Fibular Epiphysis Research Articles

Magnetic Resonance Imaging Has Utility in Clinical Decision-Making for Children and Adolescents With Symptomatic Subfibular Ossicles.

We performed a retrospective study of pediatric patients with lateral ankle pain, recurrent sprains, and radiographs showing SOs who had undergone an MRI as part of their diagnostic work-up.We identified 22 patients from the senior author's registry of pediatric patients with lateral ankle injuries. Eleven were girls, and 11 were boys, ages ranging from five to 19 years.Eleven involved the left ankle; 11 involved the right. Positive MRIs showed a high-intensity signal between the SO and the distal fibular epiphysis; negative MRIs had a low-intensity signal. The main outcome measure was operative versus non-operative treatment. Sixteen of the 22 patients had positive MRIs, and six had negative MRIs. Twelve of the 16 patients with positive MRIs had undergone an operation. All six patients with negative MRIs responded to nonoperative management. MRI has utility in clinical decision-making for symptomatic patients with SOs.Patients with negative MRI sequences responded to nonoperative management.Most patients with positive MRI sequences will require surgery to alleviate their symptoms and return to full activities. IV.

Forensic age estimation of the knee by post-mortem DR, CT, and MR imaging: a comparative study

It is believed by many that reference data for age estimation purposes must be imaging-modality specific. A study from our department has however proven otherwise. We therefore found it interesting to investigate this further by looking at the level of agreement between different imaging modalities. The aim of this study was to investigate the level of agreement between the three radiological modalities, computed tomography (CT), magnetic resonance imaging (MRI), and digital radiography (DR), in assessing the ossification of the epiphyses of the knee. A total of 34 deceased individuals of 10–25 years of age, brought in for a medicolegal autopsy at our department, were scanned by CT, MRI, and DR. The ossification stages of the three bones of the right knee, distal femoral, proximal tibial, and proximal fibular epiphysis were assessed using the established combined staging method by Schmeling et al. and Kellinghaus et al. Analysis of the results by Cohen’s weighted kappa showed a good agreement between CT and DR (K = 0.61–0.70), and MRI and DR (K = 0.68–0.79) but only moderate agreement between CT and MRI (K = 0.55–0.57). This leads us to conclude that different radiological images cannot be used interchangeably for age estimation purposes, so reference material needs to be imaging-modality specific. However, to make a more general conclusion research on a larger population is needed.

Supplementary Fibular-guided Growth in Treatment of Late-onset Blount Disease

Purpose: Blount disease is due to an idiopathic defect in the posteromedial proximal tibial physis resulting in increasing bowing of the leg in addition to lateral knee thrust with lateral collateral ligament laxity. Our rationale is that Blount disease has a bony and ligamentous laxity element of the lateral collateral ligament that can be corrected simultaneously through hemiepiphysiodesis of the tibia and epiphysiodesis of proximal fibula physis by cannulated screws. Patients and Methods: This is a retrospective study conducted on 23 limbs with tibia vara treated between 2010 and 2017 followed up for 2 to 6 years. Ages ranged from 9 to 13 years with a late-onset type of Blount disease. We used a percutaneous transphyseal fully threaded screws traversing the proximal tibial lateral hemiepiphysis, and another screw inserted traversing the proximal fibular epiphysis. Results: There was a statistically significant improvement of the radiographic parameters, especially in the form of joint line congruence angle in both supine and standing positions. All patients were clinically and radiographically completely corrected without complications, except 1 patient with a surgical site superficial infection, treated medically. Conclusion: Fibular-guided growth surgery with lateral proximal tibia epiphysiodesis is a minimally invasive technique that improves the corrective power of hemiepyphysiodesis of the posterolateral compartment of the knee. Level of Evidence: Level IV, retrospective case series.

Sexual Dimorphism in the Fibular Extremities of Italians and South Africans of Identified Modern Human Skeletal Collections: A Geometric Morphometric Approach.

