Fibula Research Articles

Evaluation of the lower limb and trunk muscles’ electromyographic activity during different squat techniques

Squatting is a widely used exercise in rehabilitation programs for strength and stability gain. However, little is known about muscle activation in variations of squat exercises. The purpose of this study was to compare the muscle activation of the vastus lateralis (VL), rectus femoris (RF), gluteus medius (GM), long fibular (FL), and erector spinae (EE) during traditional squatting compared to variations of unipodal squatting. Twenty physically active men (age= 21± 2 years, height =1.78± 0.05 m, mass = 84.5± 9.9 Kg) participated in this study. Muscle activation were extracted from electromyography of the rectus femoris, vastus lateralis, fibularis longus, gluteus medius and erector spinae during five exercises: traditional squat, bulgarian squat, single leg leaning forward squat, single leg leaning backward squat and lateral step up. The muscle activations were compared between exercises. Muscle activation in all unipodal squat without foot support exercises was considerably higher than that of traditional squatting (p<0.001). The similar pattern in the EMG activity that was recorded for unilateral squat without foot support (p >0.05). In conclusion, the unilateral squat without foot support exercises are appropriate for facilitating the muscle activity of the muscles of the lower limb and trunk.

Mechanical, structural, and physiologic differences between above and below-knee human arteries

Peripheral Artery Disease (PAD) affects the lower extremities and frequently results in poor clinical outcomes, especially in the vessels below the knee. Understanding the biomechanical and structural characteristics of these arteries is important for improving treatment efficacy, but mechanical and structural data on tibial vessels remain limited. We compared the superficial femoral (SFA) and popliteal (PA) arteries that comprise the above-knee femoropopliteal (FPA) segment to the infrapopliteal (IPA) anterior tibial (AT), posterior tibial (PT), and fibular (FA) arteries from the same 15 human subjects (average age 52, range 42–67 years, 87 % male). Vessels were imaged using μCT, evaluated with biaxial mechanical testing and constitutive modeling, and assessed for elastin, collagen, smooth muscle cells (SMCs), and glycosaminoglycans (GAGs). IPAs were more often diseased or calcified compared to the FPAs. They were also twice smaller, 53 % thinner, and significantly stiffer than the FPA longitudinally, but not circumferentially. IPAs experienced 48 % higher physiologic longitudinal stresses (62 kPa) but 27 % lower circumferential stresses (24 kPa) and similar cardiac cycle stretch of <1.02 compared to the FPA. IPAs had lower longitudinal pre-stretch (1.12) than the FPAs (1.29), but there were no differences in the stored elastic energy during pulsation. The physiologic circumferential stiffness was similar in the above and below-knee arteries (718 kPa vs 754 kPa). Structurally, IPAs had less elastin, collagen, and GAGs than the FPA, but maintained similar SMC content. Our findings contribute to a better understanding of segment-specific human lower extremity artery biomechanics and may inform the development of better medical devices for PAD treatment. Statement of significancePeripheral Artery Disease (PAD) in the lower extremity arteries exhibits distinct characteristics and results in different clinical outcomes when treating arteries above and below the knee. However, their mechanical, structural, and physiologic differences are poorly understood. Our study compared above- and below-knee arteries from the same middle-aged human subjects and demonstrated distinct differences in size, structure, and mechanical properties, leading to variations in their physiological behavior. These insights could pave the way for creating location-specific medical devices and treatments for PAD, offering a more effective approach to its management. Our findings provide new, important perspectives for clinicians, researchers, and medical device developers interested in treating PAD in both above- and below-knee locations.

Features of the macroscopic structure of the posterior inferior tibiofibular ligament based on anatomical study.

Aim: To study the anatomy of the posterior inferior tibiof i bular ligament (PITFL) and specify the features of its morphology and linear parameters. Materials and Methods: The peculiarities of morphology and linear parameters of PITFL on 10 fresh amputated lower limbs were studied. The average age of the patients was 64.7 ± 9.3 (7 males, 3 females). Macroscopic characteristics, insertion, orientation in relation to the corresponding bony and ligamentous anatomical structures were studied, and linear parameters of PITFL were measured using a caliper. Average values were calculated. Results: PITFL was detected in all the studied samples. It represented a strong, compact anatomical structure of a trapezoidal or triangular shape. The proximal width of the PITFL averaged 20 ± 3.65 mm, while the distal width was 36.6 ± 4.62 mm. The attachment length of PITFL to the posterior part of the tibia was 28.6 ± 5.13 mm and to the fi bula was 17.4 ± 3.2 mm. The ligament is closely connected to the posterior intermalleolar ligament, the inferior transverse ligament, and the tendinous sheaths of the posterior tibial and fi bular muscles. Conclusions: The obtained results of the study of linear and morphological parameters of PITFL should contribute to a better understanding of the anatomy of the posterior part of the ankle joint and improve surgical approaches to the treatment of posterior malleolus fractures and related PITFL injuries.

