Fibular Length Research Articles

An anthropometric survey of US pre-term and full-term neonates

Background: Anthropometric data prove valuable for screening and monitoring various medical conditions. In young infants, however, only weight, length and head circumference are represented in publicly accessible databases.Aim: To characterise length and circumferential measures in pre-term and full-term infants up to 90 days post-natal.Subjects and methods: In eight US medical centres, trained raters recorded humeral, ulnar, femoral, tibial and fibular lengths along with mid-upper arm, mid-thigh, chest, abdominal and neck circumference. Data were pooled by post-menstrual age into 1-week intervals and population curves created using the lambda, mu and sigma (LMS) method. Goodness-of-fit was assessed by examining de-trended quantile-quantile plots, Q statistics and fitted centiles overlaid on empirical centiles.Results: In total, 2097 infants were enrolled in this study with a mean ± SD gestational age and post-natal age of 37.1 ± 3.3 weeks and 27.3 ± 25.3 days, respectively. A re-scale option was used to describe all curves. The resultant models reliably characterised anthropometric measures from 33–52 weeks PMA, with less certainty at the extremes (27–55 weeks).Conclusion: The population curves generated under this investigation expand existing reference data on a comprehensive set of anthropometric traits in infants through the first 90 days post-natal.

Significant Increases in Sagittal Translation and Transverse Rotation of the Fibula Occur with Sequential Disruption of the Syndesmosis

This study demonstrates that significant fibular motion occurs with isolated AITFL disruption and only minimally increases with sequential PITFL and IOM transection. Clinical diagnostic protocol should be expanded to evaluate beyond ML translation of the fibula and account for sagittal and rotational displacements as well. Injury to the Anterior inferior tibiofibular ligament (AITFL), Posterior inferior tibiofibular ligament (PITFL) and Interosseus membrane (IOM) predicts residual symptoms in ankle sprains. Limited kinematic knowledge of the tibiofibular joint results in missed diagnosis and poor clinical outcomes. Lateral fibular displacement on radiologic assessment signifies syndesmotic disruption which dictates operative management. Previous studies demonstrated that fibular motion is multiplanar after injury. The purpose of this study is to determine increases in fibular motion with sequential syndesmotic injury and the contribution of the AITFL. Five fresh-frozen human cadaveric tibial plateau-to-toe specimens with a mean age of 58 years (range 38-73 years) were tested using a 6-degree-of-freedom robotic testing system. The tibia and calcaneus were rigidly fixed. The subtalar joint was fused. The full fibular length was maintained and fibular motion was unconstrained. A 5Nm external rotation moment and 5Nm inversion moment were applied to the ankle at 0°, 15°, and 30° plantarflexion and 10° dorsiflexion. The motion of the fibula was tracked by a 3D optical tracking system. Outcome variables included fibular medial-lateral (ML) translation, anterior-posterior (AP) translation, and external rotation (ER) during each max moment and flexion angle in the following conditions: 1) intact ankle, 2) AITFL transected, 3) PITFL and IOM transected. Statistical analysis included an ANOVA with a post-hoc Tukey analysis to compare the changes in fibular motion between the intact and injury models at each applied moment and flexion angle (*p<0.05). The only significant differences in fibular motion were during the 5Nm inversion moment. The posterior translation of the fibula was significantly greater with AITFL injury compared to the intact ankle at 15° and 30° plantarflexion. Significant increases in posterior translation between the intact ankle and AITFL, PITFL, and IOM injury exists at 0°, 15°, and 30° plantarflexion. No significant motion differences were observed between the AITFL injury and combined injury at any condition. When comparing the intact ankle and combined injury, significant increases in ER exist at 0° and 30° plantarflexion and 10° dorsiflexion. The only significant difference in ER between the intact ankle and AITFL injury exists at 0° plantarflexion. The data from this study showed that transecting the AITFL resulted in the largest increases fibular motion with only minimal further fibular displacement with transection of the PITFL and IOM. Total syndesmotic disruption creates significant fibular motion compared to the intact ankle but, a significant portion of the displacement of the fibula already occurs after isolated AITFL injury. A previous study demonstrated no measureable fibular ML displacement with syndesmosis injury but this was not supported by the current findings. This study utilized a novel setup with unconstrained motion in a full length, intact fibula. Basing clinical syndesmotic stability on ML translation alone could underestimate sagittal and rotation instability in AITFL injuries. Evaluating fibular AP translation and ER are not part of current standard diagnostic protocols. Physicians may consider more aggressive treatment of isolated AITFL injuries.

