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Sen S, Kar A, Das A, Naik B. Excision of a Distal Tibial Interosseous Osteochondroma Through Posterolateral Approach: A Case Report. Cureus 2024; 16:e59592. [PMID: 38832143 PMCID: PMC11144583 DOI: 10.7759/cureus.59592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2024] [Indexed: 06/05/2024] Open
Abstract
Osteochondromas arising from the interosseous border of the distal tibia are rare, but cases have been reported previously in the literature. In long-standing cases, they can cause a "mass effect" resulting in the deformation of the bones around the ankle joint, mechanical restriction of joint movement, and even degenerative joint disease. Hence, they need to be resected if patients present with such impending complications. Several surgical techniques have been described previously for tumor resection including the anterior approach and the trans-fibular approach, the latter of which required a fibular osteotomy with or without fibular reconstruction. The surgical technique described here utilizes the posterolateral approach to the ankle joint for tumor excision, thus avoiding the need for any osteotomy or fibular reconstruction and reducing the risk of injury to major neurovascular structures. It also reduces the need for long-term immobilization and promotes a faster return to activity.
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Affiliation(s)
- Soumyadip Sen
- Orthopaedics, Apollo Multispeciality Hospitals, Kolkata, IND
| | - Abheek Kar
- Orthopaedics, Apollo Multispeciality Hospitals, Kolkata, IND
| | - Abhishek Das
- Orthopaedics, Apollo Multispeciality Hospitals, Kolkata, IND
| | - Balesh Naik
- Orthopaedics, Apollo Multispeciality Hospitals, Kolkata, IND
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Nik Abdul Adel NA, Abdul Razak AH, Sri Ramulu SS, Awang MS. Surgical Technique for Varus Deformity Correction of Below-Knee Stump in a Paediatric Patient. Cureus 2023; 15:e44477. [PMID: 37791173 PMCID: PMC10544382 DOI: 10.7759/cureus.44477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 10/05/2023] Open
Abstract
Paediatric amputation is one of the treatment options for various indications, namely, trauma, infection, tumour and congenital problems, and some may be born with congenital problems. It differs from adult amputation as they have higher physical demands, and special complications may arise. Stump overgrowth by far is the commonest complication in paediatric transosseous amputation, while varus deformity of the tibia stump was reported sparsely in the literature. The growth discrepancy of the proximal tibia and fibula physis coupled with distal tibiofibular synostosis may have resulted in proximal migration of the fibula, which later resulted in varus deformity of the stump. This will cause difficulty in prosthesis fitting and lead to painful stumps due to the pressure at the abnormal bony prominence. We report a case of congenital limb deficiencies in a 12-year-old male who was treated with below-knee amputation (BKA) and experienced progressive varus deformity of the stump that caused pain during prosthetic wear, which interfered with his gait. He had a varus deformity of 15 degrees of the stump, distal tibiofibular synostosis and proximal migration of the fibula head. As the conservative management by modification of the prosthesis had failed, he underwent open wedge proximal tibia corrective osteotomy, division of the synostosis and reduction of the fibula head. The surgical intervention was successful in alleviating his problem. All efforts must be made to ensure optimum prosthetic fitting in paediatric amputation patients to maintain the patient's daily lifestyle and activities.
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Affiliation(s)
- Nik Alyani Nik Abdul Adel
- Orthopaedics, Traumatology and Rehabilitation, International Islamic University Malaysia, Kuantan, MYS
| | - Ardilla Hanim Abdul Razak
- Orthopaedics, Traumatology and Rehabilitation, International Islamic University Malaysia, Kuantan, MYS
| | - S Suresh Sri Ramulu
- Orthopaedics, Traumatology and Rehabilitation, International Islamic University Malaysia, Kuantan, MYS
| | - Mohd Shukrimi Awang
- Orthopaedics, Traumatology and Rehabilitation, International Islamic University Malaysia, Kuantan, MYS
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El-Gammal TA, Ali AES, Kotb MM, Saleh WR, Ragheb YF, Refai OA, Morsy MM, El-Gammal YT. Treatment of Concomitant Congenital Pseudarthrosis of the Fibula With Propeller Periosteal Flap. Ann Plast Surg 2023; 90:575-579. [PMID: 37311312 DOI: 10.1097/sap.0000000000003552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Congenital pseudarthrosis of the fibula is not an uncommon condition to accompany congenital pseudarthrosis of the tibia. Persistence of the fibular pseudarthrosis has been linked to inferior outcomes including tibial union and alignment, refractures, and ankle alignment. In this report, we present the results of a pedicled periosteal propeller flap technique for the treatment of fibular pseudarthrosis. METHODS Ten children with an average age at surgery of 5.3 years who had congenital pseudarthrosis of both tibia and fibula were studied. The tibia was treated with free vascularized fibular grafting, and the ipsilateral fibula was treated with a technique after resection of the pseudarthrosis. A periosteal flap from the proximal healthy part of the fibula is harvested off the bone, rotated 180° based on a branch from the peroneal vessels to cover the fibular defect and fashioned in the form of a tube filled with bone fragments. RESULTS The periosteal flap size ranged from 5 to 7 cm. Follow-up averaged 37.2 months. The tibia was united in all cases; in 2 of them, refractures occurred and healed with conservative management. The fibula was united in 8 cases. At final follow-up, 5 cases showed residual tibial deformity, and 5 showed residual ankle deformity. Average leg-length discrepancy was 1.4 cm (0-3 cm). CONCLUSION The pedicled periosteal propeller flap presents a useful new technique for managing concomitant congenital fibular pseudarthrosis.
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Affiliation(s)
- Tarek Abdalla El-Gammal
- From the Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University Hospitals and School of Medicine
| | - Amr El-Sayed Ali
- Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
| | - Mohamed Mostafa Kotb
- Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
| | - Waleed Riad Saleh
- Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
| | - Yasser Farouk Ragheb
- Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
| | - Omar Ahmed Refai
- Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
| | - Mohamed Mohamed Morsy
- Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
| | - Yousif Tarek El-Gammal
- Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut, Egypt
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Agarwal A. Nonvascularized fibular harvest in children: impact on donor limbs. J Pediatr Orthop B 2023; 32:197-205. [PMID: 35412489 DOI: 10.1097/bpb.0000000000000977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Nonvascularized fibular graft is commonly used in children. We investigated periosteal intactness, proportion of harvested fibula and the distal remnant for their association to regeneration and development of ankle valgus in 25 donor limbs (n = 18 patients). The fibulae were harvested from healthy legs with all possible care to preserve periosteum. Intraoperatively, periosteal breach and length of graft obtained were recorded. Follow-up radiographs at 6 months documented lateral distal tibial angle, fibular station, and longitudinal continuous regeneration of fibula in the donor limb. Limbs with and without regeneration/ankle valgus were matched for proportion of harvested length and distal remnant, respectively. Odds ratios for periosteum breach versus nonregeneration and nonregeneration versus ankle valgus were additionally calculated. The average harvest length and distal remnant were 15.1 and 4.5 cm, respectively. The periosteum intactness was maintained in 18 (72%) limbs. At 6 months follow-up, regeneration of fibula was present in 15 (60%) limbs. The postharvest-acquired ankle valgus was present in five limbs (24%). There was almost 2.5 times increased likelihood of nonregeneration, if periosteum was breached. The odds ratio for nonregeneration versus regeneration to the development of ankle valgus stood at 12 ( P = 0.0483). Periosteal breach increased the odds of nonregeneration of harvested fibula. The length of harvested segment did not appear to have significant influence on regeneration nor did distal segment on ankle valgus. The nonregeneration of fibula, however, made the limb prone to ankle valgus.
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Affiliation(s)
- Anil Agarwal
- Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Delhi, India
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Rahman T, Oleas-Santillan G, Wee J, Mackenzie WG. Improved distribution of leg forces after fibular resection and synostosis. J Exp Orthop 2022; 9:43. [PMID: 35576083 PMCID: PMC9110606 DOI: 10.1186/s40634-022-00480-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 04/22/2022] [Indexed: 12/02/2022] Open
Abstract
Purpose Genu varum- a common symptom in achondroplasia- may lead to ankle valgus in children. Ankle valgus may be mitigated by tibiofibular synostosis, but this is not always the case. The mechanical environment around the growth plates plays an important role in ankle valgus. The purpose of this project is 1) to determine the strain through the distal fibular growth plate before and after tibiofibular synostosis, and 2) postulate whether the change in strain affects ankle valgus. This project measured the distal fibular strain in a porcine hind leg model. Methods The lower legs of seven pigs were removed, instrumented with strain gauges, and loaded compressively in a material testing machine. Loads were applied at three phases: 1) the intact leg, 2) leg with fibula resected, and 3) leg with fibula resected and tibiofibular synostosis. Mean strains were compared between phases using a mixed affect model. The significance level was adjusted for multiple comparisons using the Bonferroni method. Results Phase 1, intact leg, had the highest strain value at 1247.9μɛ. In phase 2, the mean strain was 106.2μɛ. In phase 3, the compressive mean strain dropped to 477.4μɛ, which is 38% of the strain in phase 1. Standard error was 86.8μɛ; p < 0.001. Conclusion Results indicate that more of the force through the leg is transmitted through the tibia after fibular resection and tibiofibular synostosis, which improves the balance of forces through the leg. Supplementary Information The online version contains supplementary material available at 10.1186/s40634-022-00480-0.
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Shannon CE, Huser AJ, Paley D. Cross-Union Surgery for Congenital Pseudarthrosis of the Tibia. CHILDREN (BASEL, SWITZERLAND) 2021; 8:547. [PMID: 34202921 PMCID: PMC8303361 DOI: 10.3390/children8070547] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/20/2021] [Accepted: 06/21/2021] [Indexed: 12/26/2022]
Abstract
Congenital Pseudoarthrosis of the Tibia (CPT) is a rare condition with a reputation for recurrent fractures and failure to achieve union. A large variety of surgical procedures have been attempted for the treatment of fractured cases of CPT with an average rate of union without refracture of only 50%. Intentional cross-union between the tibia and fibula has been reported to improve these results to 100% union with no refractures. This is a retrospective study of 39 cases of CPT in 36 patients treated by the Paley cross-union protocol with internal fixation, bone grafting, zoledronic acid infusion and bone morphogenic protein 2 (BMP2) insertion. All 39 cases of CPT united at the tibia and developed a cross-union to the fibula. Two patients had a persistent fibular pseudarthrosis, one that was later treated at the time of planned rod exchange and one that has remained asymptomatic. There were few postoperative complications. There were no refractures during the up to 7-year follow-up period. The most common problem was the Fassier-Duval (FD) rod pulling through the proximal or distal physis into the metaphysis (66.7%). This did not negatively affect the results and was remedied at the time of the planned rod exchange. The Paley Cross-Union Protocol is very technically demanding, but the results have radically changed the prognosis of this once sinister disease.
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Affiliation(s)
- Claire E. Shannon
- Paley Orthopedic and Spine Institute, West Palm Beach, FL 33407, USA; (A.J.H.); (D.P.)
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Abstract
BACKGROUND Controversy exists regarding the need for proximal fibular epiphysiodesis in conjunction with proximal tibial epiphysiodesis to prevent relative overgrowth of the fibula. The purpose of this study was to determine the incidence of relative fibular overgrowth in patients who had undergone proximal tibial epiphysiodesis with or without proximal fibular epiphysiodesis to manage leg-length discrepancy. METHODS We identified patients who had undergone proximal tibial epiphysiodesis, with or without concomitant fibular epiphysiodesis, followed to skeletal maturity, and with adequate scanograms to measure tibial and fibular lengths. We assessed tibial and fibular lengths, ratios, and distances between the tibia and fibula proximally and distally preoperatively and at skeletal maturity, and obvious radiographic proximal migration of the fibular head. RESULTS A total of 234 patients met inclusion criteria, including 112 girls and 122 boys. In total, 179 patients had undergone concomitant fibular epiphysiodesis, and 55 had not. The fibular epiphysiodesis group was significantly younger preoperatively than the nonfibular epiphysiodesis group (average: 12.3 vs. 13.6 y), which accounted for most of the preoperative differences noted between the groups. Within the subset of younger patients (≥2 y of growth remaining at the time of epiphysiodesis), there were statistically significant differences between those with or without fibular epiphysiodesis at skeletal maturity in the proximal tibial-fibular distance (P<0.01) and the tibia:fibula ratio (0.96±0.02 vs. 0.98±0.02; P<0.02), but not in the distal tibial-fibular distance (P=0.46). Obvious fibular head proximal migration was noted in 10 patients, including 5/179 with concomitant proximal fibular epiphysiodesis, and 5/55 without (P<0.01). No patient was recorded as symptomatic with radiographic overgrowth, and no peroneal nerve injury occurred in any patient in this cohort. CONCLUSIONS On the basis of this study, concomitant proximal fibular epiphysiodesis does not appear to be necessary in patients with 2 years or less of growth remaining, nor does it unequivocally prevent fibular head overgrowth. While the tibia:fibula ratio was quite consistent in general, there were individuals with relative fibular head prominence for whom fibular epiphysiodesis may be appropriate, particularly in relatively immature patients. LEVEL OF EVIDENCE Level III-retrospective comparative study.
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Longitudinal Observation of Changes in the Ankle Alignment and Tibiofibular Relationships in Hereditary Multiple Exostoses. Diagnostics (Basel) 2020; 10:diagnostics10100752. [PMID: 32993014 PMCID: PMC7600422 DOI: 10.3390/diagnostics10100752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 09/25/2020] [Accepted: 09/25/2020] [Indexed: 11/17/2022] Open
Abstract
The longitudinal changes in the tibiofibular relationship as the ankle valgus deformity progresses in patients with hereditary multiple exostoses (HME) are not well-known. We investigated the longitudinal changes and associating factors in the tibiofibular relationship during the growing period. A total of 33 patients (63 legs) with HME underwent two or more standing full-length anteroposterior radiographs. Based on the change in ankle alignments, thirty-five patients with an increase in tibiotalar angle were grouped into group V, and 28 patients with a decreased angle into group N. In terms of the change in radiographic parameters, significant differences were noted in the tibial length, the fibular/tibial ratio, and the proximal and distal epiphyseal gap. However, age, sex, initial ankle alignment, location of osteochondroma, and presence of tibiofibular synostosis did not affect the tibiofibular alignment. The tibial growth was relatively greater than the fibular growth and was accompanied by significant relative fibular shortening in the proximal and distal portions. In pediatric patients with HME, age, sex, initial ankle alignment, location of the osteochondroma, and synostosis did not predict the progression of the ankle valgus deformity. However, when valgus angulation progressed, relative fibular shortening was observed as the tibia grew significantly in comparison to the fibula.
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Abstract
BACKGROUND Congenital pseudarthrosis of the fibula (CPF) is a rare disorder characterized by a deficiency in the continuity of the fibula and can lead to progressive ankle valgus malalignment. An existing classification system for CPF is imperfect and may contribute to heterogeneity in reporting and discrepancy of outcomes in the literature. METHODS Fifteen patients with CPF treated at our institution between 1995 and 2017 were retrospectively identified. Only patients with dysplasia leading to spontaneous fracture or pseudarthrosis were included in this series. The median age at presentation was 2.5 years (range: 3 mo to 13.4 y). The median duration of follow-up from the initial presentation was 11.8 years (range: 2.0 to 24 y). Chart review and serial radiographs were analyzed to assess natural history and outcomes following surgery. RESULTS The coexistence of tibial dysplasia in CPF is very common. Patients were classified into 3 groups based on the degree of tibial involvement-group 1: no evidence of tibial dysplasia, group 2: mild tibial dysplasia, and group 3: significant tibial dysplasia. Age at presentation and age at which fibular fracture occurred were progressively younger with a greater degree of tibial involvement (P<0.05). In the absence of surgical intervention, group 1 patients did not undergo progressive ankle valgus (defined as the valgus change in tibiotalar angle by ≥4 degrees), whereas all patients in groups 2 and 3 did (P<0.001). Fibular osteosynthesis was performed in 6 patients, with union seen only in group 1 patients. Ten patients underwent distal tibiofibular fusion, with no cases of nonunion seen. Distal tibiofibular fusion with or without medial distal tibial hemiepiphysiodesis halted the progression of ankle valgus in 8 of the 10 patients. Further progression of ankle valgus occurred only in patients who did not undergo concurrent medial distal tibial hemiepiphysiodesis and with considerable wedging of the distal tibial epiphysis at the time of fusion. CONCLUSIONS Tibial dysplasia and CPF are intimately related. Grouping patients on this basis may help guide natural history and treatment and may explain discrepancies in findings in the literature. Fibular osteosynthesis, distal tibiofibular fusion, and medial distal tibial hemiepiphysiodesis may all have an important role in the treatment of CPF. LEVEL OF EVIDENCE Level IV-case series.
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Mu X, Deng B, Zeng J, Zhang H, Zhao Y, Sun Q, Xu J, Wang L, Xu L. Orthopedic treatment of the lower limbs in spastic paralysis. BRAIN SCIENCE ADVANCES 2020. [DOI: 10.26599/bsa.2020.9050001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Spastic paralysis of the limb mainly results from the central lesion, in which spastic cerebral palsy is the common cause. Due to durative muscle spasm in spastic cerebral palsy, it is often accompanied by the formation of secondary musculoskeletal deformities, resulting in limb motor disability. Based on its pathogenesis, surgical treatment is currently applied: selective posterior rhizotomy (SPR) or orthopedic surgery. The primary purpose of early orthopedic surgery was simply to correct limb deformities, which usually led to the recurrence of deformity as a result of the presence of spasticity. With the application of SPR, high muscle tone was successfully relieved, but limb deformity was still present postoperatively. Therefore, this study aimed to elaborate on the management of orthopedic surgery, common deformities of the lower limb, and orthopedic operative methods; discuss the relationship between SPR and orthopedic procedure for limb deformity; and focus on the indications, timing of intervention, and postoperative outcome of different surgical methods.
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Affiliation(s)
- Xiaohong Mu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Bowen Deng
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Jie Zeng
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Houjun Zhang
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Yi Zhao
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Qi Sun
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Jie Xu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Le Wang
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Lin Xu
- Department of Orthopedics, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
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Nemoto K, Sakai N, Matsuda S, Kato H. Successful Treatment of Pediatric Posttraumatic Tibiofibular Synostosis by Resection and Peroneal Artery Perforator Adipofascial Flap: A Case Report. JBJS Case Connect 2019; 9:e0280. [PMID: 31743120 DOI: 10.2106/jbjs.cc.18.00280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Pediatric posttraumatic tibiofibular synostosis (PPTFS) is a rare postfracture complication that often leads to growth abnormalities. There are very few reports demonstrating the long-term efficacy of surgical treatment. An 11-year-old boy with PPTFS displayed progressive prominence of the fibular head and shortening of the lateral malleolus subsequent to a fracture suffered at the age of 5 years. He was treated by synostosis resection and a peroneal artery perforator adipofascial flap. Eight years postoperatively, the synostosis had not recurred, and his earlier growth abnormalities were nearly normal. CONCLUSIONS Peroneal artery perforator adipofascial flap is effective for pregrowth spurt PPTFS.
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Affiliation(s)
- Kazuaki Nemoto
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Noriko Sakai
- Department of Orthopaedic Surgery, Nagano Children's Hospital, Azumino, Nagano, Japan
| | - Satoshi Matsuda
- Department of Orthopaedic Surgery, Nagano Municipal Hospital, Nagano, Japan
| | - Hiroyuki Kato
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
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Abstract
INTRODUCTION Posttraumatic pediatric distal tibiofibular synostosis is a rare complication following fracture. This is a retrospective, multicenter case series of synostosis of distal tibiofibular fractures in children. The purpose was to evaluate the incidence and pattern of posttraumatic distal tibiofibular synostosis in children. METHODS Of the 604 pediatric distal tibiofibular fractures, 20 patients (3.3%) with synostosis after treatment of distal tibiofibular fractures were identified at 3 tertiary referral centers. There were 12 boys and 8 girls, with a mean age of 8.4±2.0 years (range, 3.7 to 11.5 y) at the time of injury. Medical records were reviewed, and serial radiographs were analyzed to determine fracture configuration, pattern of synostosis, and changes in the relative positions of the proximal and distal tibial and fibular physes and in the alignment of the ankle. RESULTS The time from the occurrence of fracture until the recognition of the synostosis ranged from 2 to 6 months (mean, 2.8 mo). The most common fracture configuration was oblique tibial fracture combined with comminuted fibular fracture. There were 12 focal types and 8 extensive types. The proximal tibiofibular distance was decreased in 13 patients. Proximal migration of the distal fibular physis developed in all cases. Five patients exhibited ankle valgus of 10 degrees or greater with moderate or severe distal fibular shortening. Eight patients were symptomatic after synostosis and 12 patients were asymptomatic. CONCLUSIONS We identified 2 patterns of synostosis after the treatment of pediatric distal tibiofibular fracture: focal and extensive. The focal type was more prevalent than the extensive type, which was more likely to occur due to high-energy injury. When a tibiofibular cross-union develops, it creates growth abnormalities that warrant observation and potential treatment, as it may lead to progressive deformity or ankle pain. LEVEL OF EVIDENCE Level IV.
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Correction of Tibial Torsion in Children With Cerebral Palsy by Isolated Distal Tibia Rotation Osteotomy: A Short-term, In Vivo Anatomic Study. J Pediatr Orthop 2017; 36:743-8. [PMID: 27603097 DOI: 10.1097/bpo.0000000000000525] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Excessive internal or external tibial torsion is frequently present in children with cerebral palsy. Several surgical techniques have been described to correct excessive tibial torsion, including isolated distal tibial rotation osteotomy (TRO). The anatomic changes surrounding this technique are poorly understood. The goal of the study was to examine the anatomic relationship between the tibia and fibula following isolated distal TRO in children with cerebral palsy. METHODS Twenty patients with 29 limbs were prospectively entered for study. CT scans of the proximal and distal tibiofibular (TF) articulations were obtained preoperatively, at 6 weeks, and 1 year postoperatively. Measurements of tibia and fibula torsion were performed at each interval. Qualitative assessments of proximal and distal TF joint congruency were also performed. RESULTS The subjects with internal tibia torsion (ITT, 19 limbs) showed significant torsional changes for the tibia between preoperative, postoperative, and 1 year time points (mean torsion 13.21, 31.05, 34.84 degrees, respectively). Measurement of fibular torsion in the ITT treatment group also showed significant differences between time points (mean -36.77, -26.77, -18.54 degrees, respectively). Proximal and distal TF joints remained congruent at all time points in the study.Subjects with external tibia torsion (ETT, 10 limbs) showed significant differences between preoperative and postoperative tibial torsion, but not between postoperative and 1 year (mean torsion 54, 19.3, 23.3 degrees, respectively). Measurement of fibular torsion in the ETT treatment group did not change significantly between preoperative and postoperative, but did change significantly between postoperative and 1 year (mean torsion -9.8,-16.9, -30.7 degrees, respectively). Nine of 10 proximal TF joints were found to be subluxated at 6 weeks postoperatively. At 1 year, all 9 of these joints had reduced. CONCLUSIONS Correction of ITT by isolated distal tibial external rotation osteotomy resulted in acute external fibular torsion. The fibular torsion alignment remodeled over time to accommodate the corrected tibial torsional alignment and reduce the strain associated with the plastic deformity of the fibula. Correction of ETT by isolated distal internal TRO resulted in acute subluxation of the proximal TF articulation in almost all cases. Subsequent torsional remodeling of the fibula resulted in correction of the TF subluxation in all cases. Acute correction of TT by isolated distal TRO occurs by distinct mechanisms, based upon the direction of rotational correction. LEVEL OF EVIDENCE Level II-Diagnostic.
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Appy-Fedida B, Krief E, Deroussen F, Plancq MC, Collet LM, Klein C, Gouron R. Mitigating Risk of Ankle Valgus From Ankle Osteochondroma Resection Using a Transfibular Approach: A Retrospective Study With Six Years of Follow-Up. J Foot Ankle Surg 2017; 56:564-567. [PMID: 28268141 DOI: 10.1053/j.jfas.2017.01.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Indexed: 02/03/2023]
Abstract
To prevent worsening of ankle valgus and functional repercussions, a distal inter-tibiofibular osteochondroma can be removed using a transfibular approach. We evaluated the difference between the preoperative and postoperative tibiotalar tilt at the last follow-up examination and the clinical and radiologic outcomes. We included 10 consecutive ankles that had undergone removal of an osteochondroma using a transfibular approach. The mean patient age was 10.6 years. One ankle was lost to follow-up. The mean postoperative follow-up duration was 5.9 years. The mean preoperative and postoperative tibiotalar tilt was 7.2° and 7.1°, respectively, with no significant difference. The mean postoperative American Orthopaedic Foot and Ankle Society score was 92.4. Tibiofibular synostosis developed in 7 cases. Osteochondroma recurred in 1 case. The transfibular approach stabilizes ankle valgus and is associated with good functional outcomes. However, it is an extensive procedure associated with postoperative synostosis and, thus, should be considered primarily when surgical access for an anterior approach is limited.
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Affiliation(s)
- Benjamin Appy-Fedida
- Surgeon, Department of Pediatric Orthopaedic Surgery, Amiens University Hospital and Jules Verne University of Picardie, Amiens, France
| | - Elie Krief
- Surgeon, Department of Pediatric Orthopaedic Surgery, Amiens University Hospital and Jules Verne University of Picardie, Amiens, France
| | - François Deroussen
- Surgeon, Department of Pediatric Orthopaedic Surgery, Amiens University Hospital and Jules Verne University of Picardie, Amiens, France
| | - Marie-Christine Plancq
- Surgeon, Department of Pediatric Orthopaedic Surgery, Amiens University Hospital and Jules Verne University of Picardie, Amiens, France
| | - Louis-Michel Collet
- Professor, Department of Pediatric Orthopaedic Surgery, Amiens University Hospital and Jules Verne University of Picardie, Amiens, France
| | - Céline Klein
- Surgeon, Department of Pediatric Orthopaedic Surgery, Amiens University Hospital and Jules Verne University of Picardie, Amiens, France
| | - Richard Gouron
- Professor, Department of Pediatric Orthopaedic Surgery, Amiens University Hospital and Jules Verne University of Picardie, Amiens, France.
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Muzykewicz DA, Goldin A, Lopreiato N, Fields K, Munch J, Dwek J, Mubarak SJ. Nonossifying fibromas of the distal tibia: possible etiologic relationship to the interosseous membrane. J Child Orthop 2016; 10:353-8. [PMID: 27259988 PMCID: PMC4940240 DOI: 10.1007/s11832-016-0745-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 05/15/2016] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Nonossifying fibromas (NOFs) present in a characteristic pattern in the distal tibia. Their predilection to this region and etiology remain imprecisely defined. METHODS We performed a retrospective chart review of patients between January 2003 and March 2014 for distal tibial NOFs. We then reviewed radiographs (XRs), computed tomography (CT), and magnetic resonance imaging (MRI) for specific lesion characteristics. RESULTS We identified 48 distal tibia NOFs in 47 patients (31 male, 16 female; mean age 12.3 years, range 6.9-17.8). This was the second most common location in our population (30 % of NOFs), behind the distal femur (42 %). Thirty-four lesions had CT and nine had MRI. Thirty-one percent were diagnosed by pathologic fracture. Ninety-six percent of lesions were located characteristically in the distal lateral tibia by plain radiograph, in direct communication with the distal extent of the interosseous membrane on 33 of the 34 (97 %) lesions with CT available for review and all nine (100 %) with MRI. The remaining two lesions occurred directly posterior. CONCLUSIONS The vast majority of distal tibial NOFs occur in a distinct anatomic location at the distal extent of the interosseous membrane, which may have etiologic implications. LEVEL OF EVIDENCE IV (case series).
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Affiliation(s)
- David A Muzykewicz
- Department of Orthopedic Surgery, Rady Children's Hospital, 3030 Children's Way, Suite 410, San Diego, CA, 92123, USA
- Department of Orthopedic Surgery, University of California, 200 West Arbor Drive, San Diego, CA, 92103, USA
| | - Amanda Goldin
- Department of Orthopedic Surgery, Rady Children's Hospital, 3030 Children's Way, Suite 410, San Diego, CA, 92123, USA
- Department of Orthopedic Surgery, University of California, 200 West Arbor Drive, San Diego, CA, 92103, USA
| | - Nicholas Lopreiato
- Department of Orthopedic Surgery, Rady Children's Hospital, 3030 Children's Way, Suite 410, San Diego, CA, 92123, USA
| | - Katie Fields
- Department of Orthopedic Surgery, Rady Children's Hospital, 3030 Children's Way, Suite 410, San Diego, CA, 92123, USA
| | - John Munch
- Department of Orthopedic Surgery, Rady Children's Hospital, 3030 Children's Way, Suite 410, San Diego, CA, 92123, USA
| | - Jerry Dwek
- Department of Radiology, Rady Children's Hospital, 3030 Children's Way, Suite 410, San Diego, CA, 92123, USA
| | - Scott J Mubarak
- Department of Orthopedic Surgery, Rady Children's Hospital, 3030 Children's Way, Suite 410, San Diego, CA, 92123, USA.
- Department of Orthopedic Surgery, University of California, 200 West Arbor Drive, San Diego, CA, 92103, USA.
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Sonnery-Cottet B, Alessio-Mazzola M, Luz BF, Barbosa NC, Tuteja S, Kajetanek C, Dellal A, Thaunat M. Diaphyseal tibiofibular synostosis in professional athletes: Report of 2 cases. Orthop Traumatol Surg Res 2016; 102:135-8. [PMID: 26615768 DOI: 10.1016/j.otsr.2015.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/09/2015] [Accepted: 10/26/2015] [Indexed: 02/02/2023]
Abstract
Anterior leg pain is common in professional athletes and tibiofibular synostosis is reported to be a rare cause of anterior compartment pain or ankle pain related to sports activities. The management and appropriate treatment of this condition in professional athletes is controversial and the literature on the topic is sparse. Distal synostosis is usually related to ankle sprain and syndesmotic ligament injury, and proximal synostosis has been linked to leg length discrepancy and exostosis. Mid-shaft synostosis is even less common than proximal and distal forms. We present the treatment of mid-shaft tibiofibular synostosis in 2 cases of professional athletes (soccer and basketball player), along with a review of the literature. When diaphyseal synostosis is diagnosed, first-line conservative treatment, including ultrasound-guided steroid injection is recommended. However, if it does not respond to conservative management, surgical resection may be indicated to relieve symptoms.
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Affiliation(s)
- B Sonnery-Cottet
- Générale de Santé, centre orthopédique Santy, FIFA Medical Center of Excellence, 24, avenue Paul-Santy, 69008 Lyon, France.
| | - M Alessio-Mazzola
- Générale de Santé, centre orthopédique Santy, FIFA Medical Center of Excellence, 24, avenue Paul-Santy, 69008 Lyon, France
| | - B F Luz
- Générale de Santé, centre orthopédique Santy, FIFA Medical Center of Excellence, 24, avenue Paul-Santy, 69008 Lyon, France
| | - N C Barbosa
- Générale de Santé, centre orthopédique Santy, FIFA Medical Center of Excellence, 24, avenue Paul-Santy, 69008 Lyon, France
| | - S Tuteja
- Générale de Santé, centre orthopédique Santy, FIFA Medical Center of Excellence, 24, avenue Paul-Santy, 69008 Lyon, France
| | - C Kajetanek
- Générale de Santé, centre orthopédique Santy, FIFA Medical Center of Excellence, 24, avenue Paul-Santy, 69008 Lyon, France
| | - A Dellal
- OGC Nice Parc-Charles-Erhmann, 155, boulevard du Mercantour, 06200 Nice, France
| | - M Thaunat
- Générale de Santé, centre orthopédique Santy, FIFA Medical Center of Excellence, 24, avenue Paul-Santy, 69008 Lyon, France
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Fibular lengthening for the management of translational talus instability in hereditary multiple exostoses patients. J Pediatr Orthop 2015; 34:726-32. [PMID: 24705345 DOI: 10.1097/bpo.0000000000000181] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
UNLABELLED Hereditary multiple exostoses (HME) patients frequently present with ankle valgus deformity and marked fibular shortening. Loss of the lateral buttress may cause translational talus instability (TTI) that manifests as ankle pain after physical exercise, medial clear space widening on plain radiographs, and gross translational movement of the talus within the mortise. Among 123 HME patients examined and/or surgically treated, 10 patients (14 ankles) with symptomatic TTI underwent fibular lengthening with osteochondroma excision. Twelve ankles of 9 patients were followed for >1 year after surgery. Total fibular length gain averaged 15.3 mm and distal migration of the distal fibular fragment averaged 5.5 mm. The mean medial clear space decreased from preoperative 6.7 mm to postlengthening 3.5 mm. Gross instability of the talus within the ankle mortise disappeared in all cases. AOFAS ankle-hindfoot score improved from preoperative 80.3 to 97.3 at the latest follow-up. The current study showed the fibular lengthening improved lateral ankle stability by providing lateral buttress on the talus and providing favorable short-term result by ameliorating exercise-induced ankle pain in TTI of HME. The authors carefully conclude that TTI is a rare but potentially disabling condition in HME patients, requiring special attention during follow-up of HME patients. LEVEL OF EVIDENCE Level IV.
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Santa Maria DL, Shaw T, Allen M, Marin J. Fractured Diaphyseal Tibiofibular Synostosis in an Adolescent Soccer Player. PM R 2015; 7:84-7. [DOI: 10.1016/j.pmrj.2014.08.947] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 08/17/2014] [Accepted: 08/24/2014] [Indexed: 11/30/2022]
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Jung ST, Park H, Lee JH, Kim JR. Residual angulation of distal tibial diaphyseal fractures in children younger than ten years. J Orthop Surg Res 2014; 9:84. [PMID: 25297892 PMCID: PMC4201686 DOI: 10.1186/s13018-014-0084-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 09/09/2014] [Indexed: 11/22/2022] Open
Abstract
Background The purpose of this study was to evaluate the factors that influence residual angulation after treating pediatric distal tibial diaphyseal fractures. Methods We retrospectively reviewed the records of 75 children under the age of ten who were treated at two referral centers for distal tibial diaphyseal fractures. The mean patient age was 6.8 ± 2.3 years, and the mean follow-up duration was 4.1 ± 1.3 years (range, 3 to 6 years). Early postoperative and late follow-up radiographs were used to measure angulation. Results Twenty-four patients had valgus angulations >5° at the final follow-up. There was no varus, or anteroposterior residual angulations >5°. There was more residual valgus angulation when the postoperative angulation was >5° (p = 0.006) and when intramedullary nail and external fixators were applied for treatment (p = 0.004). Multivariate logistic regression analysis showed that postoperative angulation (adjusted odds ratio (OR) 4.33, 95% confidence interval (CI) 1.07–17.53) and treatment methods (intramedullary nail: adjusted OR 7.33, 95% CI 1.31–41.07; external fixator: adjusted OR 11.35, 95% CI 1.91–67.40 compared with the cast group) were associated with residual deformity. Conclusions Valgus angulation after pediatric distal tibial fractures persisted in this study sample. Accurate reduction should be performed to prevent residual deformity.
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Lugeder A, Jäger C, Fecht E, Riemer C, Sattler M, Kalbe P, Zeichen J. [Salter-Harris type IV epipyseal fracture of the lateral malleolus. A rare injury in childhood]. Unfallchirurg 2013; 117:169-73. [PMID: 23703619 DOI: 10.1007/s00113-013-2362-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This is a case presentation of a 9-year-old boy who sustained a rare Salter-Harris type IV distal fibular fracture including an avulsion fracture of the anterior inferior tibiofibular ligament at the fibular attachment. Treatment consisted of open reduction and internal fixation by Kirschner wire and cerclage. Possible posttraumatic growth disturbances and the major implications are highlighted.
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Affiliation(s)
- A Lugeder
- Abteilung der Berufsgenossenschaftlichen Unfallklinik Duisburg, Klinik für Unfallchirurgie und Orthopädie, Johannes Wesling Klinikum Minden, Hans-Nolte-Straße 1, 32429, Minden, Deutschland,
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van den Bekerom MPJ, Kloen P, Luitse JSK, Raaymakers ELFB. Complications of distal tibiofibular syndesmotic screw stabilization: analysis of 236 patients. J Foot Ankle Surg 2013; 52:456-9. [PMID: 23632070 DOI: 10.1053/j.jfas.2013.03.025] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Indexed: 02/03/2023]
Abstract
The objective of the present study was to evaluate our complications of screw stabilization and to formulate recommendations for clinical practice. Using a prospectively collected fracture database, the data from 236 consecutive adult patients were analyzed who had undergone syndesmotic screw stabilization from January 1979 to December 2000 at our level I academic trauma center. We observed 16 complications in 15 patients. The average patient age was 37.5 years. Of the 15 patients, 1 had a Weber B fracture and 14 had a Weber C ankle fracture. These complications included tibiofibular synostosis in 11 patients, screw breakage in 4 patients, and late diastasis in 1 patient. All breakages occurred in Weber C fractures. In particular, the 3.5-mm screws, penetrating both tibial cortices, tended to break. Synostosis was observed in 3% of the Weber B fractures and 5% of the Weber C fractures. Weightbearing in a plaster cast during syndesmotic screw stabilization is a safe postoperative treatment. We suggest that the use of 3.5-mm screws and screws penetrating 2 tibial cortices have a greater risk of breakage. Because of the low complication rate and more difficult treatment of late syndesmotic diastasis, a syndesmotic screw should be placed when in doubt of the indication.
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Affiliation(s)
- Michel P J van den Bekerom
- Orthopaedic Surgeon, Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
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Abstract
BACKGROUND According to the authors' multi-targeted, fibular status-based algorithmic approach using the Ilizarov technique, ankle stabilization by end-to-end osteosynthesis of the fibula is advocated for mild (type B1), "4-in-1 osteosynthesis" in which all 4 proximal and distal segments of the tibia and fibula are placed in 1 healing mass for moderate (type B2), and distal tibiofibular (TF) fusion for severe (type B3) fibular pseudarthrosis in association with atrophic-type congenital pseudarthrosis of the tibia (CPT). This report describes the indications, operative technique, and outcomes of "4-in-1 osteosynthesis" for atrophic-type CPT associated with type B2 fibular pseudarthrosis. METHODS Thirteen patients presented with atrophic-type CPT associated with type B2 fibular pseudarthrosis underwent Ilizarov osteosynthesis between 1989 and 2007 for atrophic-type CPT. To validate the efficacy of "4-in-1 osteosynthesis" in these patients, fracture risk and ankle function were compared between 2 groups of type B2 patients, namely, 8 patients (mean age, 6.3 y) who underwent "4-in-1 osteosynthesis" according to our current protocol (Group I), and 5 patients (mean age, 3.2 y) treated by other techniques (3 distal TF fusion, 2 failed end-to-end osteosynthesis) during the learning period (Group II). RESULTS No refracture occurred in Group I, whereas refracture occurred in all except 1 in Group II. Ankles were eventually stabilized by distal TF fusion in all patients in Group II. The Kaplan-Meier method revealed a refracture-free cumulative survival rate of 100% in Group I, whereas in Group II, it dropped progressively and reached 60% at 1.8 years and 20% at 2.7 years. No significant difference in ankle function was evident between the 2 groups (american orthopaedic foot and ankle society (AOFAS) score, 89.25 ± 7.25 after 7.4 y of follow-up in Group I, and 84.6 ± 9.53 after 13 y of follow-up in Group II). CONCLUSIONS It is imperative that fibular status be evaluated carefully to enable the planning of the most effective, safe, practical treatment. "4-in-1 osteosynthesis," which is primarily considered for bony union with a large cross-sectional area and ankle stabilization, seems to be a better choice for atrophic-type CPT associated with type B2 fibular pseudarthrosis, in which end-to-end osteosynthesis of the fibula often fails. LEVEL OF EVIDENCE Level III, Retrospective comparative study.
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Lubek J, Shihabi A, Salama A. Tibiofibular synostosis--an unusual case during vascularized fibula flap harvest. J Oral Maxillofac Surg 2010; 68:2629-31. [PMID: 20580144 DOI: 10.1016/j.joms.2009.09.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2009] [Accepted: 09/23/2009] [Indexed: 11/24/2022]
Affiliation(s)
- Joshua Lubek
- Head and Neck Surgical Associates, Legacy Emanuel Hospital and Health Center, Portland, OR, USA.
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Synostosis of the proximal tibiofibular joint. Case Rep Med 2010; 2010:794594. [PMID: 20592991 PMCID: PMC2892697 DOI: 10.1155/2010/794594] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Accepted: 04/08/2010] [Indexed: 11/18/2022] Open
Abstract
The incidence of synostosis of the proximal tibiofibular joint (TFJ) was assessed among
1029 patients examined for osteoarthritis of the knee in a 4-year period. Radiographic
evidence of a synostosis of the proximal TFJ was demonstrated in 3 knees (3 patients). The synostosis appeared incidental and was not the cause of symptoms in any of them. These
patients were further examined with MRI and/or CT scans. In two cases, which were
found to be primary (idiopathic), the synostosis was complete and bony. In a third case
the lesion was secondary (acquired) to surgical reconstruction for a depressed fracture of
the lateral tibial plateau. This iatrogenic complication followed open reduction, internal
fixation, and grafting with synthetic bone. The bridging of the joint on the CT views was
partial and compatible with ectopic calcification rather than ossification. The patients
were treated conservatively and were followed for an average period of 3 years. No
evidence that the synostosis accelerated the onset or progression of the degenerative
changes to the ipsilateral knee could be verified.
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Abstract
BACKGROUND Progressive varus deformity of the tibia in pediatric patients after transtibial and Syme amputations has not been reported in a series. A distal tibia to fibula synostosis, created surgically to minimize the risk of terminal overgrowth or occurring spontaneously, was noted in most patients. The goals of this study are to address the causes of the deformity, the implications for prosthetic wear, and potential treatment options. METHODS Twelve patients identified from the juvenile amputee database at 2 centers developed progressive varus deformity of the residual limb. One patient had bilateral involvement. A distal tibia-fibula synostosis was noted in 12 (92%) of the residual limbs, and in one, a fibrous union was suspected. The level of amputation was trans-tibial in 10 patients, and Syme amputation in 3 patients. Two patients had acquired trans-tibial level of amputation from congenital constriction band syndrome. Nine of the patients (75%) were between the ages of 3 and 5 years at the time of injury. RESULTS The mean proximal medial tibial angle was 80.5 degrees (range, 75-85 degrees). Ten of the patients underwent procedures to correct the mechanical axis and resolve or prevent problems with prosthetic fitting. Four patients has proximal tibial osteotomies (HTO), 2 oblique closing wedge osteotomies, 1 shaft osteotomy, and 4 lateral proximal tibial hemi-epiphyseodesis. In 2 patients, no correction was recommended. CONCLUSIONS The presence of a distal tibia-fibula synostosis in pediatric amputee patients may contribute to the risk of developing a progressive varus deformity and should be monitored during a child's growth. Distal tibiofibular synostosis may disrupt normal differential longitudinal growth and may contribute to this progressive angular deformity. Severe deformity may require prosthetic modifications or operative correction to provide for a normal mechanical axis. Lateral hemiepiphyseodesis of the proximal tibia can be effective if the deformity is detected early. We do not recommend creation of a synostosis in the young child for terminal growth. LEVEL OF EVIDENCE Level 4.
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Isolated congenital pseudoarthrosis of the fibula: a comparison of fibular osteosynthesis with distal tibiofibular synostosis. J Pediatr Orthop 2008; 28:825-30. [PMID: 19034172 DOI: 10.1097/bpo.0b013e31818e192d] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Isolated congenital pseudoarthrosis of the fibula is associated with progressive ankle valgus and rare subsequent tibial involvement. Two operative techniques were compared: (1) osteosynthesis with intercalary grafting and (2) distal tibiofibular synostosis. Hemiepiphysiodesis or osteotomy supplemented the primary procedure when necessary. METHODS A retrospective review of isolated congenital pseudoarthrosis of the fibula-Dooley types 2 (without ankle valgus) and 3 (with ankle valgus); cases with tibial involvement (Dooley types 1 and 4) were excluded. Nine patients were identified (mean age, 7.6 years, follow-up, 6.6 years). One is under observation without bracing (type 2). Five patients (one type 2 and four type 3) were treated with osteosynthesis. Three were treated with distal tibiofibular synostosis (one type 2 and two type 3). One patient in each group also underwent concomitant medial distal tibia hemiepiphysiodesis; 1 patient in the synostosis group underwent distal tibia varus osteotomy with the primary procedure. RESULTS In the osteosynthesis group (5 patients), mean lateral distal tibial angle (LDTA) improved from 75.6 to 86.6 degrees. Union was achieved in 4; 1 had early graft resorption requiring revision. Four of the 5 had neutral ankle alignment at the final follow-up. Among the 3 patients with primary union and no deformity correction, mean LDTA improved from 81 to 88 degrees over 9.8 years of follow-up. One patient had mild residual valgus (LDTA, 79 degrees) after temporary screw hemiepiphysiodesis. Complications were as follows: nonunion (n = 1), compartment syndrome with mild residual plantar flexion weakness (n = 1), and fibular stress fracture, which healed with immobilization (n = 1).In the synostosis group (3 patients), the mean LDTA improved from 64.3 to 80.0 degrees. One achieved union with distal tibia medial hemiepiphysiodesis (final LDTA, 86 degrees). Two had failure: one synostosis nonunion underwent repeat varus osteotomy (final LDTA, 81 degrees), and the other (Dooley type 2) had crossunion; however, persistent fibular pseudoarthrosis proximal and distal to the synostosis, progressive valgus developed (final LDTA, 73 degrees). CONCLUSIONS Osteosynthesis with intercalary grafting achieved primary union in 4 of 5 patients; mild residual ankle valgus was present in 1 patient at final follow-up. Synostosis failure with residual ankle valgus at maturity occurred in 2 of 3 patients. Progression to tibial pseudoarthrosis was not observed in either group. In this series, osteosynthesis eliminated fibular discontinuity, allowing correction of ankle valgus. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Abstract
Treatment of cases of congenital pseudarthrosis of the fibula presenting with severe or progressive valgus deformity in early childhood is challenging. The purpose of the study presented was to analyse the deforming mechanisms to get therapeutic recommendations for this condition. A 2.5-year-old child was treated by resection of pseudarthrosis and distal tibiofibular fusion (Langenskiold operation) with autogenous bone grafting, associated with subtalar arthroereisis: progressive correction of the deformity was achieved. A 21-month-old child was treated with resection of pseudarthrosis, homologous bone grafting and fibular osteosynthesis: after failure, Langenskiold operation with autogenous bone grafting was performed and stabilization of the deformity was achieved. In young children with congenital pseudarthrosis of the fibula and valgus deformity, early surgical treatment is advisable: fibular ostheosynthesis has limited indications; distal tibiofibular fusion remains the treatment of choice, providing correction that may exceed the simple stabilization of deformity expected. Radiographic findings lead the authors to suggest that part of the effectiveness of the procedure is due to abnormal growth patterns.
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The treatment of congenital pseudarthrosis of the tibia with ipsilateral fibular transfer to make a one-bone lower leg: a review of the literature and case report with a 23-year follow-up. J Pediatr Orthop 2008; 28:478-82. [PMID: 18520288 DOI: 10.1097/bpo.0b013e31817440f4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The surgical making of a one-bone lower leg is, in a way, an operation of necessity or last resort. It has been attempted for many conditions and by many techniques. METHODS This is a review of the literature and a case report of transferring a congenitally pseudarthritic fibula to replace an ipsilateral pseudarthritic tibial diaphysis without exposing the fibular vascular pedicle, or using microvascular techniques, and with the specific aim of purposely creating a true one-bone lower leg, the tibula. RESULTS AND CONCLUSION The concept and surgical technique used here leave the contralateral leg undisturbed and are less demanding, time consuming, and costly than a vascularized pedicle graft or bone transport. This procedure is new and can also be applied when the fibula is normal and to repair tibial diaphyseal deficiency from any cause in both children and adults.