Simple SummaryThe extremities of the fibula may reflect differences between males and females, although so far only few studies included this bone for post-cranial sex assessment. Our work explored shape and size variation between sexes in identified skeletal samples comprising different populations from Italy and South Africa and showed that fibular extremities are significantly smaller, with narrower articular surfaces in females than in males. Consistent sex-related differences are revealed in fibular form and size in Italians but not in South Africans. Potential application in forensic and bioarcheological contexts may benefit from the use of this approach.Fibular metric variations have revealed their potential in distinguishing between males and females; however the fibula remains scarcely analyzed in studies of sexual dimorphism. This work aims at investigating sexually dimorphic features in fibular proximal and distal epiphyses through geometric morphometrics methods. A total of 136 left fibulae, from two Italian and one South African identified skeletal collections were virtually acquired through CT and laser scanning and analyzed using geometric morphometric methods. Statistical analyses were performed on shape, form, and size variables. Results show that fibular epiphyses are smaller with narrower articular surfaces in females than in males in both extremities. Relevant sexual differences emerge in fibular form and size for the two Italian samples but not for the South African one, likely for its small sample size. Discriminant analysis on form principal components (PCs) offers accuracy above 80% when the samples are pooled, and reaches accuracy of 80–93% when the Italian samples are considered separately. However, our method on form PCs was not successful for the South African sample (50–53% accuracy), possibly due to the small sample size. These results show relevant morphological variation in relation to fibular form and size, with a degree of accuracy that indicates the utility of the present method for sexing human fibulae in both forensic and bioarchaeological contexts for Italian samples.

Skeletal Maturity Using Knee X-rays: Understanding the Resilience of 7 Radiographic Parameters to Rotational Position.

Recently, a skeletal maturity system using knee radiographs, named the modified Roche-Wainer-Thissen (RWT) system, has been developed using 7 discrete radiographic parameters. While the system has been shown to significantly outperform the Greulich and Pyle atlas, the effect of rotational variation of the knee radiograph on skeletal maturity determinations has not been studied. Normal knee computed tomography scans of 12 male children ages 10 to 16 years and 8 female children ages 8 to 14 years were obtained retrospectively, converted into 3-dimensional reconstructions, and then used to simulate knee radiographs in 5 different rotational positions. Images were graded using the modified RWT system, and 1-way repeated measures analysis of variance was used to compare skeletal age in the patella centered view versus the other positions. We next retrospectively found 85 pediatric patients with both bilateral standing anteroposterior hip to ankles and separate knee radiograph within 6 months of each other. The skeletal maturity values from the 2 different radiographs were compared in 39 males between the ages of 10 and 16 years and 46 females between 8 and 14 years of age using paired t test and Wilcoxon-signed rank test. On the computed tomography scan-based images, there was no statistically significant effect of rotational position on the modified RWT score using repeat measures analysis of variance (P=0.210). Only the width ratio of the tibial epiphysis and metaphysis and the width ratio of the fibular epiphysis and metaphysis were statistically different between rotational positions (P<0.05). Comparing clinical full length versus knee radiographs, we found a small difference of 0.069 years which trended towards a statistically significant difference (P=0.009). This retrospective study supports the resilience of the RWT model to rotational variation, reassuring clinicians that bone age estimation can be performed in a slightly rotated knee x-ray within a reasonable margin of error. These results can minimize the number of radiographs needed to assess skeletal maturity limiting radiation exposure and expedite clinical flow. Level-III-diagnostic study.

THE UTILITY OF MRI IN CLINICAL DECISION-MAKING FOR PEDIATRIC ATHLETES WITH SYMPTOMATIC SUBFIBULAR OSSICLES

Background:Pediatric athletes commonly sustain inversion-type ankle fractures.1,2 Approximately 1% will form post-traumatic subfibular ossicles (SO), especially after tip avulsion fractures.3,4 Athletes with SOs can have pain and recurrent sprains.5,6,7 Here we show the utility of magnetic resonance imaging (MRI) in clinical decision-making for athletes with ankle symptoms and the presence of a SO. Our hypothesis is that MRI can predict which athletes have a stable SO and will respond to non-operative management, and which athletes have an unstable SO and will need surgery.Methods:We performed an IRB approved retrospective cohort study. Children were eligible from our practices if (1) they had radiographic evidence of a SO, (2) they had symptoms of pain and recurrent sprains, and (3) they had undergone MRI during their clinical evaluation. We identified 19 eligible children (20 ankles;) eight girls and eleven boys, ages 5–19 years. Nine involved the left ankle; 11 the right ankle. Most frequent sport was soccer (12/16) followed by basketball (3/14.) From the radiograph we determined ossicle size and location. MRI images were considered positive if fluid-sensitive sequences showed a high-intensity signal between the SO and the fibular epiphysis. Main outcome was treatment (non-surgical or surgical) relative to the MRI findings.Results:Size shape and location:Size and shape were variable. Width ranged from 2 – 10.4 mm and length from 4 – 13.5 mm. Concerning location all were in the distal 1/3 pf the epiphysis. Six were anterior and 14 were anterior-inferior to the fibular tip.MRI findings:Sixteen of the 20 ankles (80%) had positive MRI findings (figure 1), and 4 had negative findings (figure 2). The ATFL attached directly to the fragment in 11 of the 16 MRI positive ankles.Clinical decision making:All athletes with negative MRI findings responded to non-operatively management. Ten of the 16 ankles with positive MRIs have had surgery. Eight had excision of the ossicle and two had internal fixation based on the size of the ossicle. Surgical findings confirmed attachment of the ATFL to the fragment (figure 3.) Six athletes with positive MRIs continue to be under observation.ConclusionsThe results support our hypothesis that MRI has predictive value in clinical decision-making for symptomatic athletes with a SO. When fluid-sensitive MRI sequences show high signal intensity between the ossicle and the fibular epiphysis, and when the ATFL attaches to the ossicle, the athlete has a poor prognosis for non-operative management.Figure 1.Seventeen-year-old with positive MRI who had internal fixation of the fragmentFigure 2.Note direct attachment of the ATFL to the mobile SO.

PO 18191 - Congenital distal tibiofibular diastasis

Introduction: Congenital distal tibiofibular diastasis is an extremely rare entity of unknown etiology that compromises the feet and ankles with different degrees of deformity, although in general, the feet show equinovarus deformity, and the talus is proximally dislocated due to the separation of the distal tibial and fibular epiphyses. There are few reports of this disorder in the literature, and most describe cases that ultimately lead to limb amputation. We present the cases of 2 patients treated from birth to skeletal maturity. Methods: Two female patients with clubfoot at birth were diagnosed with congenital distal tibiofibular diastasis. One of them had the deformity of the right foot, and the other had deformity of both limbs. Both patients underwent early distal tibiofibular arthrodesis and serial stretching of the compromised feet and legs. Results: After 20 years of clinical follow-up and after reaching skeletal maturity, both patients had plantigrade feet without significant shortening of the lower limbs or pain, and both performed activities of daily living without restrictions, wearing conventional shoes. Conclusion: Early distal tibiofibular arthrodesis followed by limb stretching was effective for treating congenital distal tibiofibular diastasis and is a good alternative to amputation, which is indicated in the literature.

Radiographic study of the development of the pelvis and hip and the femorotibial joints in domestic cats.

The aims of the present study were to monitor, by radiographic examination, the skeletal development of the pelvis and the femorotibial joints of the domestic cat from the first week of life until the closing of the growth plates. Radiographic examinations were collected from 15 domestic cats at weekly intervals during the first month and every 2 weeks from the second to the fourth month of age. After that, examinations were performed monthly until the age of 18 months. The ischiopubic growth plate closed at 2 months of age, followed by the fusion of the iliopubic, ilioischial, proximal femoral, greater trochanter and proximal fibular growth plates. The distal femur and proximal tibial growth plates were the last to close, with fusion occurring at 18 months. The mean time to closure of the iliopubic, ilioischial and distal femoral growth plates was shorter in females. The ossification centers first appeared, in ascending order, beginning with the lesser trochanter, followed by the greater trochanter, proximal fibular epiphysis, tibial tuberosity, patella, ischial tuberosity and lateral sesamoid of the popliteus muscle. The complete closure of the growth plates of domestic cats occurs at approximately 18 months of age. Skeletal maturation at approximately 18 months of age is an important parameter to be considered in radiographic evaluation of certain skeletal changes, evolution of fractures and nutritional imbalance.

THE NATURAL HISTORY OF TYPE VII ALL INTRA-EPIPHYSEAL FRACTURES OF THE LATERAL MALLEOLUS

Background: Inversion-type ankle injuries are common in pediatric athletes, often resulting in lateral malleolar fractures (1). Ogden described the Type VII lateral malleolar physeal fracture as an injury in which the fracture line is totally within the secondary ossification center of the distal fibular epiphysis (2). The purpose of this paper is to report on the outcomes of 31 children participating in various types of sports activities who had sustained a Type VII fracture of the lateral malleolus. Methods: Here we report the results of an IRB approved prospective (longitudinal) cohort study carried out at a tertiary care pediatric hospital from March 2012 to December 2017. Eligible patients were those with a type VII (all epiphyseal) fracture of the lateral malleolus, either treated initially or seen in follow-up by the senior author. Exclusion criteria included those patients with all other lateral malleolar injuries and those with negative radiographs. Thirty-one children were enrolled during the study interval. Type VII fractures were classified as either transverse, oblique, or tip avulsion, depending on the trajectory and location of the fracture line within the secondary center of ossification of the lateral malleolus. We recorded the following demographic data: sex of the patient, age at the time of injury, mechanism of injury, sport involved, weight bearing status at the time of injury, treatment of the injury, and time from injury to release to sports activity. Children were permitted to return to sports when they had no discomfort on palpation and an ankle range of motion was equal to the uninvolved side. The primary outcome focus was radiographic status of the fracture at the time of the last clinical evaluation. Results: Thirty-one children with a Type VII fracture of the lateral malleolus were enrolled during the study interval. There were 8 girls and 23 boys. The average age at the time of injury was 107 months (˜9 years.) All the children had sustained a supination inversion-type injury while participating in a full spectrum of sports activities. Twenty-five children were initially unable to bear weight, and 6 could walk but with a limp. Twenty-six children were treated with a weight-bearing cast and crutches, and five of those who could bear weight were treated with a cast boot. Four fractures were oblique, 8 were transverse, and 19 were tip avulsions. All the children were asymptomatic and had a negative drawer test when cleared for sports participation at an average time of 3.5 months (range 2.5 to 4) after injury. Eighteen children had radiographs showing uneventful healing of the fractures (Figure 1) when released to full activity, but 13 (31%) healed with formation of a discrete os subfibulare (Figure 2.) The 18 fractures that healed uneventfully were located above the distal third of the fibular epiphysis. All of the 13 that healed with an os subfibulare were located either at the distal tip of the fibula (4) or at the anterior distal aspect of the tip (9) corresponding to the area of attachment of the ATFL. Conclusions: All of children sustaining a Type VII fracture of the lateral malleolus were able to return to full sports activities. Eighteen of the 31 Type VII fractures (58%) healed uneventfully. However, 13 (42%), healed with the formation of an os subfibulare. Since the presence of an os subfibulare has been associated with recurrent ankle instability and pain (3), it may be prudent to observe and even recommend ankle rehabilitation exercises for these children to help prevent long-term problems. [Figure: see text][Figure: see text] Su AW, Larson AN. Pediatric Ankle Fractures: Concepts and Treatment Principles. Foot Ankle Clin. 2015;20(4):705-719.26589088. Ogden JA. Injury to the growth mechanisms of the immature skeleton. Skeletal Radiol. 1981;6(4):237-253.7292021. Pill SG, Hatch M, Linton JM, Davidson RS. J Bone Joint Surg Am. 2013;95: e115(1-6) d http://dx.doi.org/10.2106/JBJS.L.00847 .

