Radiologic findings for prediction of rehabilitation outcomes in patients with chronic symptomatic os subfibulare

Surgical treatment of ankle instability in children with os subfibulare

INTRODUCTION

Ankle instability in children due to soft tissue injury usually resolves after non-operative treatment. However, some children and adolescents with chronic instability require surgical treatment. A rarer cause of developing ankle instability is injury to the ligament complex in the presence of os subfibulare, an accessory bone inferior to the lateral malleolus. The aim of this study was to assess the results of operative management of chronic ankle instability in children with os subfibulare.

MATERIALS AND METHODS

16 children with os subfibulare and chronic ankle instability who failed non-operative treatment were enrolled prospectively into the study. One child was lost to follow-up and excluded from analysis. The mean age at the time of the surgery was 14 years and 2 months (range 9.5-17 years). The mean follow-up time was 43.2 months (range 28-48 months). Surgical treatment in all cases involved removal of os subfibulare and a modified Broström-Gould lateral complex reconstruction with anchors. Ankle status was assessed before and after surgery with The 100 mm Visual Analogue Scale and Foot and Ankle Outcome Score questionnaire.

RESULTS

The mean Foot and Ankle Outcome Score improved from 66.8 to 92.3 (p < 0.001). Pain level improved from 67.1 preoperatively to 12.7 (p < 0.001). All children reported improvement in their ankle stability. There was one case of scar hypersensitivity that improved during observation and one superficial wound infection that resolved with oral antibiotics. One child reported intermittent pain without symptoms of instability following another injury.

CONCLUSIONS

Ankle joint sprain with associated injury to os subfibulare complex can lead to chronic instability in children. If conservative management fails, then surgical treatment with modified Broström-Gould technique and excision of accessory bone is a safe and reliable method.

Optimal Visualization of Os Subfibulare Using 3D Water Selective Cartilage Scan (3D_WATSc) MRI Sequencing: A Case Report

Os subfibulare is an accessory ossicle of the lateral malleolus at the distal end of the fibula. In most instances, os subfibulare is found incidentally on radiographs. While os subfibulare typically remains asymptomatic, some cases may present with ankle pain or instability. To initiate appropriate treatment and maximize patient outcomes, it is crucial to accurately visualize the accessory ossicle. Here, we report a symptomatic case of os subfibulare diagnosed with ankle radiographs and a 3D water selective cartilage scan (3D_WATSc, Ingenia, Philips Healthcare, The Netherlands) magnetic resonance imaging sequence and treated surgically with open ossicle excision and a modified Broström procedure.

Management of sarcoma recurrence after megaprosthesis of the knee

BACKGROUND

The management of local sarcoma recurrence about the knee (at the distal femur or proximal tibia) is challenging. The objective of this study was to describe the locations of local sarcoma recurrences about knee megaprostheses, the treatments used for each type of recurrence, and the outcomes according to the treatment used.

HYPOTHESIS

The strategy for treating a local sarcoma recurrence about the knee must be based on the topography of tumour involvement.

MATERIALS AND METHODS

We included 13 patients who had local sarcoma recurrence about a knee megaprosthesis and were followed up for at least 2 years. The diagnosis was osteosarcoma in 10 patients and chondrosarcoma in 3 patients. The distal femur was involved in 11 patients and the proximal tibia in 2 patients. We classified the patients into two groups based on whether the tumour involved important structures or was at a distance within the soft tissues.

RESULTS

The recurrence was a nodule at a distance of important structures in 8 (57%) patients, in whom the mean time to recurrence was 15 months (range, 2-34 months). The remaining 5 (38.5%) patients had involvement of important structures in the popliteal fossa and a mean time to recurrence of 42 months (range, 16-80 months). Surgery was performed in 10 patients; the other 3 patients received palliative care due to rapid metastatic dissemination. Of the 6 patients who had surgery for a recurrence at a distance from important structures, 5 (83.3%) underwent isolated tumour resection with the goal of salvaging the limb and 1 (16.7%) underwent transfemoral amputation. Transfemoral amputation was performed in all 3 patients who had surgery for popliteal recurrences. Lung metastases were detected in 10 (77%) patients, 2 at the time of initial sarcoma diagnosis and 8 at the time of the local recurrence. At last follow-up, 5 patients were alive, including 2 (33.3%) of the 6 patients with recurrences at a distance from important structures and all 3 patients with popliteal recurrences. Of the 5 survivors at last follow-up, 2 had metastases.