ИМПОРТ В МАТЕРИАЛАХ МОГИЛЬНИКА УСТЬ-ТАРТАССКИЕ КУРГАНЫ (БАРАБИРСКАЯ ЛЕСОСТЕПЬ)

Th e article presents the results of a study of imported materials from the burial ground of Ust-Tartas mounds which located in the Vengerovskyi district of the Novosibirsk region. Th e site is one of the largest funerary objects of the Sargat culture, whose history dates back to the 18th century. Th e fi rst excavations were carried out in 1895 and 1896 by S.M. Chugunov. Excavations examined 18 objects, of which seven were attributed to the Sargat culture. Th e purpose of the work is to introduce imported materials from the excavations of mound No. 51 in 2023 into scientifi c circulation, to present a brief description of imported products identifi ed at the burial ground. It was recorded that in the materials of the studied mounds one category was singled out — decorations. Th ey are presented as a set, where the main part consists of beads and little beads, sewn-on plaques and badges. Th ree mirrors were recorded. Th e remaining items are single: earrings, a torc, a fi bula, fragments of fabric. Analogies and dates were given for all products. It has been established that most of the materials were used in the 3rd–1st centuries BC; the fi bula is dated back to the 2nd–1stcenturies BC — 2nd century AD.

Functional outcome of distal tibia extra articular fractures treated by Joshi’s External Stabilization System (JESS)

Objective: Distal tibia extra articular fractures amount to nearly 10-13% of all tibial fractures. Precarious vascularity, propensity for open fractures and poor soft tissue coverage over these fractures make them particularly vulnerable for infection and non-union and surgical site complications.We evaluated the shortterm functional outcome of fracture distal tibia fibula treated by single stage external fixation using Joshi’s External stabilizing system (JESS). Methods: In a non-control prospective interventional study on 30 patients with extra articular distal tibia fractures we used the JESS fixator as a definitive treatment modality. Fibula was internally fixed using a nail or plate when fractured. After achieving temporary fracture reduction, two pins were inserted each in tibia and calcaneum and were connected by JESS rods using clamps. In case of open fractures wound was managed by serial debridement and dressings as required. The patients were followed up for a minimum of 12 months. Results: There were 20 male and 10 females. The mean age was 39.1 years (range 18-60 years). There were 18 open and 12 closed fractures. According to the AO/OTA classification of extra articular distal tibia fractures 20 belonged to type A1, 3 in type A2 and 7 in type A3. The mean time to union was 15 weeks and the average duration of surgery was 35 minutes. At the final follow up all fractures united except one and the mean AOFAS score was 83.13. There were 2 cases of pin track infections, one non-union and one mal-union. One patient had ankle arthritis managed conservatively till last follow up. Conclusions: Definitive fixation of distal tibia extra- articular fractures with JESS is a simple procedure with good functional outcome and avoids complications associated with open reduction and internal fixation. Keywords: Distal tibia, JESS, Plating, ORIF, Fixator.

Postoperative position change of fibular bone after reconstruction of maxillary defect using free fibular flap

To investigate the position change of the fibular bone after maxillary reconstruction by free fibular flap and to analyze the factors affecting the position change. Patients who underwent maxillary reconstruction by free fibular flap in the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology from November 2012 to November 2016 were enrolled in this study. CT scans 1 week and 1 year postoperatively were collected and stored in DICOM format. The ProPlan CMF software was used to reconstruct the CT scans and separate the maxilla and each segment of the fibular flap. The Geomagic Control software was used to measure the long axis direction vector of each fibular segment. And the position change direction was recorded. The patients were divided into groups according to the use of the fibula or titanium plate to reconstruct the zygomaticmaxillary buttress. A total of 32 patients were enrolled. Among them, 21 were in the titanium plate group and 11 in the fibula bone group. The angle between the long axis of the fibular segment and the X axis in the X-Y plane was 95.65°±53.49° and 95.53°±52.77°, 1 week and 1 year postoperatively, and there was no statistical difference (P>0.05). The angle between the long axis of the fibular segment and the X axis in the X-Z plane was 96.88°±69.76° and 95.33°±67.42°, respectively, with statistical difference (P=0.0497). The angular changes of the long axis of the fibular segment in the titanium plate group and the fibular bone group were 3.23°±3.93° and 1.94°±1.78°, respectively, and the angular changes in the X-Z plane were 6.02°±9.89° and 3.27°±2.31°, respectively. There was no significant difference between the groups (P>0.05). The long axis changes of the fibular segment in the X-Y plane for reconstruction of the anterior alveolar, posterior alveolar, and buttress were 3.13°±3.78°, 2.56°±3.17°, and 5.51°±4.39°, respectively. There was a statistical difference (P = 0.023) between the posterior and buttress. In the X-Z plane, theses were 4.94°±4.75°, 5.26°±10.25°, 6.69°±6.52°, respectively. There was no statistical difference among the three groups (P>0.05). The main positional deviation directions of the titanium plate group and the fibular bone group were interior and superior sides, and there was no statistical difference between the two groups (P>0.05). One year postoperatively, the position of the free fibular flap was changed compared with 1 week postoperatively. The position of the free fibular flap was mainly changed to the interior and superior sides.

Bosworth fracture treated with immediate open reduction and internal fixation 6 hours after injury: A case report

Ankle fractures are among the most common fractures from orthopedic injuries. Bosworth fracture-a rare ankle fracture-occurs when the proximal fibular fragment gets impacted behind the posterior tubercle of the distal tibia. Given the rarity of the Bosworth fracture, delayed management of or neglect in reducing the entrapped proximal fibula behind the posterior tibia may lead to catastrophic complications, including compartment syndrome, early arthritic changes, and residual ankle pain. Here, we present a case of this rare type of ankle injury that was treated with immediate open reduction and internal fixation (ORIF) 6 hours after injury and review the previous literature on ankle injuries. The proximal fibula was levered out from behind the tibia with posterior traction, and the proximal fibular fragment was internally rotated gently to minimize the damage to the surrounding soft tissues. Immediate ORIF performed within 6 hours resulted in good surgical outcomes in our case.

CT classifications of tibial plateau fractures

Current classifications of tibial plateau fractures include three-pillar classification, four-quadrant classification, eight-segment classification, ten-segment classification, and four-column & nine-segment classification. This article reviews the various CT classifications of tibial plateau fractures, their advantages and disadvantages and surgical approaches as well. The essence of the CT classifications is to pay more attention to the coronary fracture line, especially the posterior coronal fracture fragments. A classification which combines the four-quadrant idea of the articular surface of the tibial plateau with the four-column idea of the peripheral cortex of the tibial plateau, and is supplemented by descriptions of non-articular surface structures (intercondylar spine, tibial tubercle and fibula head), may provide a more comprehensive understanding of a specific tibial plateau fracture, but may therefore be too complicated and difficult to use clinically due to too many combinations that need matching. Key words: Tibial plateau; Fracture; Classification; CT

Ewing Sarcoma of Fibula: A Pediatric Case of Disease Regression and Bone Regeneration. Case Report and Literature Review.

Ewing’s sarcoma is a rare type of bone malignancy that occurs mostly in the bones of the pelvis and the limbs. We report a case of Ewing’s sarcoma developed in the peroneal bone of a 10-year-old boy, with a severe affectation of the bone and pulmonary metastasis. Chemotherapy was administered to the patient. Approximately two years after first presentation, radiological exams indicated a nearly complete regenerated fibula and PET-CT scan indicated an inactive right lung mass. This case showed the incredible potency of recovery in pediatric patients and highlights the need for a personalized approach in pediatric orthopedic oncology.

Transplantation of free fibula composite tissue flap to repair bone and soft tissue defect after open fracture of proximal tibial

Objective To explore the clinical application and effect of free fibula composite tissue flap trans-plantation to repair bone and soft tissue defect after open fracture of proximal tibial. Methods From June, 2012 to June, 2018, free fibula composite tissue flap transplantations were applied to repair bone and soft tissue defect after open fracture of proximal tibial in 11 cases. Of the 11 cases, there were 10 males and 1 female(their ages ranged from 32 to 56, 36 on average); Six cases were caused by traffic accident, and 5 by crash. There were 3 fresh wounds and 8 chronic and infective wounds. Free fibular flaps were used in 7 cases, and free fibular flexor hallucis myocutaneous flaps were used in 4 cases. The fibular length with transplantation was 7-18 cm. The area of flaps or muscle flaps was ranged from 4 cm×8 cm to 8 cm×20 cm. Bone fracture healing was observed at 3, 6 and 12 months after operation. The function of injured extremity was evaluated in 1 year after surgical operation. Results All were successfully repaired, and composite tissue flaps survived. Of which, 10 wounds healed by first intention, and 1 wound healed by secondary intention, with the healing time of 12-18 days. All 11 cases were followed-up. The mean followed-up time was 18 months. The bone healing time ranged from 6 to 9 months (7 months on average). The Enneking Score System was applied to evaluate the leg function. Of the 11 cases, the mean scores was 25 (ranged from 22 to 27). The donor sites were not found malfunctional. Conclusion Transplantation of free fibula composite tissue flap can reduce the treatment time with good mechanical strength. It is an ideal method to repair bone and soft tissue defect after open fracture of proximal tibial. Key words: Fibula composite tissue flap; Fracture of tibial; Open fracture; Microsurgical technique