Morphology of the Incisura Fibularis at the Distal Tibiofibular Syndesmosis in the Japanese Population

The morphology of the distal tibiofibular syndesmosis can determine the pathology and mechanism of syndesmotic injury. The present study assessed measurements obtained from computed tomography (CT) images of the normal distal tibiofibular syndesmosis in Japanese subjects. CT scans of 120 right feet with a normal distal tibiofibular syndesmosis obtained from January 2009 to December 2016 were retrospectively assessed at the level 10 mm proximal to the tibial plafond. The incisura fibularis was considered concave when its depth was ≥4 mm and shallow when its depth was <4 mm. The depth of the incisura fibularis, anterior tibiofibular distance (TFD), posterior TFD, and longitudinal/transverse length of the distal fibula were measured. The incisura fibularis was concave in 64.2% of the feet and shallow in 35.8%. The mean anterior TFD was 2.2 ± 0.8 mm (2.4 ± 0.8 mm in males; 2.1 ± 0.8 mm in females; 2.1 ± 0.8 mm for concave; 2.2 ± 0.9 mm for shallow). The mean posterior TFD was 5.9 ± 1.6 mm (6.7 ± 2.1 in males; 5.7 ± 1.3 mm in females; 5.5 ± 1.3 mm for concave; 6.5 ± 1.9 mm for shallow). The mean longitudinal/transverse length of the distal fibula at the level of the syndesmosis was 1.2 mm (1.3 mm in males; 1.2 mm in females; 1.1 mm for concave; 1.3 mm for shallow). The mean posterior TFD was significantly greater than the mean anterior TFD and was also significantly greater in males than in females. Significant differences were found in the body mass index, posterior TFD, and longitudinal/transverse length of the distal fibula according to whether the incisura fibularis was concave or shallow. The present study has provided measurements of the normal tibiofibular syndesmosis in the Japanese population. These data suggest that the morphology of the syndesmosis varies, especially with respect to whether the incisura fibularis is concave or shallow.

Teratogenic Effects of Chlorantraniliprole on chick embryos (Gallus gallus domesticus)

The present study was designed to assess the teratogenic effects of Chlorantraniliprole on chick embryos (Gallus gallus domesticus). Different doses of commercial Chlorantraniliprole (0.1, 0.5, 1.0 and 1.5µl/1000µl/egg, in four experimental groups B, C, D, and E respectively) were injected into the yolk sac of eggs before incubation. Embryos were recovered at day 12 of incubation. The mortality rate gradually increased from lower to higher doses. A total of twelve morphometric parameters viz., wet body weight, crown rump length, anterior posterior head diameter, eye diameter, beak length, neck length, humor length, radius and ulna length, metacarpus length, femur length, fibula length and metatarsus length were recorded and compared with control group. These quantitative parameters indicated significant (p&gt;0.05) decreases in all treated groups compared to control group. While the qualitative anomalies such as microcephaly, hydrocephaly, edematous swelling, hematoma formation, abnormal body coloration, microphthalmia, deformed beak, agnathia, micromelia, amelia, omphalocele and ectopia cardis were also observed in treated groups as compared to untreated groups. Therefore it is concluded that Chlorantraniliprole has potentially harmful effects on the development of avian embryos even at very low dose concentration. Hence, due to toxicity of this pesticide it can be used with utmost caution.

Radiographic Results of Intramedullary Nails for Lateral Malleolus Fractures

Category: Ankle, Trauma Introduction/Purpose: Plating the lateral malleolus yields predictable patient outcomes and anatomic reductions with an efficient surgical procedure. However, large incisions and prominence result in wound complications in 5% to 16% of patients. Although rudimentary intramedullary fixation has been applied for these fractures for decades, new intramedullary devices have become available with broader indications. These nails have the promise of holding accurate reductions and faster patient rehabilitation with virtually non-existent wound issues due to the minimal incisions required for implantation. The aim of this study was to determine if a new intramedullary nail could provide radiographically sound reductions while reducing wound complications and providing faster rehabilitation in a variety of ankle fracture classifications. Methods: We retrospectively reviewed the x-rays of 40 ankle fracture patients repaired by two surgeons at different institutions from March 2015 through October 2016. Patients were followed for a minimum of six weeks. Radiographs were reviewed for fracture healing, mortise alignment and fibular length (figure 1). The group was comprised of usual fracture patterns SER 2, 3,4, PER, uni bimalleolar and trimalleolar. Most reductions were performed percutaneously, however a small-incision was used to reduce older fractures or those that could not be reduced without direct visualization. Results: All fractures appeared to have complete union and radiographically anatomic reductions. No wound infections presented, and patients experienced reduced pain with early weight-bearing. Conclusion: Modern intramedullary nails can deliver excellent results and provide an important part of a surgeon’s treatment armamentarium for lateral malleolus fractures. The nails are especially valuable for non-compliant patients or those with comorbidities that negatively affect skin healing.

Proximal Tibiofibular Joint Dislocation as a Maissoneuve Equivalent Fracture

Category: Ankle, Trauma Introduction/Purpose: Dislocation of the proximal tibiofibular joint (PTFJ) in association with ankle fracture is an infrequent injury. The mechanism involves a pronation-external rotation injury in which the energy exits through the PTFJ instead of the proximal fibula, like in a Maissoneuve fracture. Early diagnosis and treatment is of paramount importance to avoid complications such as pain, posterolateral knee instability and peroneal nerve injury due to chronic traction by the dislocated fibular head. In addition, an anatomical reduction of the PTFJ is mandatory to restore the fibular length in order to obtain anatomic reduction at the ankle. The objective is to report 3 cases with PTFJ dislocation in association with ankle fracture and to provide a treatment guide based on the management of these patients. Methods: Three cases of PTFJ dislocation in association with ankle fracture, surgically treated in our institution between 2009 and 2016, were retrospectively analyzed. For each case, clinical history at admission, pre and post operative radiographs and computed tomography (CT) were obtained. Clinical follow up time was between 1 and 6 years. Results: Diagnosis of the PTFJ dislocation required a high degree of suspicion. All the patients had subtle radiographic abnormalities at the PTFJ, thus requiring a CT of the knee to confirm the diagnosis. The first surgical step was to perform an open reduction of the PTFJ. Common peroneal nerve was identified and retracted. Reduction was performed with a clamp and for fixation we used one cortical positioning screw from the fibula to the tibia. After the achievement of an anatomic reduction, the second step was to approach the ankle according the specific fracture pattern. Anatomical reduction was obtained in all the patients checked by ankle and knee CT. At final follow up none of the patients had knee pain, and all returned to their activities. Conclusion: The PTFJ dislocation in association with ankle fracture is an infrequent injury and should be considered as a Maissoneuve equivalent fracture in terms of mechanism and diagnosis. A high index of suspicion is needed and the diagnosis is confirmed with a knee CT. As the Essex Lopresti injury of the upper extremity, this type of lesion requires proximal and distal stabilization. Our recommended treatment, based on the good clinical results of our 3 patient, is open reduction and screw fixation of the PTFJ as the first step in order to allow anatomical reduction of the distal injury at the ankle.

Restoration of Tibiofibular Kinematics with a Tricortical Screw or Suture Button Fixation After Syndesmotic Ankle Injuries

Category: Ankle, Sports, Trauma Introduction/Purpose: Anterior inferior tibiofibular ligament (AITFL), Posterior inferior tibiofibular ligament (PITFL) and Interosseous membrane (IOM) disruption is a predictive measure of residual symptoms after ankle injury. In unstable injuries, the syndesmosis is treated operatively with cortical screw fixation or a suture button apparatus. Biomechanical analyses of suture button versus cortical screw fixation methods show contradicting results regarding suture button integrity and maintenance of fixation. The objective of this study is to quantify tibiofibular joint motion in syndesmotic screw and suture button fixation models compared to the intact ankle. Methods: Five fresh-frozen human cadaveric specimens (mean age 58 yrs.; range 38-73 yrs.) were tested using a 6-degree-of- freedom robotic testing system. The tibia and calcaneus were rigidly fixed to the robotic manipulator and the subtalar joint was fused. The full fibular length was maintained and fibular motion was unconstrained. Fibular motion with respect to the tibia was tracked by a 3D optical tracking system. A 5 Nm external rotation moment and 5 Nm inversion moment were applied to the ankle at 0°, 15°, and 30° plantarflexion and 10° dorsiflexion. Outcome variables included fibular medial-lateral (ML) translation, anterior-posterior (AP) translation, and external rotation (ER) in the following states: 1) intact ankle, 2) AITFL transected, 3) PITFL and IOM transected, 4) 3.5 mm cannulated tricortical screw fixation, 5) suture button fixation. An ANOVA with a post-hoc Tukey analysis was performed for statistical analysis (*p&lt;0.05). Results: Significant differences in fibular motion were only during the inversion moment. Fibular posterior translation was significantly higher with complete syndesmosis injury compared to the intact ankle at 0°, 15°, and 30° plantarflexion and the tricortical screw at 15° and 30°. Significantly higher fibular posterior translation was observed with the suture button compared to the intact ankle at 15° and 30 plantarflexion and to the tricortical screw at 15°. ER was significantly increased with complete injury compared to the tricortical screw at 0° and 30° plantarflexion. The suture button demonstrated significantly greater ER at 0° plantarflexion and 10° dorsiflexion compared to the intact ankle. The only significant difference in ML translation exists between the tricortical screw and complete injury at 30° plantarflexion. Conclusion: The suture button did not restore physiologic motion of the syndesmosis. It only restored fibular ML translation. Significant differences in AP translation and ER persisted compared to the intact ankle. The tricortical screw restored fibular motion in all planes. No significant differences were observed compared to the intact ankle. These findings are consistent with previous studies. This study utilized a novel setup to measure unconstrained motion in a full length, intact fibula. Physicians should evaluate AP translation and ER as critical fibular motions when reconstructing the syndesmosis with suture button fixation.

Anterior-Posterior Translation and Axial Rotation of the Fibula are Significantly Increased with Sequential Disruption of the Syndesmosis

Category: Ankle, Sports, Trauma Introduction/Purpose: Injury to the Anterior inferior tibiofibular ligament (AITFL), Posterior inferior tibiofibular ligament (PITFL) and Interosseus membrane (IOM) predicts residual symptoms in ankle sprains. Limited kinematic knowledge of the tibiofibular joint results in missed diagnosis and poor clinical outcomes. Lateral fibular displacement on radiologic assessment signifies syndesmotic disruption which dictates operative management. Previous studies demonstrated that fibular motion is multiplanar after injury. The objective of this study is to determine increases in fibular motion with sequential syndesmotic injury and the contribution of the AITFL. Methods: Five fresh-frozen human cadaveric tibial plateau-to-toe specimens with a mean age of 58 years (range 38-73 years) were tested using a 6-degree-of-freedom robotic testing system. The tibia and calcaneus were rigidly fixed. The subtalar joint was fused. The full fibular length was maintained and fibular motion was unconstrained. A 5 Nm external rotation and 5 Nm inversion moment were applied to the ankle at 0°, 15°, and 30° plantarflexion and 10° dorsiflexion. The motion of the fibula was tracked by a 3D optical tracking system. Outcome variables included fibular medial-lateral (ML) translation, anterior-posterior (AP) translation, and external rotation (ER) during each applied moment and flexion angle in the following conditions: 1) intact ankle, 2) AITFL transected, 3) PITFL and IOM transected. Statistical analysis included an ANOVA with a post-hoc Tukey analysis to compare the changes in fibular motion between the intact and injury models at each applied moment and flexion angle (*p&lt;0.05). Results: The only significant differences in fibular motion were during the 5 Nm inversion moment. The posterior translation of the fibula was significantly greater with AITFL injury compared to the intact ankle at 15° and 30° plantarflexion. Significant increases in posterior translation between the intact ankle and AITFL, PITFL, and IOM injury existed at 0°, 15°, and 30° plantarflexion. No significant motion differences were observed between the AITFL injury and combined injury at any condition. When comparing the intact ankle and combined injury, significant increases in ER existed at 0° and 30° plantarflexion and 10° dorsiflexion. The only significant difference in ER between the intact ankle and AITFL injury existed at 0° plantarflexion. Conclusion: This study showed that transecting the AITFL resulted in the largest increases in fibular motion with only minimal further increases after complete syndesmotic injury. Fibular displacement was primarily in the sagittal plane. This study utilized a novel setup with unconstrained motion in a full length, intact fibula. Measuring ML translation alone could underestimate sagittal and rotational instability of the syndesmosis in AITFL injuries. Evaluating fibular AP translation and ER are not part of current standard diagnostic protocols. Physicians may consider more aggressive treatment of isolated AITFL injuries.

Fibula hook plate as an excellent implant of choice for lateral malleolar fracture

Fractures involving the ankle are one of the most common injuries treated by orthopedic surgeons. The anatomy of the joint makes it very unstable in cases of fractures or ligamentous injuries of the ankle. As fractures of the ankle have been treated with various modes of internal fixation devices, the best possible implant is determined according to the anatomy of the fracture. Various internal fixation devices like interfragmentary screw, reconstruction plate, tubular plate have been used for lateral malleolus fracture. We studied the use of fibula hook plate for lateral malleolus fracture. Total 40 patients were studied and were followed up post-operatively after 3 months, 6 months and 12 months. The fractures were classified according to the Lauge-Hansen classification system. Ankle score for symptom evaluation of ankle fracture by C. Olerud and H. Molander was calculated. Radiological evaluation was done by Kristenson’s criteria. Out of 40 patients, 10 patients had excellent outcome and 19 patients had good outcome. Eight patients showed fair results whereas three patients had poor results. No intra-operative complication was observed. Post-operatively six patients developed skin infection. Anatomical reduction of ankle fractures is very important for normal weight bearing stress. The length of fibula must be maintained for this purpose. Hook plate helps to achieve this by holding the reduction of lateral malleolar fragment.

The Relationships Between Surface Measurements and Underlying Tendon Autograft Length for Upper Extremity Reconstructive Surgery

The availability of tendon grafts is an important consideration for successful upper extremity reconstructive surgery, including flexor or extensor tendon reconstructions, tendon transfers, and ligament reconstructions. Graft selection is based on availability, expendability, ease of harvest, and length. Given variations in patient height and extremity length, existing average values may provide suboptimal insight into actual tendon lengths available. The purpose of this study is, therefore, to pursue a method of estimating available donor tendon lengths based on easily measured anatomical surface landmarks. Thirty cadaveric upper and lower extremity limbs were dissected and the length of commonly harvested tendon grafts including the palmaris longus, extensor indicis proprius, extensor digiti minimi, plantaris, and second long toe extensor was measured. Surface forearm length (from finger tip to cubital fossa) and surface fibular length (from lateral malleolus to fibular head) were also measured. Correlations between surface measurements and underlying tendon lengths were analyzed, and linear models were generated that predicted tendon length as a function of surface measurements. Surface measurements were correlated with underlying tendon length (R= 0.46 - 0.66). Linear models could predict tendon lengths based on surface measurements. A ratio of donor tendon length compared with the limb segment measured was established for each tendon and can be applied to estimate donor tendon length. For the upper extremity tendons, the multipliers for the palmaris longus, extensor indicis proprius, and extensor digiti minimi were 0.51, 0.20, and 0.18, respectively. Lower extremity tendon ratios for the plantaris and extensor digitorum longus were 0.69 and 0.60, respectively. Although length of available donor tendon can be a limiting variable at the time of surgery, surgeons may be better able to estimate underlying tendon lengths using easily obtained superficial measurements. Information obtained from these cadaveric measurements may aid in preoperative planning in hand and upper extremity surgery.

Weber C ankle fractures with tibiofibular diastasis: syndesmosis-only fixation.

ABSTRACTOBJECTIVES: To evaluate syndesmosis-only fixation in Weber C ankle fractures with tibiofibular diastasis and to assess the need for additional fibular fixation.METHODS: Twenty-one patients with Weber C ankle fractures and tibiofibular diastasis were followed for at least 24 months after treatment. In treatment of the Weber C fractures, only a syndesmosis screw was used through a mini open lateral incision if the syndesmosis could be anatomically reduced and fibular length and rotation could be restored. At follow-up, anteroposterior tibiofibular distance, lateral fibular distance, medial mortise distance and fracture healing were compared and patients were clinically evaluated using the Olerud and Molander ankle scale scoring system.RESULTS: The average duration of follow-up was 49 months and the decreases in anteroposterior tibiofibular distance and lateral fibular distance were statistically significant. At the last follow-up the average clinical score was 86. Ankle mortise was reduced at follow-up in all cases except one, which resulted in a late diastasis.CONCLUSIONS: Syndesmosis-only fixation can be an effective method of treating Weber type-C lateral malleolar fractures with syndesmosis disruption in cases where intraoperative fibular length can be restored and anatomical syndesmosis reduction can be achieved. Level of Evidence IV, Case Series.

Free vascularised fibular flap harvesting in children: An analysis of donor-site morbidity

BackgroundThe free vascularised fibular flap (FVFF) is widely used to treat bone defects, although it must be harvested from a healthy site. The objective of this study was to assess clinical morbidity and radiological changes at the FVFF donor site in children. HypothesisDistal fibular stabilisation using a tibial strut decreases the prevalence of valgus ankle deformity. Material and methodThirty-one children managed at two centres between 1994 and 2014 were included. Mean age was 8.9 years (range, 2–14 years) and mean follow-up was 6.6 years (range, 2–21 years). Early and delayed complications were evaluated. ResultsOf the 17 early complications, 82.4% resolved fully within 7 months. Valgus ankle deformity developed in 6 (19.4%) patients. Age-residual fibula index under 16 was not significantly associated with valgus ankle deformity, although the P-value was borderline (P<0.058). Residual distal fibula length did not predict valgus ankle deformity. Three techniques were used for fibular reconstruction: syndesmotic screw, tibial strut, and both. None of these techniques prevented the occurrence of valgus ankle deformity. DiscussionClinical donor-site morbidity after FVFF harvesting, although noticeable, usually resolved promptly. Taken alone, an age-residual fibula index under 16 did not predict valgus ankle deformity. We recommend a distal tibio-fibular quadricortical syndesmotic screw or combined syndesmotic screw-tibial strut fixation to prevent valgus ankle deformity, which is common when a tibial strut is used alone. Level of evidenceIV.

Functional outcome of close Bimalliolar fracture treated by open reduction and internal fixation by various methods: A retrospective study

Background: Ankle injuries gain importance because body weight is transmitted through it and location depends upon the stability of this joint. Unstable displaced and open fractures require open reduction internal fixation. Objectives were retrospective study of functional out come and results of surgical treatment of bi-malleolar fractures and to know the complications of open reduction and internal fixation in bi- malleolar fractures. Methods: The results of retrospective study of 125 patients were studied from January 2009 to January 2015. They were classified according to Lauge Hansens classification and treated according to the AO system. Assessment of the outcome was done using the scoring system of Baird and Jackson which is based on subjective, objective and radiological criteria. Results: Mean follow up was 3.5yr in between January 2009-January 2015. Out of 125 patients evaluated, overall good to excellent results were obtained in 95 (76%) patients. The results were fair in 15 (12%) and poor in 15 (12%) patients. There were no intraoperative complications. The post-operative complication we came across is superficial skin infection in 20 (16%) patients. Interpretation and conclusion: Anatomical reduction is essential in all intra articular fractures, more so if a weight bearing joint like ankle is involved open reduction and internal fixation guarantee high standard of reduction besides eliminating chances of loss of reduction. The fibular length has to be maintained for lateral stability of the ankle. Chances of non-union of medial malleolus interposition of the periosteum and deltoid ligament are avoided. Poor clinical results are found to be associated with unsatisfactory surgical reduction.

Role of autologous non-vascularised intramedullary fibular strut graft in humeral shaft nonunions following failed plating.

Non-union humeral shaft fractures are seen frequently in clinical practice at about 2-10% in conservative management and 30% in surgically operated patients. Osteosynthesis using dynamic compression plate (DCP), intramedullary nailing, locking compression plate (LCP), Ilizarov technique along with bone grafting have been reported previously. In cases of prior failed plate-screw osteosynthesis the resultant osteopenia, cortical defect, bone loss, scalloping around screws and metallosis, make the management of non-union more complicated. Fibular graft as an intramedullary strut is useful in these conditions by increasing screw purchase, union and mechanical stability. This study is a retrospective and prospective follow up of revision plating along with autologous non-vascularised intramedullary fibular strut graft (ANVFG) for humeral non-unions following failed plate osteosynthesis. Seventy eight cases of nonunion humeral shaft fractures were managed in our institute between 2008 and 2015. Of these, 57 cases were failed plate osteosynthesis, in which 15 cases were infected and 42 cases were noninfected. Out of the 78 cases, bone grafting was done in 55 cases. Fibular strut graft was used in 22 patients, of which 4 cases were of primary nonunion with osteoporotic bone. Applying the exclusion criteria of infection and inclusion criteria of failed plate osteosynthesis managed with revision plating using either LCP or DCP and ANVFG, 17 cases were studied. The mean age of the patients was 40.11yrs (range: 26-57yrs). The mean duration of non-union was 4.43yrs (range: 0.5-14yrs). The mean follow-up period was 33.41 months (range: 12-94 months). The average length of fibula was 10.7 cm (range: 6-15cm). Main outcome measurements included bony union by radiographic assessment and pre- and postoperative functional evaluation using the DASH (Disabilities of the Arm, Shoulder and Hand) score. Results: Sixteen out of 17 fractures united following revision plating and fibular strut grafting. Average time taken for union was 3.5 months (range: 3-5 months). Complications included one each of implant failure with bending, transient radial nerve palsy and transient ulnar nerve palsy. No case had infection, graft site morbidity or peroneal nerve palsy. Functional assessment by DASH score improved from 59.14 (range: 43.6-73.21) preoperatively to 23.39 (range: 8.03-34.2) postoperatively (p=0.0003). Conclusion: The results of our study indicate that revision plating along with ANVFG is a reliable option in humeral diaphyseal non-unions with failed plate-screw osteosynthesis providing adequate screw purchase, mechanical stability and high chances of union with good functional outcome.

