advances in the use of imaging methods have shown promise in the ability to predict the final grade. The most important clinical distinction is between grade 1 chondrosarcomas, which are amenable to curettage, and resection-grade chondrosarcomas (grade 2 and 3) which require en bloc resection. The aim of this study was to evaluate the use of a Radiological Aggressiveness Score (RAS) to predict the grade of primary chondrosarcomas in long bones and thus to guide management.

Aims

The scapula is a rare site for a primary bone tumour. Only a small number of series have studied patient outcomes after treatment. Previous studies have shown a high rate of recurrence, with functional outcomes determined by the preservation of the glenohumeral joint and deltoid. The purpose of the current study was to report the outcome of patients who had undergone tumour resection that included the scapula.

Aims

The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK.