Ankle instability after fibular resection

Radiological landmark of syndesmotic ligament complex by magnetic resonance imaging correlate with fibula free flap harvesting procedure

Preservation of syndesmotic ligaments is crucial for preventing adverse sequelae at the donor site following free fibula osteocutaneous flap harvesting. This study sought to determine the relationship between distal tibiofibular ligaments and the fibular segment to identify radiological landmarks that facilitate safe and precise flap. The distances between the distal tibiofibular ligaments (anterior inferior tibiofibular ligament [AITFL], posterior inferior tibiofibular ligament [PITFL]) and the fibular segment, as well as the lower border of the interosseous membrane, were measured on magnetic resonance imaging (MRI) scans of 296 patients without any perceivable ankle abnormalities. The mean distances (± SD) between the distal end of the fibula and the AITFL, PITFL, and lower interosseous membrane border were 3.0 ± 0.4 cm, 2.6 ± 0.4 cm, and 3.9 ± 0.6 cm, respectively. The distance between the talar dome and the PITFL exhibited a range of 0.0-0.5 cm. Our findings support preserving a distal fibular remnant of at least 4 cm to avoid injury to the syndesmotic ligament throughout fibula osteocutaneous flap harvesting. The talar dome could serve as a useful radiological landmark for identifying the upper border of PITFL during preoperative evaluation, and thus facilitating precise and safe flap procurement.

Donor-site morbidity of free fibula flap in pediatric patients: A systematic review and meta-analysis

The morbidity of free fibula flap (FFF) in pediatric patients has gained attention. Thus, we aimed to evaluate donor-site morbidity after FFF harvesting in pediatric patients and its relationship with age. A systematic literature search of databases for cross-sectional studies related to pediatric donor-site morbidity after FFF harvesting was performed. Two independent reviewers evaluated relevant article titles and abstracts to extract data regarding donor-site morbidity from each article. Fifteen studies were included in the meta-analysis that evaluated the rate of complications. Individual cases of ankle instability were divided into the 0-13- and 13-17-year-old groups. The Chi-square test was used to compare ankle instability between both groups. A logistic regression model was created to analyze the relationships between age and ankle instability/claw toe. Sixteen English articles published between 2007 and 2021 were included in the systematic review. Information on morbidities of 294 cases in which FFF was used was collected. The mean incidence rate of complications, instability, claw toe, and nerve injury were 19.3%, 12.9%, 5.9%, and 5.1%, respectively. Bivariate analysis showed that age was significantly correlated with the incidence of ankle instability but not with the incidence of claw toe. The Chi-square test showed that the incidence rate of ankle instability between the age groups was significantly different. Therefore, we recommend 14 years of age as a new predictive factor for ankle instability. Nevertheless, there is limited evidence in this field, and more pediatric research is needed to clarify these findings.

Ankle joint salvage surgery with an ipsilateral mid-fibula osteocutaneous free flap and contralateral anterolateral thigh free flap: A case report and literature review

The tibiofibular joint can be reconstructed after distal fibular sarcoma salvage surgery to maintain ankle stability and achieve early gait. Classical reconstructive options include ligamentoplasties, arthrodesis, prosthetic replacement, bone grafts, and pedicled ipsilateral or free contralateral fibular bone flaps. We present a novel strategy for reconstruction of the ankle in an elderly patient and a literature review. A 68-year-old man presented with a high-grade myxofibrosarcoma to his distal fibula. Wide resection of the tumor and adjacent structures left a 12 × 12 × 8 cm defect including the distal fibula (10 cm), a 2 cm fragment of the lateral cortex of the tibia, the lateral anterior and superficial posterior compartments, and the lateral compartment. A 3 cm distal fibula remnant was left in the ankle mortice. Reconstruction was performed using a free ipsilateral 13-cm diaphyseal osteocutaneous fibular flap telescoped into the distal fibula remnant and anastomosed to the anterior tibial artery. A pre-bent L-shaped locking plate was used to reconstruct a syndesmotic joint. A 21 × 13 cm suprafascial ALT flap was anastomosed to the proximal stump of the peroneal artery to cover the soft tissue defect. The patient had no complications and was ambulating with full weight bearing by postoperative week 11. He received postoperative chemo and radiotherapy. Three years postoperatively, he is tumor free, has complete ankle ROM and stability, and ambulates with no restrictions. Limb sparing surgery with a functional tibiofibular joint reconstruction should be considered to attain an early functional recovery after distal fibula sarcomas resection.

Donor-Site Morbidity Following Free Fibula Flap Harvest for Mandibular or Maxillary Reconstruction in Pediatric Patients

INTRO AND AIM

The morbidity at the donor-site in the free fibula flap is a well-studied fact in the adult population, but in children, there are few reports of the long-term adverse effects at the donor site. In this study, we evaluate donor-site morbidity, complications, and functional outcome in pediatric patients undergoing free fibula flap harvest for mandibular or maxillary reconstruction, and the relation between pain and walking abilities.

METHODS

A retrospective study of 22 pediatric patients undergoing free fibula flap harvest for mandibular and maxillary reconstruction between 2003 and 2014 was conducted. A certified point evaluation system was used, analyzing several factors like pain, walking ability, restriction in activities, gait alteration, paresthesia, and cosmetic appearance, and the relationship between variables.

RESULTS

Mean age follow up of patient was 8.5 years (range 2-13 years). Pain was reported in 27% (n = 6), paresthesia and numbness 9% (n = 2), walking ability alteration in 50% (n = 11), restriction in activities in 18% (n = 4), gait alteration in 23% (n = 5), and cosmetic appearance alteration in the 14% (n = 3). We compare the pain and the gait alteration and did not find any relation between pain and gait alteration (P = 0.6016) and there was no relation between restriction in activities and walking ability (P = 0.1455).

CONCLUSION

Free fibula flap is the gold standard for head and neck reconstruction, but the morbidity at the donor site, especially in a growing child, should not be ignored or minimized when counseling patients and their families.More studies, with more population and with a long-term follow-up should be carried out to determine the impact on the daily activities on the pediatric population.

Crawford Type IV Congenital Pseudarthrosis of the Tibia: Treatment With Vascularized Fibular Grafting and Outcome at Skeletal Maturity

BACKGROUND

Vascularized fibular grafting (VFG) is currently accepted as one of the best treatments for congenital tibial pseudoarthrosis (CPT). However, with longer follow-up, functional results deteriorate, and some problems become evident.

METHODS

Thirty-nine patients with CPT were treated with VFG. Their age at surgery averaged 5.2 years. Twenty-one cases aged 3 years or less at the time of surgery. All cases were Crawford type IV affected by neurofibromatosis-1. Fourteen patients had 1 to 7 previous surgeries with an average of 4.2 procedures. The length of the fibula used averaged 9.9 cm, and the fibula was fixed by intramedullary wires in 26 cases, and transfixion screws in 11 cases.

RESULTS

Follow-up averaged 8.1 years. Seventeen cases (43.6%) reached skeletal maturity before the final follow-up. Primary bone union was achieved in 37 cases (96%) after an average of 3.2 months. Stress fracture occurred in 21 cases (51.3%) and was recurrent in 11 cases. Twenty-one cases (53.8%) developed tibial shaft deformities with an average valgus angle of 13.8 degrees and procurvatum angle of 18.8 degrees. The overall final limb length discrepancy (LLD) averaged 2.2 cm. Ipsilateral ankle valgus deformity occurred in 21 cases (53.8%) and averaged 10 degrees. A total of 17 cases required an average of 2 secondary procedures. The tibial deformity did not appear to remodel with age, but the LLD and the angle of ipsilateral ankle valgus deformity continued to significantly increase until skeletal maturity.

CONCLUSION

This study reports the largest single center experience of CPT cases treated with VFG. Free VFG is an excellent treatment option for CPT. Best results are achieved when the procedure is performed at or before the age of 3 years, in the absence of previous surgeries, and with the use of intramedullary fixation. The resulting LLD and the degree of ipsilateral ankle valgus increase with age until skeletal maturity, however, tibial deformity does not remodel and should be corrected at any age if it is excessive. Donor side mild ankle valgus may occur despite sound tibiofibular synostosis.

LEVEL OF EVIDENCE

Level IV.

Saving the ankle in distal fibular giant cell tumour - A case report

Distal Fibula Giant cell tumour (GCT) is a rare condition. The described methods of treatment for distal fibula GCT include excision of tumour and ankle arthrodesis, replacement of distal fibula with ipsilateral proximal fibula and autograft or allograft reconstruction. This case report describes treatment of distal fibula grade 3 GCT with involvement of syndesmosis with tumour excision, proximal fibular slide and reconstruction of ankle joint. With this technique the ankle joint movements are preserved and stability is maintained.

Adamantinoma Arising in the Distal End of the Fibula

Adamantinoma is a rare, low-grade, malignant bone tumor. It frequently occurs in the tibia but rarely arise in the distal end of the fibula. This study reported a case of adamantinoma arising in the distal end of the fibula, resulting in good prognosis. A 38-year old female felt left ankle pain, and was suspected as having a bone tumor at the distal end of the fibula by X-ray. She was diagnosed as the classical adamantinoma of the fibula by open biopsy. En bloc wide resection of the tumor, primary arthrodesis of the ankle was performed. During the follow-up period of 7 years after the surgery, she has lived without any metastasis and local recurrence. A wide resection and arthrodesis of the ankle joint can provide a good outcome for adamantinoma arising in the end of the fibula.

The relative position of the human fibula to the tibia influences cross-sectional properties of the tibia

OBJECTIVES

The fibula transmits loads within the lower limb of hominids. The few studies of variation in the cross-sectional geometric (CSG) properties of the fibula have established differences in its rigidity among groups engaged in distinct habitual loading activities. This study adds to this research by considering the relationship between CSG properties and the anatomical position of the fibula relative to the tibia among groups with differences in documented activity patterns.

MATERIAL AND METHODS

We used pQCT scans taken at 50% of the length of the lower leg in 83 healthy young adult collegiate-aged individuals divided into five activity groups: runners, swimmers, cricketers, field hockey players, and non-athletes. We compared variation in calculated CSG properties against the distance between fibular and tibial centroids, as well as the angle of that plane relative to the plane of tibial I_max .

RESULTS

Tibial and fibular CSG properties vary with respect to the relative position of the two bones. Tibial CSG properties differ in concert with the relative angle of the fibula to tibial I_max , while fibular CSG properties differ with the distance between the elements. Fibulae are more posterior-medially positioned in groups engaged in terrestrial athletics than among swimmers.

DISCUSSION

The tibia and fibula experience different loads. The relative position of the two bones leads to compensatory differences in their CSG properties, perhaps due to increased resistance to bending in fibulae with greater distances from the tibia. Examinations of tibial CSG properties without considering the fibula limits interpretations about activity.

Long-term donor-site morbidity after vascularized free fibula flap harvesting: Clinical and gait analysis

The aim of this study was to determine the clinical morbidity and changes in gait temporal spatial parameters after harvesting of a vascularized free fibula flap. This study included 11 patients (mean age: 52 ± 17 years) and 11 healthy controls (mean age: 50 ± 14 years). The patients were assessed between 5 and 104 months post surgery. The study consisted of a subjective functional evaluation with two validated clinical scores (Kitaoka Score and Point Evaluation System (PES) score), clinical and neurological examination of the legs, and evaluation of gait temporal spatial parameters while walking at a comfortable speed. The mean functional Kitaoka score was 78/100, and the mean PES score of 12.18 was considered average. At the time of the review, five patients had sensory disorders, two had toe deformities, and eight had pain at the donor site. The gait analysis showed that the patient's comfortable walking speed was significantly lower in comparison to that of the controls, and that stride length and cadence were reduced. In addition, most of the gait-specific parameters were significantly different. The donor leg displayed greater variability during walking. To reduce the risk of falling, this study revealed that the patients' gait pattern had changed as they took a more cautious approach during walking. Early rehabilitation is expected to help improve and/or restore the physical abilities of patients after harvesting of the vascularized free fibula flap.

Long-term effect on foot and ankle donor site following vascularized fibular graft resection in children

This study was carried out to evaluate the long-term effect on the donor side of the foot and ankle following vascularized fibular graft resection in children. Eight patients underwent resection of the fibula for the purpose of a vascularized fibular graft by a surgical team who practiced leaving at least 6 cm residual distal fibula. The age of these children at the time of surgery was between 3 and 12 years. They were reviewed between 3 and 12 years after surgery. Two patients who underwent resection of the middle shaft of the fibula at 3 and 5 years of age developed abnormal growth of the distal tibia, leading to ankle valgus. They were treated with growth modulation of the distal tibial physis and supramalleolar osteotomy with tibiofibular synostosis. Another patient who underwent the entire proximal fibula resection at the age of 6 years had developed hindfoot valgus because of weakness of the tibialis posterior muscle. He required talonavicular fusion and flexor hallucis to tibialis posterior muscle transfer. Patients operated at the age of older than 8 years neither had ankle nor hindfoot deformity. We concluded that resection of the middle shaft of the fibula for the purpose of a vascularized fibula graft, leaving a 6 cm distal fibular stump in children younger than 6 years old, may give rise to abnormal growth of the distal tibial physis, leading to valgus ankle. The entire proximal fibular resection for the similar purpose in a 6-year-old child may give rise to weakness of tibialis posterior and hindfoot valgus.

Distal tibial fractures are a poorly recognised complication with fibula free flaps

The fibula free flap is ideal for complex jaw reconstructions, with low reported donor and flap morbidity. We discuss a distal tibial stress fracture two months following a vascularised fibula free flap procedure. Despite being an unrecognised complication, a literature review produced 13 previous cases; only two were reported in the reconstructive surgery literature, with the most recent claiming to be the first. The majority of these studies treated this fracture non-operatively; none reported their patient follow-up. Each case presented with ipsilateral leg pain, which has been cited as an early donor site morbidity in as many as 40% of fibula free flap cases. It is known that the fibula absorbs at least 15% of leg load on weight bearing. Studies have shown severe valgus deformities in up to 25% of patients with fibulectomies. We treated our patient operatively, first correcting his worsening valgus deformity with an external fixator, then reinforcing his healed fracture with a long distal tibial plate. We believe that this complication is underreported, unexpected and not mentioned during the consenting process. By highlighting the management of our case and the literature, we aim to increase awareness (and thus further reporting and appropriate management) of this debilitating complication.

Reverse Transfer of the Proximal Vascularized Fibula to Reconstruct the Lateral Malleolus: A Case Report and Literature Review

Defects of the lateral malleolus and distal fibula occur occasionally, mainly because of severe trauma or wide resection of fibular neoplasms. These bony defects should be reconstructed to avoid persistent pain and to prevent an abnormal gait induced by ankle instability. Various methods of repair have been developed, including allografting, autologous iliac crest transplantation, scapular apophysis transplantation, and arthrodesis and prosthetic reconstruction. A reverse transfer of the proximal vascularized fibula is also effective. Its morphologic advantage is apparent, and the surgery is simple and direct, with no need for vascular anastomosis. We treated recurrent fibrous dysplasia in the distal fibula of a young male with wide resection and reconstruction using reverse transfer of the proximal, vascularized fibula. At the 6-year follow-up examination, the patient had an American Orthopaedic Foot and Ankle Society ankle-hindfoot score of 100, without any apparent complications. Additionally, we critically reviewed other methods for reconstructing the lateral malleolus and distal fibula and have concluded that reverse transfer of the proximal vascularized fibula compares favorably and could be the treatment of choice.

Open Dislocation of the High Ankle Joint After Fibular Graft Harvesting

The free microvascular fibula and soft tissue transfer has become a widely used method for reconstruction of different regions. Donor site morbidity for free fibula microvascular flaps has generally been reported to be low, or at least acceptable. We describe the case of a patient who underwent vascularized free fibula graft harvest for mandibular reconstruction. After 21 months, he had sustained an open dislocation of the left high ankle joint during recreational sports activity. We did not found such case in the published data.

Coverage of Exposed Bone of the Lateral Malleolus With a Proximally Based Lateral Malleolar Perforator Flap

The treatment of soft tissue defects of the ankle, combined with an implant-related infection, remains a challenge. The present case report illustrates the use of a pedicled perforator flap for soft tissue reconstruction to cover a postoperative defect at the lateral malleolus after an ankle fracture.

Lateral ankle stabilization after distal fibular resection using a novel approach: a surgical technique

BACKGROUND

After tumor resection involving the distal fibula, the method for recreating stability of the lateral ankle remains controversial. Many reconstructive options exist, including allograft reconstruction and arthrodesis; however, each of these approaches has significant potential disadvantages.

DESCRIPTION OF TECHNIQUE

The distal fibula is resected as necessary to obtain negative margins for local control of the neoplasm. Reconstruction of the lateral ankle ligamentous complex is performed using the peroneus brevis tendon to reestablish lateral and anterior stability of the tibiotalar joint. The peroneus brevis tendon is transected proximally at it myotendinous junction and then sutured to the calcaneofibular and anterior talofibular ligaments in sequence and then tenodesed to the lateral distal tibia with suture anchors and a staple.

METHODS

We present three patients who underwent distal fibulectomy for tumors originating in the distal fibula. All patients who have undergone the reconstruction being described are included within this cohort study. The patients were assessed clinically and radiographically at a range of 14 months to 9.5 years (average, 4.8 years) for functional recovery, return of range of motion, stability of the ankle, and imaging evidence of arthrosis and instability.

RESULTS

There were no episodes of instability or early progression to arthrosis. In addition, all patients obtained excellent ankle stability and range of motion on examination, but two had complications. One sustained a traumatic fracture to the base of the fifth metatarsal that healed with nonsurgical treatment and another who underwent further fibular shortening and bursectomy at the tip of the residual fibula with complete relief of his symptoms.

CONCLUSIONS

Reconstruction of the lateral ankle after distal fibular resection is possible using the peroneus brevis tenodesed to the distal tibia and sutured to the remnants of the calcaneofibular and anterior talofibular ligaments as described in this surgical technique. In this small group, we found that patients were able to return to normal daily activities without instability or progression to tibiotalar arthrosis at short term; however, longer followup and larger series of patients are called for to confirm these findings.

Controversies in the management of congenital pseudarthrosis of the tibia and fibula

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.

Outcomes and complications of fibular head resection

The fibular head is often used as donor graft material for reconstruction of defects of the distal radius. However little is known on the safety of such a procedure. This report describes the long-term donor-site morbidity following the procedure. Fourteen patients who underwent simple or marginal resections of the proximal fibula between 1990 and 2007 were reviewed. Subjective donor-site morbidity, knee and ankle range of motion and instability, presence of sensory or motor function loss, gait and fibular regeneration were assessed. The mean age at surgery was 25 years; six were male, eight were female and the mean follow-up was 11 years. Abnormal clinical findings were present in 10 patients (71.4 %): nine patients (64.3 %) had Grade 2 varus laxity at the knee confirmed by stress radiographs; one had sensory loss in the distribution of the superficial peroneal nerve. Patients with varus laxity had significantly higher mean age at surgery than those without varus laxity (p = 0.001). None had deformity at the knee or ankle. The range of joint movements was normal. All had a normal tibiotalar angle and none had proximal migration of the fibula. One patient demonstrated near-complete regeneration of the fibula. Donor-site morbidity following simple and marginal resection of the proximal fibula is acceptable. Older patients had a higher risk of demonstrable varus laxity at the knee but proximal fibula resection in children appears to be safe.