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

Pediatric ankle injuries are common, giving rise to ∼17% of all physeal injuries. An os subfibulare in a child with an ankle sprain may be confused with a type VII transepiphyseal fracture. Here, we evaluate the clinical and radiographic features of type VII transepiphyseal fractures to those of os subfibulare presenting with acute ankle trauma with the hypothesis that radiographs are necessary for final diagnosis and neither clinical history nor examination would be diagnostic. We performed an internal review board-approved, retrospective chart review of patients identified with a traumatic os subfibulare or type VII ankle fracture over an 18-month period. Charts were reviewed for demographics, mechanism, and clinical findings on initial presentation. Radiographic measurements of the distal fibular fragment as well as epiphysis were made on presenting ankle series radiographs. A total of 23 patients were identified. Eleven patients had a traumatic type VII ankle fracture and 12 had trauma associated with an os subfibulare on initial radiographs. The history and clinical presentations were similar and were nondiagnostic. The ratio of the width of the fibula at its largest point on the anterior posterior view to the width of the fibular fragment was significantly larger in the type VII ankle fractures (P=0.05). All os subfibulare were located within the inferior third of the epiphysis, whereas all type VII fractures were either at the equator or within the middle third of the fibular epiphysis. Radiographs, not clinical presentation, can differentiate an os subfibulare from a type VII transepiphyseal fracture. Children with type VII fractures have a long, irregular fracture line within the middle third of the distal fibular epiphysis. Those with an ankle sprain and os subfibulare have a smooth-edged ossicle of relatively short length located within the inferior pole of the epiphysis. Furthermore, the radiographic width of the fragment in the type VII fractures is significantly larger in width than the os subfibulare. Level II.

Vascularized fibular epiphyseal transfer for proximal humeral reconstruction in children with a primary sarcoma of bone.

Preserving growth following limb-salvage surgery of the upper limb in children remains a challenge. Vascularized autografts may provide rapid biological incorporation with the potential for growth and longevity. In this study, we aimed to describe the outcomes following proximal humeral reconstruction with a vascularized fibular epiphyseal transfer in children with a primary sarcoma of bone. We also aimed to quantify the hypertrophy of the graft and the annual growth, and to determine the functional outcomes of the neoglenofibular joint. We retrospectively analyzed 11 patients who underwent this procedure for a primary bone tumour of the proximal humerus between 2004 and 2015. Six had Ewing's sarcoma and five had osteosarcoma. Their mean age at the time of surgery was five years (two to eight). The mean follow-up was 5.2 years (1 to 12.2). The overall survival at five and ten years was 91% (confidence interval (CI) 95% 75% to 100%). At the time of the final review, ten patients were alive. One with local recurrence and metastasis died one-year post-operatively. Complications included seven fractures, four transient nerve palsies, and two patients developed avascular necrosis of the graft. All the fractures presented within the first postoperative year and united with conservative management. One patient had two further operations for a slipped fibular epiphysis of the autograft, and a hemi-epiphysiodesis for lateral tibial physeal arrest. Hypertrophy and axial growth were evident in nine patients who did not have avascular necrosis of the graft. The mean hypertrophy index was 65% (55% to 82%), and the mean growth was 4.6 mm per annum (2.4 to 7.6) in these nine grafts. At final follow-up, the mean modified functional Musculoskeletal Tumour Society score was 77% (63% to 83%) and the mean Toronto Extremity Salvage Score (TESS) was 84% (65% to 94%). Vascularized fibular epiphyseal transfer preserves function and growth in young children following excision of the proximal humerus for a malignant bone tumour. Function compares favourably to other limb-salvage procedures in children. Longer term analysis is required to determine if this technique proves to be durable into adulthood. Cite this article: Bone Joint J 2018;100-B:535-41.

Proximal femur reconstruction using a vascularized fibular epiphysis within a cadaveric femoral allograft in a child with Ewing sarcoma: a case report

Periarticular reconstruction of appendicular bones in skeletally immature patients after tumor resection is a surgical challenge that requires a multidisciplinary approach. The authors present a case of Ewing sarcoma of the proximal femur in an 8-year old girl treated with wide resection of the primary tumor and reconstruction using a vascularized fibula epiphyseal autograft within a cadaveric femoral allograft. The native femoral head was preserved to restore articular anatomy. Postoperative course was without complications. This report demonstrates the use of a vascularized fibula autograft within a cadaveric femoral allograft to optimize growth potential and joint durability in a pediatric patient.