Plane-shaped flap for reconstruction of the web space in polysyndactyly of the fifth toe fused with the fourth toe

Objective To discuss the application of plane-shaped flaps for reconstruction of the web space in polysyndactyly of the fifth toe fused with the fourth toe. Methods A total of 62 cases (81 feet) with polysyndactyly of the fifth toe fused with the fourth toe were involved in the study, 53 of which were incomplete and 9 were complete fusion of the fourth and fifth toe. The fifth toe showed various degrees of fibular clinodactyly and minor deformities. Excision of polydactyly and then using arthroplasty or osteotomy correction deviation was for fibular clinodactyly. All plane-shaped flaps were used for reconstruction of the web space deeply, and the lateral sides of toes were closed with flaps and the distal soft tissues of polydactyly were used lengthening the reconstructed fifth toe. Brachydactylias were improved, and nail folds were reconstructed. Thus, the appearances reached the normal level. Results All the webs were reconstructed primarily without skingraft. After 12 months of follow-up, these reconstructed web space were satisfied with good appearances of width, depth and gradient. The fibular clinodactyly was completely corrected, and brachydactylias were corrected in various degrees. Nail folds reached the normal ones. Conclusions Plane-shaped flap in polysyndactyly of the fifth toe fused with the fourth toe for reconstruction of the web space is satisfactory. The reconstructed webs not only achieves good appearance, but also avoids skin grafts. It is one of the best choices of the polysyndactyly treatment. Key words: Reconstructive surgical procedures; Child; Polysyndactyly of the toes; Syndactyly; Web space reconstruction; Plane-shaped flap

Total knee arthroplasty after proximal fibula osteotomy for knee osteoarthritis: A case report and discussion

The knee osteoarthritis(KOA)is a kind of degenerative disease, which is more common in the elderly.In recent years, according to the Knee Uneven Settlement Theory, a new treatment method for the knee osteoarthritis by using the proximal fibula osteotomy is popularized in many hospitals.In this article, we reported 1 case undergoing the total knee arthroplasty after the proximal fibula osteotomy for the treatment of knee osteoarthritis and reviewed the relevant literatures. Key words: Knee prosthsis; Fibula; Osteotomy

Perioperative deep venous thrombosis in patients with tibiofibular fracture

Objective To investigate the regularity in and risk factors for perioperative deep venous thrombosis (DVT) and the changes in plasma D-dimer in patients with tibiofibular fracture. Methods A retrospective analysis was done of the 180 patients with tibiofibular fracture who had been treated at Department of Orthopaedics and Trauma, Xi'an Honghui Hospital from September 2014 to February 2018. They were 114 males and 66 females, aged from 16 to 83 years (average, 47.6 years). The levels of plasma D-dimer were detected at admission, one day preoperation, and 1, 3, 5 days postoperation. B-ultrasound examination of both lower extremities was performed before and after surgery. According to the results of B-ultrasound, the patients were divided into a DVT group and a non-DVT group. The 2 groups were compared in the plasma D-dimer levels measured at different time points. DVT risk factors were screened by univariate analysis, and multivariate logistic regression analysis was used to determine independent risk factors. Results Of this cohort, 54 cases (30%) developed DVT and 39 cases (21.7%) did preoperation. Of the 39 cases (mixed DVT in one and distal DVT in 38 ones), DVT disappeared in 14 postoperation. Of the 40 cases (22.2%) of postoperative DVT (proximal DVT in one, mixed DVT in one and distal DVT in 38 ones), 15 developed newly postoperation. Multivariate logistic regression analysis showed that age, time from injury to operation, pre-operative and postoperative D-dimer elevation were independent risk factors for DVT in the patients. The D-dimer levels in the DVT group were significantly higher than in the non-DVT group at one day preoperation, and 1, 3, 5 days postoperation (P<0.05). The area under the receiver operating characteristic curve was 0.704. When the critical value of D-dimer was 1.4 mg/L, its sensitivity for DVT diagnosis was 0.944 and its specificity 0.246 (poor). When the concentration of D-dimer was 4.45 mg/L, its sensitivity for DVT diagnosis was 0.574 and its specificity 0.817 (the highest). Conclusions Perioperative DVT may happen in patients with tibiofibular fracture, mostly at the distal end beyond the popliteal vein. Clinically, patients who are advanced in age, have plasma D-dimer elevation at admission and after operation, and have waited long for operation should be alert to the occurrence of DVT. The plasma D-dimer level with a recommended threshold of 4.45 mg/L may have a certain diagnostic value for patients with tibiofibular fracture. Key words: Tibia; Fibula; Fractures, bone; Deep vein thrombosis; Risk factors; D-dimer

The clinical characteristics and outcomes of Maisonneuve fractures

Objective To investigate the clinical characteristics and outcomes of Maisonneuve fractures. Methods Data of 21 cases of Maisonneuve fractures from February 2015 to December 2017 were retrospectively analyzed. There were 16 males and 5 females with an average age of 38.8 years (range, 21 to 61 years). The fractures occurred on the left side in 11 patients and on the right side in 10 patients. The causes of injuries were traffic accident in 4 patients, sprain injury in 9 patients and falling injury from height in 8 patients. There were 16 cases of medial malleolar fractures and 5 cases of ruptures of deltoid ligament (4 entirely and 1 partial). There were 17 cases of fractures of the posterior malleolus, among which there were 5 of typeⅠ, 8 of typeⅡ and 4 of type Ⅲ according to the Bartonicek classification of posterior malleolus. There were 4 cases without fracture of posterior malleolus including 1 complete disruption of posterior inferior tibiofibular ligament. Four cases were overlooked of Maisonneuve fracture at the first time. The interval between injury and operation was 2-12 days (mean, 4.9 days). Results Stabilization of proximal fibular fractures were achieved with plate in 3 cases. There were 16 cases of medial malleolar fractures, and the fixation were achieved with cannulated screws in 13 cases and with anti-glide plates in 3 cases. The entirely rupture of deltoid ligament was repaired in 4 cases with suture anchors, the partial rupture of deltoid ligament was not repaired. There were 17 cases of posterior malleolar fractures, 12 cases treated with open reduction and internal fixation including cannulated screws in 9 cases and anti-glide plates in 3 cases. Stabilization of syndesmosis was achieved with syndesmotic plate in 1 case; the medial and posterior malleolar fractures were stabilized and anterior inferior tibiofibular ligament was repaired with suture anchor in 1 case; the other 19 cases were stabilized with syndesmotic screws, 2 screws in 11 cases and 1 screw in 8. Twenty-one patients were followed up for 13-48 months with an average of 25.6 months. The time of bony union was from 3 to 6 months with an average time of 4.9 months after operation. All patients received anatomical reduction without postoperative complications such as incision infection, reduction lose, breakage of screw and posttraumatic arthritis. In 13 cases, the syndesmotic screw was removed at the mean time of 15.38 weeks postoperative (range, 13-25 weeks). At the latest follow up, AOFAS score was from 84 to 100, with excellent in 13 cases, good in 8 cases, and the excellent and good rate was 100% (21/21). Baird-Jackson score was from 83 to 100, with excellent in 11 cases, good in 8 and fair in 2, and the excellent and good rate was 90.48%(19/21). Conclusion The diagnosis of proximal fibular fracture of Maisonneuve fracture is easily missed. The complete rupture of deep deltoid ligament and displaced obviously of posterior malleolar fracture should be reduction and stabilization. The accuracy of reduction of the syndesmosis is of great concern. The outcome of operation is satisfied. Key words: Ankle joint; Fibula; Fractures, bone; Ligaments

Orthopaedic robot-assisted free vascularised fibular grafting for the treatment of avascular necrosis of the femoral head

Objective To introduce the surgical procedure of orthopaedic robot-assisted vascularised fibular grafting for the treatment of ANFH and report the short-term result. Methods From September, 2016 to November, 2018, 17 patients (21 hips) with ANFH had undergone robot-assisted free fibular grafting. There were 14 males and 3 females, of which, 8 cases were associated with the right side, 5 cases the left side, and 4 cases with both sides. The average age was 35 (ranged from 17 to 55) years. There were 7 patients suffered from idiopathic ischemic necrosis of femoral head, 4 patients who had cannulated screws fixed after a femoral neck fracture, 4 patients who had a history of alcohol consumption, 1 patient who had taken corticosteroids for 6 months to treat nephritis, and 1 patient who had a history of alcohol consumption and had also taken corticosteroids. Seventeen hips were in Ficat stage II, and 4 hips were in Ficat stage III. The orthopaedic surgical robot workstation was used to plan the entry point and target of the guide pin during the operation, to place a cannula in the optimal position. Then a bone window was created and the fibula was placed into the bone tunnel. Using fluoroscopy to monitor each step of the procedure and verify the position of the fibula. Finally, the vessels were anastomosed. The patient remain in bed completely for a week with the use of vasodilator. The follow-up was accomplished with phone call and outpatient clinic, and Harris score was evaluated. Results All 21 surgical procedures were successful. The guide pins and fibula were accurately placed according to the robot’s plan, and the tips of the fibula were placed at the centre of the load-bearing region of the femoral heads, 4 to 6 mm from the articular surface. Conventional anticoagulant, anti-infective therapy was performed after the procedure. Ten patients were followed-up postoperatively more than 1 year, with an average of 15 (from 12 to 24) months. The function of the hip joint recovered smoothly for 9 patients. Frontal and lateral X-ray and CT scans showed that the tips of the fibula were placed at the centre of the load-bearing region, 4 to 6 mm from the articular surface. One patient suffered from bilateral femoral head necrosis and the right side recovered smoothly after operation. However, joint movement was restricted for the left hip and the pain was significant. An arthroscopic examination was performed 1 month after the operation and did not identify any problems such as intraarticular incular infection or articular surface of the femoral head was protruded by the tip of the fibula. The symptoms were alleviated after removing the osteophytes at the rim of the acetabulum. The Harris score was 62.4±13.6 before operation, and 84.5±4.5 at the last time of followed-up after operation. The difference in Harris scores was statisticly significant (P<0.05). Conclusion With the assistance of an orthopaedic robot system, the guide pin can be accurately positioned, thereby allowing the tip of the fibula to be inserted into the optimal anatomical position and maximising its mechanical efficacy. In theory, it is the best choice for performing fibular bone transplantation in ANFH. And the early effect of treatment is good. Key words: Avascular necrosis of femoral head; Orthopaedic robot; Fibula grafting; Microsurgical technique

Repair of composite tissue defect of lower extremity with free fibula composite tissue flaps assisted by 3D-CT angiography

Objective To investigate the clinical efficacy of free fibula composite tissue flap transplantation for repair of composite tissue defects of lower extremity assisted by three-dimensional CT angiography (3D-CTA). Methods From May 2013 to February 2018, 16 patients with severe lower extremity trauma were treated with fibular composite tissue flaps. The course, distribution and vascular variation of peroneal artery were determined by preoperative 3D-CTA. The survival and appearance of the flaps were observed after the operation. X-ray examination was performed 6 weeks, 3 months, 6 months and 1 year after the operation to observe the healing of the fracture and evaluate the functional recovery of the affected limbs. Results The anatomical structure of composite tissue flaps can be clearly displayed by 3D-CTA. The findings during operation were basically consistent with the preoperative design. The follow-up period ranged from 6 to 24 months, with an average of 13 months. All the flaps survived and the fracture healed well. According to Enneking system score the average point was 22. The lower extremity function recovered to 73% of that of the normal side. Ankle joint activity was normal in donor area, and there was no abnormal sensation in common peroneal nerve innervation area. Conclusion At the same time of repairing bone defects with free composite tissue flaps, the combined skin flaps can repair soft tissue defects, which effectively solve the problem of wound coverage and restore the function of affected limbs. The patients are satisfied with the prognosis. Key words: Lower extremity; Treatment outcome; Three-dimensional CT angiography; Fibula composite tissue flap

Clinical outcomes of modified reattachment of superior peroneal retinaculum for recurrent peroneal tendon dislocation