Biomechanical analysis of the impact of fibular osteotomies at tibiotalar joint: A cadaveric study

BACKGROUND

Osteotomy of the fibula is a common orthopedic procedure performed for various indications, including harvesting fibula for grafting purposes. The effect of fibular osteotomy and need for tibiofibular syndesmotic fixation fusion at different levels on tibiotalar joint is matter of debate. We performed a biomechanical analysis of the impact of fibular osteotomies at different levels and whether the fixation of distal tibiofibular joint mitigates instability caused by the osteotomy.

MATERIALS AND METHODS

Six lower limb specimens from fresh adult cadavers were used to prepare leg-foot models. The specimens were assigned to six status according to the level of osteotomy and whether fixation of distal tibiofibular joint was performed or not. Each specimen was then loaded axially to 700 N by the material testing machine, and the tibiotalar joint contact area and peak pressure were measured using an electronic pressure sensor.

RESULTS

The contact area and the pressure of tibiotalar joint showed significant changes when compared to the normal specimen. All osteotomy specimens had a decreased tibiotalar contact area and an increased peak pressure. This positively correlated with proximity of level of osteotomy to the lateral malleolus.

CONCLUSIONS

Through this study, we found that fibular osteotomy had an adverse effect in terms of decreasing the contact surface of tibiotalar joint that led to increased peak pressure in the joint. However, bone fusion and screw fixation of the distal tibiofibular joint reduced these adverse effects.

Congenital pseudoarthrosis of the tibia – results of treatment by free fibular transfer and associated procedures – preliminary study

We evaluated 16 children with congenital pseudoarthrosis of the tibia treated with contralateral fibular graft, with the aim to report the difficulties and clinical results in the affected limb after consolidation. Sixty-three percent of the children had characteristics of neurofibromatosis. Consolidation was achieved after the main surgery in 37%of patients, and the remainder, after multiple procedures. Consolidation time was longer for male patients. Refracture was observed in six patients and recurrence of the anterior bowing in six; four of these patients were submitted to correction. Four patients presented femur overgrowth. The average shortening of the affected leg was 3.6 cm. The proposed procedure leads to a long treatment course with many reoperations for correction of possible complications.

Donor site morbidity following the harvesting of cortical bone graft from the tibia in children

INTRODUCTION

Since the nature of complications following the harvesting of bone from the tibia in children is not well documented in the literature, we undertook this study in order to determine the frequency and nature of donor site complications following the harvesting of large cortical strut grafts from the tibial diaphysis in children.

MATERIALS AND METHODS

During the past 19 years, tibial cortical grafts were harvested from 47 children on 77 separate occasions, mainly for the treatment of congenital pseudarthrosis of the tibia. The technique of graft harvesting was identical in every case. Case records of these 47 children were reviewed. Forty of these children were reviewed at a mean period of 5.5 years.

RESULTS

No immediate post-operative complications were noted and, at follow-up, apart from mild bowing of the anterior cortex of the tibia, no deformities were encountered. The tibial cortex reformed completely and this facilitated repeat graft harvesting when required. The only major complication was a stress fracture of the tibia in one boy.

CONCLUSION

Harvesting cortical bone graft from the tibia is simple and is fraught with negligible morbidity.

Partial fibulectomy for symptomatic fibular nonunion

Level of Evidence: V, Expert Opinion

Donor-site complications of autogenous nonvascularized fibula strut graft harvest for anterior cervical corpectomy and fusion surgery: experience with 163 consecutive cases

BACKGROUND CONTEXT

The fibula is a source of bone graft for reconstruction of the appendicular and axial skeleton.

PURPOSE

The aim of this study is to determine donor-site complications and morbidity in a large series of patients who underwent autogenous fibula harvesting for anterior cervical corpectomy and fusion (ACCF) surgery.

STUDY DESIGN/SETTING

Retrospective review (Level III).

PATIENT SAMPLE

One hundred sixty-three patients over an eight-year period who underwent ACCF with autogenous fibula.

OUTCOME MEASURES

Donor site complications (such as infection, cellulitis, pain, damage to the superficial peroneal nerve, ankle instability, tibial stress fracture, and so forth), treatment, and final outcome were determined from patient records.

METHODS

Retrospective study of patients who underwent ACCF with autogenous nonvascularized fibula strut graft over an eight-year period (from 1995 to 2002) was conducted. Donor site complications (such as infection, cellulitis, pain, damage to the superficial peroneal nerve, ankle instability, tibial stress fracture, and so forth), treatment, and final outcome were determined from patient records.

RESULTS

One hundred sixty-three patients underwent ACCF with autogenous fibula graft during the study period. The most common short-term complication (lasting <3 months) was incisional pain, present in 86 of 163 patients (53%). Incisional pain lasted longer than 3 months in 25 of 163 patients (15%) but resolved in all but two patients by 24 months. Two patients (1.2%) developed superficial peroneal neuromas. Five patients (3%) developed tibial stress fractures. Two patients (1.2%) developed ankle instability. Fifteen (9%) patients developed cellulitis that resolved in all patients after a short course of oral antibiotics, with one additional patient developing a deep infection requiring surgical debridement and intravenous antibiotics.

CONCLUSIONS

Although autogenous fibula is an excellent graft for multilevel ACCF reconstruction, surgeons should carefully consider the associated morbidity of fibular harvest before surgery. In this series, most complications were of short duration. However, nine patients with long-term complications required five additional surgical procedures. Therefore, patients who are scheduled to undergo autogenous fibula harvest should be advised about these potential complications.

Tibia adaptation after fibula harvesting: an in vivo quantitative study

Absence of the fibula after harvesting to reconstruct an upper-limb segment increases loads on the donor-side tibia and thereby provides a unique opportunity to analyze the bone adaptation process in humans. We therefore quantified densitometric and morphologic changes of the donor-side tibia in three young patients (ages 8, 13, 16 years), on the basis of computed tomography (CT) examinations of both legs (one preoperatively and two postoperatively). The range of final followup was 27-43 months. Three-dimensional models of shank bones were generated from CT data and used to measure cross-sectional area, diaphyseal cortical thickness, and cross-sectional moment of inertia. In addition, density of the newly formed bone was evaluated. The donor-side tibia showed morphologic and density adaptation with time. New bone was deposited predominantly in the interosseous space and almost replaced the bone area lost by excision of the fibula. The second moment of area grew more in the donor-side tibia than in the intact one, without fully recovering the contralateral tibia-fibula complex values, and the principal axes rotated toward the preoperative direction. Thus, while considerable adaptation had occurred by 27-43 months in these young patients, the adaptation was incomplete; the mineral density of the newly formed bone recovered normal cortical bone values only in the patient with the longest followup (43 months).

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Arthrodesis for ankle osteoarthritis after harvesting of free vascularized fibular bone: a case report

INTRODUCTION

Although free vascularized fibular bone grafting is a good method for the reconstruction of large bone defects, it might cause morbidity of the donor leg. Progression of ankle osteoarthritis, valgus deformity and instability of the donor leg subsequently leading to arthrodesis has rarely been reported.

MATERIALS AND METHODS

A 53-year-old man suffered from a left tibial comminuted and Gustilo type IIIb open fracture. A folded free vascularized osteoseptocutaneous flap was harvested from the right fibula and transferred to the left tibial bone defect. After the reconstructive surgery, the patient obtained a solid union of the left tibial shaft uneventfully. Ten years later, he suffered intermittent pain on his right ankle. Plain radiographs revealed progressive tibiotalar osteoarthritis. Right ankle arthrodesis with crossed cannulated screws fixation and osteosynthesis of the fibula to the tibia and talus were performed. However, this procedure failed due to a deep infection and osteomyelitis. A revision of the failed ankle fusion was performed by using a vascularized iliac bone flap to strut the anterolateral aspect of the tibiotalar bone defect. A ventral plate fixation and supplementary onlay bone grafting were applied across the anterior aspect of the tibiotalar joint. At the 2-year follow-up, the patient had no pain and resumed his regular daily activities.

CONCLUSIONS

Harvesting of the fibula may cause longterm ankle osteoarthritis that requires ankle arthrodesis. In revision arthrodesis a ventral plate fixation and vascularized iliac bone flap may be the treatment of choice, neutralizing the large moment due to the long lever arms.

Distal fibular length needed for ankle stability

BACKGROUND

The fibula is commonly used for bone grafts. Previous clinical and biomechanical studies have suggested that the length of the residual portion of the distal part of the fibula has an important effect on the long-term stability of the ankle joint. However, we cannot find clear-cut guidelines for the amount of bone that can be harvested safely.

METHODS

Using six normal fresh-frozen cadaver legs, motions of the tibia, talus and calcaneus were measured. The fibula was cut sequentially 3 cm from the proximal tip of the fibula and distally 10 cm, 6 cm, and 4 cm from the distal tip of the lateral malleolus. The angular motion of each bone was measured while a medial and lateral traction force of 19.6 N was applied to the proximal tibia. Angles of the tibia, talus, and calcaneus were measured.

RESULTS

Sequential resection of the fibula increased the inversion angles of the ankle joint. The proximal 3-cm cut increased the inversion angle from 42.1 +/- 6.2 degrees to 49.6 +/- 3.6 degrees, and the distal 4-cm cut increased the angle from 57.6 +/- 6.6 degrees to 67.4 +/- 5.9 degrees. The rotational angles were almost constant with sequential resections of the fibula; however, the distal 4-cm cut increased the rotational angle from 11.3 +/- 25.1 degrees to 78.7 +/- 37.5 degrees.

CONCLUSIONS

The whole fibula including the head is essential for the stability of the ankle joint complex, and the distal fibula is responsible for stabilizing the ankle mortise during external rotation and inversion. We recommend fixation of the syndesmosis or bracing to prevent ankle joint instability with rotation of the talus in the mortise, especially when the distal fibula is shortened 6 cm or more.

Evaluation of fibula free flap donor site morbidity

OBJECTIVE

To evaluate foot and ankle function in a series of patients undergoing fibula microvascular free tissue transfer.

STUDY DESIGN

A nonrandomized, nonblinded analysis was performed using the ankle-hindfoot scale as well as radiographic analysis to determine donor site morbidity.

RESULTS

Overall, foot ankle function was deemed to be good in this series of patients. Average ankle-hindfoot score was 84.82 of a possible 100 (range, 55-100). Radiographic analysis of donor and contralateral ankles showed no difference in the syndesmotic space or medial clear space. Only 1 patient had increased talar tilt compared with the contralateral side, although this patient had preservation of stability.

CONCLUSION

Fibula free flap harvest appears to be associated with acceptable donor site morbidity and preservation of good foot and ankle function in most individuals.

Dynamic function of the fibula. Gait analysis evaluation of three different parts of the shank after fibulectomy: proximal, middle and distal

The purpose of this case study was to investigate the dynamic features of fibular movement to gait pattern by analyzing the gait of individuals with three different parts of the fibula resected. Gait analyses revealed that proximal fibula resection impaired knee stability, whereas distal fibula resection disturbed ankle kinematics significantly. Except a mild secondary quadriceps weakness, middle fibula resection did not cause a significant biomechanical disturbance on gait.

Outcome Analyses of Interbody Titanium Cage Fusion Used in the Anterior Discectomy for Cervical Degenerative Disc Disease

Anterior discectomy and fusion to treat cervical degenerative disc disease is the preferred procedure for many spine surgeons. The ideal device for structural reconstruction of the anterior cervical spine remains controversial. The purpose of this prospective study was to investigate the effectiveness of a non-threaded titanium cage in performing anterior spinal fusion for cervical degenerative disc disease. The clinical and radiologic data of 78 consecutive patients were reviewed. Neurologic outcome was assessed using Odom's criteria. Neck pain was graded using a 10-point visual analog scale. The cervical spinal curvature, the height of foramina, and fusion status were evaluated on preoperative and postoperative radiographs. Mean follow-up was 24.9 (range 18-35) months. An excellent or good result was found in 92% of the patients with radiculopathy, 69% of those with myelopathy, and 73% of those with myeloradiculopathy. Statistical analyses also showed improvement of cervical pain after surgery (P < 0.001) and a significant increase in foraminal height (P = 0.035). Cervical kyphosis was present in 27 (34%) patients before surgery; it was corrected to lordosis in 9. The fusion rate at 12 months and 24 months was 91% and 95%, respectively. No surgery or cage-related complication occurred in these patients. Non-threaded interbody cage fusion in this study achieved a high fusion rate and had a good neurologic outcome. These results suggest that non-threaded cage fusion is a safe and effective method for anterior cervical discectomy.

Lateral malleolus en bloc resection and ankle reconstruction for malignant tumors

Four children and six adults required en bloc resection of the lateral malleolus for malignant tumors. There were four osteosarcomas, three chondrosarcomas, two Ewing's sarcomas, and one adamantinoma. Surgical margins were wide in seven patients, marginal in two, and intralesional in one. A primary ankle arthrodesis was done in four adults and bracing without any reconstruction was done in four children and two adults. During a mean followup of 14.5 years (range, 3-30 years), there were two local recurrences (two of 10 patients) after a marginal excision and an intralesional excision. One patient had reoperation for a skip osteosarcoma lesion in the proximal fibula. Other complications included chronic osteomyelitis, a lateral talus subluxation and cavovarus deformity, and recurrent ankle instability and degenerative changes of the ankle. At the latest followup, all 10 patients showed no evidence of disease. Five patients who had primary or late ankle arthrodesis had a Musculoskeletal Tumor Society and International Society of Limb Salvage functional score of 28 points (92%), and two adolescents who had postoperative bracing alone had a functional score of 24 points (80%). The three remaining patients had a salvage amputation.