Use of a Pin Distractor as an Aid for Fixation of Pronation-External Rotation Fibular Fractures.

Restoration of fibular length in pronation and other comminuted ankle fractures is key to good clinical outcomes and is often a challenging aspect of open reduction and internal fixation of the fibula. This article reports the use of a pin distractor to achieve appropriate fibular reduction in otherwise challenging ankle fractures. The authors describe the use of a pin distractor to obtain length and minimize the number of surgical assistants needed for these challenging ankle fractures. The authors find this technique particularly useful with pronation type and subacute ankle fractures. [Orthopedics. 2017; 40(1):e192-e194.].

Realignment Osteotomy in Fibular Malunion

Category: Ankle Introduction/Purpose: The exact incidence of distal fibula malunions after fibular reconstructions is not known, but incidence up to 33% is described in the literature. The most frequent malunions of the fibula are shortening and malrotation, resulting in the widening of the ankle mortise and talar instability. It has been demonstrated that substantial fibular displacement may substantially increase the contact pressures in the ankle joint. Therefore distal fibular malunion is a risk factor for development of posttraumatic ankle osteoarthritis. The objectives of this study were to (1) describe our treatment algorithm and surgical technique in patients with posttraumatic fibula malunions; (2) determine intra- and postoperative complications rates, and (3) to describe mid-term clinical and radiological outcomes and quality of life. Methods: 19 consecutive patients (11 male, 8 female, mean age 42 years, range 19 – 68) with symptomatic fibular malunions were included into this prospective study. The initial injury was Weber B and C fracture in 7 and 12 ankles, respectively. The mean time between the injury and reconstructive surgery was 17 months (range 6 – 101). In all patients a z-shaped osteotomy of the fibula was performed to achieve the appropriate length/rotation of the fibula. Fixation was performed using a plate. If necessary, supramalleolar and inframalleolar deformities were corrected by supramalleolar tibial and calcaneal osteotomies, respectively. Prior to the osteotomies an anterior ankle arthroscopy was performed in all patients. All patients were evaluated pre- and postoperatively (mean follow-up 4.9 years, range 3.2 – 6.7). Radiological outcomes were assessed using standardized weight- bearing radiographs. Clinical outcomes were assessed using visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale, and SF-36 questionnaire. Results: There were no intraoperative complications. In two patients early wound healing problems were observed, and resolved with i.v. antibiotics. Osseous healing was observed in all ankles within 10 weeks after surgery. The length and rotation of the fibula was improved in all patients, according to Weber criteria. All patients experienced significant pain relief (VAS: 6.5 ± 1.1 to 0.9 ± 0.8, P &lt; 0.001) and functional improvement (AOFAS hindfoot scale: 48.4 ± 14.5 to 85.7 ± 7.4, P &lt; 0.001; ROM:37° ± 6° to 46° ± 5°, P &lt; 0.001). The SF-36 score also significantly increased in all 8 subgroups. In 11 patients hardware was removed due a discomfort after a mean of 11.8 months (range 7.2 – 22.8). Conclusion: A z-shaped osteotomy is an efficient and successful method to restore fibula length and rotation in patients with posttraumatic malunion. Our findings in this series confirm that this realignment surgery results in significant pain relief and functional improvement.

Fibula regeneration following non-vascularized graft harvest in children.

A peculiarity of non-vascularized fibular harvest is that the donor site regenerates new bone provided periosteum is preserved. We prospectively investigated the regenerated fibula quantitatively and studied clinical implications of non-regeneration. The fibula was harvested using a periosteum preserving technique. Only fibulae from healthy legs were harvested. X-rays were done pre- and post-operatively at three and sixmonths. Clinical assessment of donor limb included pain, gait, motor and sensory examination. Fibular regeneration was quantified using defined length and width criteria. There were 16 children with 21 harvested fibula. About 65% of total fibular length was available for use as graft. There was regeneration of fibula similar to the pre-operative dimensions as early as sixmonths in 71% of cases. There were no clinical morbid findings as assessed at sixmonths follow up despite non-continuity being observed in 29% of cases. The predominant site for non-continuity was middle third-distal third junction. Periosteal preserving non-vascularized fibula grafting was a low morbidity procedure. In two-third of the cases, there was regeneration of fibula comparable to pre-operative dimensions as early as sixmonths. The non-continuous regeneration had no clinical implications.