CONCLUSION

In patients with local recurrence of knee sarcoma, three presentations can be distinguished. When the local recurrence coincides with distant recurrence, failure to control the disease is likely and the local treatment should be designed as a component of palliative care. When no metastases are detected but the local recurrence is in contact with important structures, amputation is advisable at present given the complexity of limb-salvage surgery and high risk of further local recurrence. Finally, when no metastases are detected and the local recurrence is at a distance from important structures, limb-salvage surgery deserves consideration.

LEVEL OF EVIDENCE

IV, retrospective observational study.

Is lateral ankle sprain of the child and adolescent a myth or a reality? A systematic review of the literature

BACKGROUND

Ankle trauma in children and adolescents is the most common orthopedic injury encountered in pediatric trauma. It has long been recognized that a lateral ankle injury in this population is often a Salter and Harris type I fracture of the distal fibula (SH1). The purpose of this study is to confirm the existence of a lateral ankle sprain and to report the incidence of each pathology of the lateral ankle compartment: SH1 fracture, ATFL injury, and osteochondral avulsions.

METHODS

A systematic review of the literature is done using the database provided by PubMed and Embase. All articles reporting the incidence of imaging modality-confirmed lateral ankle injury (SH1, ATFL injury, osteochondral avulsion) in children and adolescents were included. Exclusion criteria were the following: case reports or articles with less than ten subjects, unspecified imaging modality and articles unrelated to lateral ankle lesions. Thus, 237 titles and abstracts were selected, 25 were analyzed thoroughly, and 11 articles were included for final analysis.

RESULTS

SH1 fractures were found in 0-57.5% of the cases in all series and 0-3% in the most recent series. A diagnosis of an ATFL injury was found in 3.2-80% and an osteochondral avulsion of the distal fibula in 6-28.1%. The most recent series report 76-80% and 62% for ATFL injury and osteochondral avulsion respectively.

CONCLUSIONS

There is a non-negligible incidence of ATFL sprains and fibular tip avulsions in patients with a suspected SH1 fracture of the distal fibula. According to recent evidence and MRI examinations, the most common injuries of the pediatric ankle are ATFL sprain and osteochondral avulsions. This should be taken into consideration in daily practice when ordering radiological examination and deciding on treatment modalities.

Transepiphyseal (Type VII) Ankle Fracture Versus Os Subfibulare in Pediatric Ankle Injuries

BACKGROUND

Pediatric ankle injuries are common, giving rise to ∼17% of all physeal injuries. An os subfibulare in a child with an ankle sprain may be confused with a type VII transepiphyseal fracture. Here, we evaluate the clinical and radiographic features of type VII transepiphyseal fractures to those of os subfibulare presenting with acute ankle trauma with the hypothesis that radiographs are necessary for final diagnosis and neither clinical history nor examination would be diagnostic.

METHODS

We performed an internal review board-approved, retrospective chart review of patients identified with a traumatic os subfibulare or type VII ankle fracture over an 18-month period. Charts were reviewed for demographics, mechanism, and clinical findings on initial presentation. Radiographic measurements of the distal fibular fragment as well as epiphysis were made on presenting ankle series radiographs.

RESULTS

A total of 23 patients were identified. Eleven patients had a traumatic type VII ankle fracture and 12 had trauma associated with an os subfibulare on initial radiographs. The history and clinical presentations were similar and were nondiagnostic. The ratio of the width of the fibula at its largest point on the anterior posterior view to the width of the fibular fragment was significantly larger in the type VII ankle fractures (P=0.05). All os subfibulare were located within the inferior third of the epiphysis, whereas all type VII fractures were either at the equator or within the middle third of the fibular epiphysis.

CONCLUSIONS

Radiographs, not clinical presentation, can differentiate an os subfibulare from a type VII transepiphyseal fracture. Children with type VII fractures have a long, irregular fracture line within the middle third of the distal fibular epiphysis. Those with an ankle sprain and os subfibulare have a smooth-edged ossicle of relatively short length located within the inferior pole of the epiphysis. Furthermore, the radiographic width of the fragment in the type VII fractures is significantly larger in width than the os subfibulare.

LEVEL OF EVIDENCE

Level II.