LEVEL OF EVIDENCE

Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Regenerating the fibula with beta-tricalcium phosphate minimizes morbidity after fibula resection

The aim of this study was to assess the radiologic and clinical outcome when beta-tricalcium phosphate is used as a bone graft substitute to backfill the fibular defect that is created by harvesting the fibula. Fourteen patients who had fibula resections to be used as bone grafts for bone tumor resections were assessed radiographically. Callus formation bridging the beta-tricalcium phosphate was seen in 12 of 14 patients at an average of 1.4 months after surgery. In these 12 patients the beta-tricalcium phosphate mostly was absorbed and replaced by newly formed bone at an average of 9.3 months after surgery. In all children, beta-tricalcium phosphate was replaced by newly formed bone at an average of 3.2 months after surgery. Only one adult patient had complete regeneration of the fibula. Few patients had continuity between the regenerated fibula and the native fibula. In one patient in whom free vascularized fibula was harvested, regeneration of the fibula was not observed. Clinical functional outcome was not correlated with successful fibula regeneration and union with the native fibula, as determined using radiographs. The results of the study suggest that, in children, regeneration of the fibula by implanting beta-tricalcium phosphate into a bone defect can reduce morbidity of the fibula harvest sites.

Ankle instability after vascularized fibular harvest for tumor reconstruction

BACKGROUND

The vascularized fibular graft is an important tool in the reconstruction of defects caused by resections of orthopedic tumors. Children often undergo this form of reconstruction, but there is little information about the complications after vascularized fibular graft harvest in this age group.

METHODS

We present a series of 32 patients who underwent this procedure to reconstruct an extremity in our institution. There were 12 children and 20 adults.

RESULTS

The residual distal fibula was significantly longer in adults as compared with children (P < .048). Among children, 3 of 11 undergoing the procedure developed ankle instability, in distinction to adults, none of whom developed this complication (P < .041). This reflects a disruption of normal ankle function that develops in skeletally immature patients with a short residual fibula but not in patients with a longer residual fibula (P < .008). When the sum of patient age in years and residual fibula length in centimeters was less than 16, 3 of 6 patients developed deformity, in contrast to no deformity developing in the remaining 23 when the sum was >16 (P < .004). Adults were more likely to develop pain than instability.

CONCLUSIONS

Our series suggests that children with an age-length sum <16 should be considered for prophylactic tibiofibular synostosis creation.

The use of titanium mesh cages in the cervical spine

Titanium mesh cages have been used widely for spinal reconstruction since 1986 when they first were introduced. Despite their popularity, relatively few studies have been published on their use in the cervical spine. These cages can be used as structural devices containing autologous local bone or iliac crest bone graft, obviating the need to harvest large structural bone grafts. The main disadvantages of their use are the increased costs and the difficulty of assessing fusion status. The authors review surgical techniques that can be used using titanium mesh cages in cervical spine applications and discuss some of their advantages and disadvantages.

Effect of distal fibular resection on ankle laxity

Ten cadaver specimens were used to study the effect of distal fibular resection and ligamentous repair on ankle laxity. The distal fibula was resected sequentially at three levels. Talar tilt and anterior drawer were measured on stress radiographs after resection and then after ligament repair. Sequential resection of the distal fibula caused a progressive increase in talar tilt and anterior drawer at each cut level (p < 0.5), regardless of whether the ligaments were repaired or not. Ligament repair significantly decreased talar tilt at cuts above the ATFL insertion and decreased anterior drawer at cuts at the tibiotalar level, but these values did not approach control values.

Ipsilateral island fibula transfer for segmental tibial defects: antegrade and retrograde fashion

Five patients with segmental tibial defects whose contralateral fibula could not be used as a donor were treated with ipsilateral island fibular transfer in an antegrade or retrograde fashion. Antegrade-flow pedicled flaps based on the peroneal vessel as in the conventional free flap were used for the proximal or middle one-third tibial defects, whereas retrograde-flow pedicled flaps based on the communicating branch between the peroneal and posterior tibial vessels were used for the middle or distal one-third of the tibia. All patients had one of the following problems: a previously failed free flap, below-knee amputation of the opposite leg because of open tibia fracture, refusal to use the contralateral sound leg, or poor general condition to endure a lengthy operation. Four of the patients also had an associated fibular fracture on the same leg, which was ultimately used as one of the osteotomy sites. The follow-up period was from 31 to 48 months. Time to bony union ranged from 4 to 7 months. Time to full weight bearing was from 5 to 9 months after operation. All of the transferred fibulas showed hypertrophy after weight bearing. Nonunion occurred in two cases, which were treated with a long leg cast and cancellous bone graft, respectively. The limb was shorter by an average of 0.5 cm in three cases, longer by 1.1 cm in one case, and in the last case, it was uncheckable because the opposite limb was previously amputated. Limited arc of rotation was not a problem. Other disabling complications were not seen. We believe that these methods can be a valuable alternative to the contralateral free fibula flap in certain cases.

Free vascularized bone graft

This article reviews free vascularized bone grafts. Indications for use, advantages, and disadvantages of free vascularized versus nonvascularized bone grafts as well as applications to foot and ankle surgery are presented. A single case report is also presented.