A simplified, validated protocol for measuring fibular reduction on ankle CT.

Inadequate ankle syndesmotic reduction is a common and important cause of poor outcome after surgery. It is not clear what magnitude or planes of displacement impact most. Many computerised tomography (CT) measurement techniques rely on landmarks that are difficult to reproduce, and none measure all types of mal-positioning in a single protocol. The purpose of this study was to design and validate a protocol for measuring the distal tibio-fibular relationship. We devised a method for measuring fibular diastasis, antero-posterior translation (APT) and fibular length on CT images. CTs of sixteen un-injured ankles were examined using our protocol and that of an established alternative method for comparison. The measurements were recorded by two independent observers and repeated for inter- and intra-observer agreement scores. Our method showed inter- and intra-observer agreement of r=0.994 and r=0.999, demonstrating strong agreement. This compared to r=0.218 and r=0.820 respectively for the comparative protocol. This ankle CT measurement protocol is accurate, reproducible and simple to use. Its aim is to be a useful tool for clinicians to quantify post-operative mal-positioning of the distal fibula in comparison to the un-injured ankle. We believe that routine, bilateral, post-operative CT imaging will lead to improvements in the understanding and outcomes of the treatment of complex ankle fractures. To our knowledge no other validated measurement of fibular length on CT images exists in the literature.

Minimally Invasive Versus Open Distal Fibular Plating for AO/OTA 44-B Ankle Fractures.

Open reduction and internal fixation (ORIF), the standard treatment for unstable ankle fractures, has well-known wound complications. Minimally invasive surgery (MIS) has been proposed to decrease these complications. The objectives of this study were to describe an algorithm of MIS for fibular plating and compare the radiographic restoration of fibular anatomy, functional outcomes, and complications between ORIF and MIS for ankle fractures. This retrospective study included 71 patients with AO/OTA 44-B ankle fractures treated by a single surgeon. ORIF group consisted of 34 patients (54.5-month follow-up) and MIS group was composed of 37 patients (55.9-month follow-up). Among 37 MIS patients, 13 patients were treated with minimally invasive percutaneous plate osteosynthesis and 24 patients with minimally invasive trans-fracture approach according to our MIS algorithm. Operative outcomes were evaluated and compared between the 2 groups by radiographic measurements, functional assessment, and complications. The MIS group had less blood loss but longer operative time and greater exposure to fluoroscopy. Radiographic measurements revealed similar union time, fibular length, talocrural angle, medial clear space, and tibiofibular clear space in both groups. Lower visual analogue pain score was observed in the MIS group in the early postoperative period. At last follow-up, there were no significant differences regarding pain score, American Orthopaedic Foot & Ankle Society ankle-hindfoot score, and range of motion between the 2 groups. Total complication rate was significantly higher in the ORIF group. Patients with AO/OTA 44-B fractures treated with MIS fibular plating achieved similar radiographic and functional outcomes but had less pain in the early postoperative period and fewer wound complications compared with those treated with ORIF. Level III, retrospective comparative study.

Anthropometric Measurement of Patients Admitted to an Intensive Care Unit

Background: Visual estimation is the usual method that many healthcare professional use to estimate the body weight of patients in the Intensive Care Unit (ICU), but this method has been shown to be significantly inaccurate. This study aimed to explores the feasibility of using fibula length to estimate the acute body weight of patients admitted to an ICU. Methods: The study collected all ICU records in which patient’s body weight was estimated by the equation: Males: 153.1 – (0.26 x age) – 11 + (1.05 x fibular length) Females: 153.1 – (0.26 x age) – 22 + (1.05 x fibular length). The body weight(BW) then estimated by: BW=20 x [estimated body height (in metres)]2. The degree of agreement between the estimated body weight by anthropometric measurement methods and the actual recorded body weight in the patient’s medical record within the four weeks immediately before ICU admission were assessed by the Bland-Altman plot. Results: Paired sample t-tests showed there were statistically significant differences between the patient’s estimated and actual height and weight (p-value=0.0001 for both). Conclusions: The study found the use of fibula length alone had a similar percentage of bias when compared with visual estimation by healthcare professionals to estimate the actual body weight of the patients admitted to ICU.