Objective To investigate clinical outcomes of modified reattachment of superior peroneal retinaculum (SPR) for patients with recurrent peroneal tendon dislocation. Methods A total of 24 cases with recurrent peroneal tendon dislocation from December 2012 to June 2017 were treated with modified reattachment of SPR. There were 20 males and 4 females. The average age was 24.9±9.3 years (14-48 years). The average BMI was 23.18±3.50 kg/m2 (15.8-32.2 kg/m2). A 4-5 cm incision was made along the lateral margin of the fibula and curved distally around the fibular tip in line with the peroneal excursion. The superior peroneal retinaculum, peroneus longus and peroneus brevis were exposed. The periosteum and SPR were stripped from the fibula. The false pouch was formed. Two suture anchors were inserted into the postero-lateral ridge of the lateral malleolus without damaging the cartilaginous ridge, after which the SPR was reattached to the lateral malleolus with the anchored suture. The inner layer of the false pouch was incised, while the outer layer (periosteum) was sutured with the SPR in a pants-over-vest style. The following items, including American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS), rate of return to previous sports level, time to return to sports activity, complication, and patients satisfaction were evaluated preoperatively and at the final follow-up. Results The average operation duration was 36.1±8.8 min (20-51 min). The blood loss was 1-10 ml, average 4.1±2.7 ml. The follow-up was carried out in 22 cases for mean 33.9±15.7 months (13-61 months). AOFAS score was improved from 77.8±7.8 points to 95.5±4.3 points significantly (t=-11.89, P<0.001). VAS score was reduced from 4.2±2.4 to 0.3±0.8 significantly (t=7.69, P<0.001). Mean duration return to sports activity was 5.0±1.9 months (3-10 months). A total of 20 patients (91%) returned to their previous sports level. Only one patient (5%) was found with limitation of range of motion, while two patients (9%) reported pain at the scar site without recurrence. The satisfaction rate was 91%. Conclusion Clinical outcomes of modified reattachment of SPR for patients with recurrent peroneal tendon dislocation was safe and effective. Key words: Tendinopathy; Dislocations; Wounds and injuries; Reconstructive surgical procedures

Free cutaneous fibular flap combined with antibiotic-loaded artificial bone graft for the treatment of antibrachial osteomyelitis of Cierny-Mader type IV

Objective To investigate the effect and application value of transplantation of the free cutaneous fibular flap combined with antibiotic-loaded calcium sulfate artificial bone graft for the treatment of antibrachial chronic osteomyelitis of Cierny-Mader type IV. Methods From August, 2013 to May, 2017, 12 cases of ulna or(and) radius chronic osteomyelitis of Cierny-Mader type IV were treated by transplantation of the free cutaneous fibular flap combined with antibiotic-loaded calcium sulfate artificial bone graft. There were 7 males and 5 females, with an average age of 36.3 (21-47) years. Pure ulnar osteomyelitis in 7 cases, radius osteomyelitis in 4 cases, and both ulnar and radius osteomyelitis in 1 case. The average range of osteomyelitis lesions was 6.3 (3.0-9.0) cm. The area of soft tissue defect (including bone scar) ranged from 8.0 cm×2.0 cm to 15.0 cm×5.0 cm. The area of the flap was 10.0 cm×3.5cm-17.0 cm×7.0 cm. The average length of the fibular flap was 8.8 (5.0-12.0) cm. Locking plate internal fixation was used in 9 cases, external fixator in 2 cases, and plate combined with external fixator in 1 case. Vancomycin/gentamicin, an effective component of calcium sulfate artificial bone, averaged 0.64 g/102.7 kU (0.4 g/64 kU-1.0 g/160 kU). Routine postoperative treatment. And monthly outpatient review in the first half year after operation, and outpatient review every 3 months after half a year. One year after operation, comprehensive evaluation of elbow, forearm and wrist function with Mayo Elbow Function Index, Anderson Forearm Double Fracture Evaluation System and Cooney Wrist Function Score. Results Vascular crisis occurred in 1 case after operation, prompt surgical exploration, and ultimately all flaps survived completely. The donor sites healed well in all cases. The lower extremity functions of donor sites had no change compared with that before operation. Followed-up of an average of 22.7 months, there were 2 cases who had sensory disturbance in the ulnar nerve innervation area and returned to normal 3 months after operation. The fibular flaps healed satisfactorily with an average healing time of 4.7 (3-6) months. No calcium sulphate artificial bone granules were seen on X-ray at 3 months after operation. One year after operation, bone healing, forearm appearance and wrist function recovered well, but elbow and forearm motor function recovered unsatisfactorily. Conclusion On the basis of mastering the applied anatomy and vascular anastomosis techniques of microsurgery, this method of transplantation of the free cutaneous fibular flap combined with antibiotic-loaded calcium sulfate artificial bone graft for the treatment of antibrachial chronic osteomyelitis of Cierny-Mader type IV has achieved satisfactory results. The recipient area is beautiful. The bone healing is reliable. And it has little influence on the recipient area and the donor area. It is worthy of clinical application. Key words: Fibular flap; Osteomyelitis; Forearm; Artificial bone; Transplantation; Microsurgical technique

Imaging characteristics of irreducible tibial shaft fractures and their clinical significance