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Lui TH, Chan KB, Ngai WK. Premature closure of distal fibular growth plate: a case of longitudinal syndesmosis instability. Arch Orthop Trauma Surg 2008; 128:45-8. [PMID: 17972126 DOI: 10.1007/s00402-007-0305-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2006] [Indexed: 10/23/2022]
Abstract
Post-traumatic premature closure of distal fibular growth plate is a rare entity and results in shortened lateral malleolus. This can lead to lateral wedging of distal tibial epiphysis, valgus ankle and medial ankle instability. Ramsey and Hamilton noted experimentally that loss of fibular length caused a dramatic lateral shift in tibiotalar surfaces. Even a displacement of as little as 1 mm will distort the areas of tibiotalar contact and lead to early joint degeneration. Colton believed it is due to the oblique articular surface of the malleolus is no longer closely applied to the talus. We present a case of premature closure of distal fibular physis with lateral malleolar shortening. Ankle arthroscopy demonstrated syndesmosis instability resulted from shortened lateral malleolus and stability restored after fibular lengthening.
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Affiliation(s)
- T H Lui
- Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China.
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Gil-Albarova J, Gil-Albarova R, Bregante-Baquero J. Fibular rotational osteotomy for the treatment of distal tibial osteochondroma: a technical modification for deformity correction and improved outcomes. J Foot Ankle Surg 2007; 46:474-9. [PMID: 17980846 DOI: 10.1053/j.jfas.2007.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2006] [Indexed: 02/03/2023]
Abstract
The technique of choice for excision of osteochondromas located in the lateral aspect of the tibia is a transfibular approach to expose the lesion for resection. A drawback of this approach is that removal of the lesion leaves a void that may cause a visible deformity and adversely affect long-term function. Fibular rotational osteotomy followed by fibular graft may minimize the resultant deformity, producing a more satisfactory functional and cosmetic result. The authors report a retrospective case series consisting of 5 cases in which a fibular graft rotation was performed after rotational osteotomy via a transfibular approach. Retrograde intramedullary fixation by means of a Kirschner wire, in combination with the design of the fibular osteotomy, provided rotational graft and fibular stability until healing occurred.
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Affiliation(s)
- Jorge Gil-Albarova
- Servicio de Cirugía, Ortopédica y Traumatología, Hospital Universitario Miguel Servet, Zaragoza, Spain.
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Jaeger GH, Marcellin-Little DJ, Ferretti A. Morphology and correction of distal tibial valgus deformities. J Small Anim Pract 2007; 48:678-82. [PMID: 17725588 DOI: 10.1111/j.1748-5827.2007.00388.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To characterise distal tibial valgus deformities in dogs through physical examination and radiographic evaluation. METHODS In a clinical study of 16 client-owned dogs, twelve unilateral and four bilateral distal tibial valgus deformities were evaluated using palpation and radiographs. The origin and amplitude of angulation, rotation and length deficits if present were measured. Radiographically, fibular length and position in relation to the tibia was compared in affected and clinically normal limbs. The dimensions of the fibular physes were also compared between clinically normal and affected limbs. RESULTS Rottweilers and Shetland sheepdogs were overrepresented. Valgus deformities ranged from 16 degrees to 48 degrees (median, 32 degrees ) in affected and from 0 degrees to 13 degrees (median, 6 degrees ) in contralateral, clinically normal limbs. Fibular length, fibular position relative to the tibia or physeal dimensions were not statistically different between affected and clinically normal limbs. CONCLUSION AND CLINICAL RELEVANCE Many distal tibial valgus deformities in dogs are a uniplanar deformity without concurrent craniocaudal or rotational changes or length deficits. A growth cessation in the fibula does not appear to be responsible for the development of the deformity.
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Affiliation(s)
- G H Jaeger
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27606, USA
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Hanypsiak B, Bergfeld JA, Miniaci A, Joyce MJ. Recurrent compartment syndrome after fracture of a tibiofibular synostosis in a National Football League player. Am J Sports Med 2007; 35:127-30. [PMID: 17130245 DOI: 10.1177/0363546506295698] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Bryan Hanypsiak
- Orthopaedic Associates of Long Island, Long Island, New York, USA.
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Abstract
INTRODUCTION Posttraumatic pediatric distal tibiofibular synostosis is a rare complication of fractures at this level, unreported at this time. Implications include limb length discrepancy, angular malalignment, and gait and biomechanical abnormalities. MATERIALS AND METHODS The authors present a case report of this complication in a 7-year-old child and review the relevant English literature. The patient was treated for a closed distal tibia-fibula fracture and developed a synostosis at that level, with valgus malalignment of the ankle joint. The synostosis was resected and latest follow-up 16 months postresection showed near normalization of the ankle malalignment. Possible etiologies, the anatomical and functional ramifications, and treatment recommendations for this condition are discussed. SUMMARY Posttraumatic tibiofibular synostosis is a rare complication that has a potential effect on limb length and alignment, both at the ankle and the knee in the skeletally immature patient. Prevention, early recognition, and prompt treatment prevent the anatomic and functional abnormalities that could result from it.
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Affiliation(s)
- Kevin Munjal
- Department of Orthopedics, The University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ 07103, USA
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Gupte CM, Dasgupta R, Beverly MC. The transfibular approach for distal tibial osteochondroma: an alternative technique for excision. J Foot Ankle Surg 2003; 42:95-8. [PMID: 12701078 DOI: 10.1016/s1067-2516(03)70008-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Surgical excision of osteochondromata occurring at the lateral aspect of the distal tibia is hampered by the difficult access to this area. Current techniques use an anterior approach, but this makes access to the posterior aspect of the tibia difficult. The authors report on 2 cases in which removal, and subsequent replacement of distal fibula and fixation with a semitubular plate, allowed complete excision of a distal tibial osteochondroma and satisfactory outcomes. This procedure provides an alternative technique to the anterior approach previously described. The literature appears to contain no similar previous reports.
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Affiliation(s)
- Chinmay M Gupte
- Department of Orthopaedics, Ealing Hospital, Southall, Middlesex, England.
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Abstract
This article discusses the complications after open reduction and internal fixation of ankle fractures. Complications are classified as perioperative (malreduction, inadequate fixation, and intra-articular penetration of hardware), early postoperative (wound edge dehiscence, necrosis, infection and compartment syndrome), and late (stiffness, distal tibiofibular synostosis, degenerative osteoarthritis, and hardware related complications). Emphasis is placed on preventive measures to avoid such complications.
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Affiliation(s)
- Manuel Leyes
- Section of Foot and Ankle Surgery, Clínica Cemtro, Madrid, Spain
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