Combination of vascularized fibular head epiphysis and superficial peroneal neurovascular reverse flap repair defects of bone and skin in lateral malleolus in children

Objective To explore the clinical effect of combination of vascularized fibular head epiphysis and peroneal neurovascular reverse flap repair defects of bone and skin in lateral malleolus in children. Methods Eight children with defects of bone and skin in lateral malleolus were recruited from May, 2009 to September, 2014. The age of children was ranging from 4 to 12 years old. Four children were injured by wheel twist, 2 children were injured by traffic accident, 1 was injured by machinery, and 1 was crashed with heavy object. The size of soft-tissue defect was ranging from 3 cm × 5 cm to 7 cm × 9 cm. The flap and bone healing along with ankle joint function scoring were evaluated. Patients were reviewed every 4 to 6 weeks during one year after their surgery, and they were reviewed every 6 months one year later. Results Secondary repair were conducted in all children. The curative effect got well after follow up for 6 months to 2 years(mean, 12 months). The flap and fibular head epiphysis were well developed. The ossification of fibular head epiphysis did not found. According to American Orthopaedic Foot and Ankle Society (AOFAS) ankle function evaluation criteria, the results were excellent in 5 cases, good in 2 cases and poor in 1 at 10 months after operation. The shape and function of ankle joint were good, with one exception. The average motion degree of ankle joint was (68±5.12) °. Conclusion Combination of vascularized fibular head epiphysis and peroneal neurovascular reverse flap repair defects of bone and skin in lateral malleolus in children is effective. Key words: Lateral malleolus injury; Fibular head; Superficial peroneal neurovascular reverse flap; Children

Skeletal assessment and secular changes in knee development: a radiographic approach.

The purpose of this study is to conduct an analysis of ossification patterns in the distal femoral, proximal tibial, and proximal fibular epiphyses, and the patella. The results generated from this analysis will be compared with previous standards published by Elgenmark () and Garn et al. () to determine if clinical and skeletal age assessment standards should be updated for contemporary Americans. Using the Pediatric Radiology Interactive Atlas (Patricia), a total of 1,317 epiphyses were scored for presence or absence from radiographs of 1,056 white individuals born in or after 1990. Statistical modeling of epiphyseal appearance was conducted for all major percentiles, including the 5th and 95th percentiles through logistic regression. Compared with Elgenmark () and Garn et al. (), our data suggest that the distal femoral and proximal tibial epiphyses show overall earlier ossification, while the proximal fibular epiphysis shows later ossification. When examining the pooled sex 50th percentile for our data, we found that ossification timing differences are 1.2 weeks earlier in the distal femoral epiphysis, 2.1 weeks earlier in the proximal tibial epiphysis, and 1.4 years later in the proximal fibular epiphysis. The epiphyses that appear early in life, for example the distal femoral epiphysis, require gestational age information to accurately estimate appearance times. There are considerable differences between the ossification timing patterns presented in this study and those of previous standards, which did not include gestational ages. Several factors may explain the observed differences in the epiphyses of the knee including: the availability of gestational age information, the analysis of longitudinal versus cross-sectional data, differences in socioeconomic status and prenatal care, and secular change. KEYWORDS age estimation, growth standards, ossification, skeletal maturation, subadult/juvenile growth.

Molecular development of fibular reduction in birds and its evolution from dinosaurs.

Birds have a distally reduced, splinter‐like fibula that is shorter than the tibia. In embryonic development, both skeletal elements start out with similar lengths. We examined molecular markers of cartilage differentiation in chicken embryos. We found that the distal end of the fibula expresses Indian hedgehog (IHH), undergoing terminal cartilage differentiation, and almost no Parathyroid‐related protein (PTHrP), which is required to develop a proliferative growth plate (epiphysis). Reduction of the distal fibula may be influenced earlier by its close contact with the nearby fibulare, which strongly expresses PTHrP. The epiphysis‐like fibulare however then separates from the fibula, which fails to maintain a distal growth plate, and fibular reduction ensues. Experimental downregulation of IHH signaling at a postmorphogenetic stage led to a tibia and fibula of equal length: The fibula is longer than in controls and fused to the fibulare, whereas the tibia is shorter and bent. We propose that the presence of a distal fibular epiphysis may constrain greater growth in the tibia. Accordingly, many Mesozoic birds show a fibula that has lost its distal epiphysis, but remains almost as long as the tibia, suggesting that loss of the fibulare preceded and allowed subsequent evolution of great fibulo–tibial disparity.