Objective To propose a concept of irreducible tibial shaft fractures and to discuss their imaging characteristics and clinical significance. Methods A retrospective study was performed in 21 patients with tibial shaft fracture who had received intraoperative intramedullary nailing after limited open reduction at Department of Orthopaedics, The Second Affiliated Hospital to Anhui Medical University from November 2013 to June 2018. They were 14 males and 7 females, aged from 2l to 66 years (average, 34.9 years). There were 15 left and 6 right sides. Firstly, closed reduction was performed followed by traction, folding and rotation, but repeated attempts failed to achieve smooth reduction or insertion of guide wire. Next, local limited open reduction had to be performed for intramedullary nailing. The X-ray and CT images of the tibial fractures were collected to analyze their imaging characteristics. The imaging manifestations were characterized into 4 types: single-segment type with intact fibula, multiple-segment type, interlocking type where the distal and proximal ends interlock commonly seen in short spiral and short oblique fractures, and incarceration type where the fracture interspace is blocked by a bone fragment. The therapeutic efficacy was evaluated at the final follow-up by knee scores of The Hospital for Special Surgery (HSS) and Kofoed ankle scores. Results Of the 21 patients, 2 were single-segment type, 4 multiple-segment type, 13 interlocking type and 2 incarceration type. They were followed up for 7 to 50 months (average, 22.7 months). The fractures united after 5 to 16 months (average, 7.3 months). Postoperative knee pain was observed in 3 cases and delayed fracture union in 2. Osteomyelitis, superficial wound infection, implant breakage or malunion occurred in none of the patients. The therapeutic efficacy evaluated at the final follow-up by HSS knee scores and Kofoed ankle scores revealed 15 excellent, 4 good and 2 fair cases, yielding an excellent to good rate of 90.5%. Conclusion The concept of irreducible tibial shaft fractures may lead to preoperative awareness on the part of the surgeons so that ineffective repeated reductions can be spared and the damage to the blood supply to the fracture ends and the operation time can be reduced. Key words: Tibia fracture; Knee joints; Ankle joints; Imaging characteristics; Irreducible

Reoperation strategy of malunited tibial plateau fracture

Objective To explore the revision strategy of the malunited tibial plateau fracture and to analysis the main points of four common revision operations and the clinical effect. Methods From January 2012 to December 2016, 18 patients (5 males and 13 females) aged 35-60 years (average 49.7 years) underwent tibial plateau revision surgery in our hospital were collected. The time from the second revision operation to the first operation was 2-24 months (average 10.4 months). Our revision strategies were as follows: Firstly, to determine whether there is an infection or not. If there was infection, we changed the original internal fixation to external fixator to control infection. Secondly, todetermine whether the patient could suffer re-reduction and internal fixation. If the patient was older (>65 years old) or with severe local bone defect, total knee arthroplasty should be performed. Thirdly, patients were divided into four operation modes according to the tibial plateau fracture malunion type: 1. the original fracture line osteotomy; 2. the tibial tubercle + original fracture line osteotomy; 3. tibial metaphyseal window-rod reduction; 4. the osteotomy of fibula head and original fracture line osteotomy. Results All patients were followed up for 12-30 months (average 16.8 months), and the operation time was 120-300 min (average 185 min). 2 cases were infected before operation and the original internal fixation were removed to instead of external fixator;1 patient underwent total knee arthroplasty; 3 cases were treated with metaphyseal open window-rod reduction and internal fixation; 6 cases were operated with the original fracture line osteotomy and internal fixation; 4 cases were treated with tibial tubercle osteotomy+original fracture line osteotomy and internal fixation; 2 patients underwent fibular head osteotomy+ original fracture line osteotomy and internal fixation. All patients achieved bony union at the last follow-up. The healing time was 3-6 months (mean 3.6 months). The postoperative knee Rasmussen score was 19-29 (average 22.9), compared with average 14.4 points before operation (t=-10.169, P=0.001). The postoperative range of motion of knee joint was 60-110 degrees (mean 94.5 degrees), compared with average 55 degrees before operation (t=-5.773, P=0.001). The post-operative VAS pain score was average 1.1 points, compared with average 4.2 points before operation (t=8.960, P=0.001). Fracture reduction was excellent in 12 cases and good in 5 cases, with the excellent and good rate of 100%. 3 patients still had 2mm collapse on the articular surface, while 3 patients still had mild valgus (less than 5 degrees). There were 2 cases of superficial infection of the wound surface after operation. Conclusion It was difficult to revise the malunion of tibial plateau fracture and it was necessary to make a detailed operation plan before the operation. Satisfactory clinical effects could be obtained for the patients by correct revision strategy. The key to success was the proper revision strategy which was adopted according to the different characteristics of the tibial plateau fracture malunion of the patients. Key words: Tibial fracture; Intra-articular fractures; Osteotomy; Joint deformities, acquired; Reoperation