Age estimation from proximal end of Fibular epiphysis in Adolescent Boys: A Radiological study

Evaluation of age of an individual using various methods is required for medico legal purposes in both civil and criminal matters. There is no statistical data to establish variation in epiphyseal fusion in population in population of central India. This significant oversight can lead to exclusion of persons of interest in a forensic investigation.

Foot centralization for tibial hemimelia.

Nineteen foot centralizations were performed in 14 patients with Jones type I and II tibial hemimelia. All feet showed equinovarus deformity and were treated by foot centralization by means of calcaneofibular arthrodesis. The average age of patients at the time of surgery was 1.3 years (range 0.4-3.8 years). The average follow-up postoperative period was 10.2 years (range 2.2-22.9). At the time of the final follow-up, four of the operated feet were plantigrade without secondary surgery. The remaining 15 limbs, however, required secondary surgery to treat postoperative early loss of correction and/or recurrent foot deformities such as equinus, varus and adduction, in addition to talipes calcaneal deformities, and fibular angular deformity at the fibular shortening osteotomy site. The deformities were treated either by repeat foot centralization, or fibular or calcaneal osteotomy. Careful observation for recurrence of the deformity is necessary until the distal fibular epiphysis closes, and the cartilagenous distal fibular end and calcaneus finally achieve ankyloses.

Isolated fracture of proximal fibular epiphysis

Proximal fibular epiphysis is the least injured long bone epiphysis. There are only seven cases reported in the literature as case studies. All other cases are described as fractures associated with tibial fractures. We present a unique case of isolated fracture of proximal fibular epiphysis in a 16-year-old boy, sustained during soccer play.

Vascular basis of free transfer of proximal epiphysis and diaphysis of fibula: an anatomical study

Transfer of proximal epiphysis and diaphysis of fibula is a treatment of bony defects in children. Although there are few reports of this procedure, different arteries or combination of arteries have been used as supplying pedicle and the reported success rates are different. This is an anatomical study to clarify the vascular anatomy of this region. A total of 16 fresh cadavers were enrolled. An incision was made in the popliteal fossa to find the popliteal artery, which was dissected distally and the lateral inferior genicular artery, anterior tibial artery, tibioperoneal trunk and its bifurcation were located. In eight subjects popliteal artery was cannulated above the level of femoral condyles and injected by latex. In the next eight cases the same material was injected in the anterior tibial artery. The next steps of dissection were done by 4.3-loupe magnification. Lateral inferior genicular artery was dissected from its origin to the fibular head and branches of anterior tibial artery were also dissected. In three specimens, the fibula and its supplying arteries were removed after dissection and put in diluted hydrochloric acid to be opened for studying the medullary vasculature. This study confirms the existence of not only periosteal but also intramedullary anastomosis between artery of the neck and peroneal artery. Artery of the neck was usually a branch of anterior tibial artery and in 24% of the subjects a branch of popliteal artery. In the latter condition the pedicle would be too short to permit the surgeon to do this surgery. Therefore preoperative angiography is mandatory to identify the origin of the artery of the neck. According to these dissections, a classification system of arterial supply of proximal fibular epiphysis is introduced in this article.

Free vascularized fibula and reconstruction of long bones in the child—Our evolution

The aim is to show our evolution for reconstruction of long bones in the child with free vascularized fibula after tumoral resection. Between 1990 and 2004, 78 children were operated on for sarcoma of long bones and one girl with congenital pseudarthrosis. The main applications are illustrated: U-shaped fibular transplant, fibular epiphysis with growth plate and diaphysis transfer, fibular graft associated to massive allograft. Follow-up of the children was performed by clinical examination and standard X-ray. No post operative death occurred. Many benign complications for femoral reconstruction were observed. So our recent evolution is to use vascularized fibula associated with massive allograft; but resorption of allograft was observed 3 years later. Vascularized fibula for reconstruction of long bones is the ideal material. The result is definitive. The future for femur is perhaps vascularized fibula associated with osseous substitute.