Fibular Nonunion Research Articles

Tibial Lengthening Over an Intramedullary Nail

Tibial Lengthening Over an Intramedullary Nail

The results of the Grice subtalar extra-articular arthrodesis for pes planovalgus deformity in patients with cerebral palsy

We evaluated the results of the Grice subtalar extra-articular arthrodesis for pes planovalgus deformity in patients with cerebral palsy and its effectiveness in providing hindfoot alignment. Grice subtalar extra-articular arthrodesis was performed for pes planovalgus deformity in 14 feet of nine patients (5 males, 4 females; mean age 10.3 years; range 6 to 12 years) with cerebral palsy. Six patients were diplegic, two patients were paraplegic, and one patient was hemiplegic. Four patients had unilateral, five patients had bilateral involvement. A fibular graft taken from the distal third of the fibula above the syndesmosis was used in all the patients without any fixation material. The patients were assessed with the AOFAS (American Orthopaedic Foot and Ankle Society) hindfoot scoring system pre- and postoperatively. The mean follow-up was 30 months (range 6 to 81 months). Compared with the preoperative values, the mean AOFAS hindfoot score increased from 53 (range 41 to 81) to 68.4 (range 51 to 96), the mean talocalcaneal angle decreased from 52.6 degrees to 30.4 degrees , and from 55.8 degrees to 35.9 degrees in frontal and sagittal planes, respectively (p<0.05). The mean ankle valgus angle measured on anteroposterior radiographs remained unchanged (mean 5 degrees ). Of five patients who underwent bilateral surgery, three (21.4%) developed donor-site fibular nonunion on one side. One (7.1%) of these patients also had graft nonunion and displacement. Treatment was rated as satisfactory by the parents of seven patients (77.8%; p<0.05). Despite donor-site morbidity, the Grice subtalar extra-articular arthrodesis is an effective procedure for the correction of hindfoot alignment in patients with pes planovalgus deformity secondary to cerebral palsy.

Congenital Distal Tibio-fibular Synostosis - Case Report -

Congenital distal tibio-fibular synostosis is a very rare disease with no reported cases in Korea. An 8 year old girl complained of ankle discomfort and deformity due to distal tibio-fibular synostosis. The patient was treated with an autogenous fat graft after a bone bridge resection and fibular osteotomy to restore the ankle mortise. Osteosynthesis with a plate was performed to treat the fibular nonunion during the follow-up. Fibular union was achieved, and there have not been any subjective symptoms or limitations of outdoor activity and ROM during a four and half year follow up.

Treatment of congenital pseudarthrosis of the tibia with the Ilizarov technique

Congenital pseudarthrosis of the tibia continues to pose one of the most difficult problems in paediatric orthopaedic surgery. The surgical procedures most used for treating congenital pseudarthrosis of the tibia are intramedullary nailing associated with bone grafting, vascularized fibular graft and the Ilizarov external circular fixator. Even when union is achieved, the residual deformities in the affected limb often result in significant disability. These deformities include leg-length discrepancy, angular tibial deformities, ankle mortise valgus and fibular non-union. The Ilizarov method allows simultaneous excision of the pseudarthrosis site, correction of the deformity and lengthening. However, refractures, ankle joint stiffness, fibular non-union with progressive ankle valgus are frequent sequelae with the Ilizarov technique. The surgeon should know when to abandon reconstructive procedures and create a more functional patient with an amputation. The authors discuss the indications and results of the Ilizarov external fixator in two patients with this complex problem. In addition, a critical review of the current literature is undertaken.

Non-union of Weber B fractures: A case series

Non-union of the distal fibula is considered rare. The fibula may serve as a model for successful fracture healing due to its endosteal blood supply and its reduced exposure to biomechanical stress. Fractures of the fibula that begin at the joint line and extend proximally, with or without the anterior syndesmosis intact (Weber B) are the commonest ankle fractures. They are generally considered to be stable if damage to the medial complex is excluded. In the absence of medial ligament injury conservative treatment is considered to provide excellent results. We report three cases of fractures through the fibula at the level of the syndesmosis, with intact medial ligament complexes, in which fracture nonunion developed despite adequate management. The purpose of this case series is to demonstrate the clinical and radiographic features of fibular nonunion and to discuss its effect on management.

Relationship of Tibial Nonunion with Fibular Nonunion in the Tibio-fibular Shaft Fracture

153 통신저자:고 상 봉 대구광역시 남구 대명 4동 3056-6번지 대구가톨릭대학교병원 정형외과 Tel:053-650-4283.Fax:053-6520-4272 E-mail:bong@cu.ac.kr *본 연구는 대구가톨릭대학교 연구비지원에 의한 것임. Address reprint requests to:Sang-Bong Ko, M.D. Department of Orthopaedic Surgery, Catholic University of Daegu College of Medicine, 3056-6 Daemyeong 4-dong, Nam-gu, Daegu 705-718, Korea Tel:82-53-650-4283.Fax:82-53-6520-4272 E-mail: bong@cu.ac.kr 경비골 간부 골절에서 비골 불유합과 경골 불유합의 상관관계

Fibular nonunion after closed rotational ankle fracture.

Historically, the standard of care for minimally or nondisplaced, closed, distal fibula fractures has been short-term immobilization and progressive weightbearing. The vast majority of such patients are expected to heal with excellent functional outcome after such treatment. There exists a subpopulation of patients sustaining these fibular fractures who develop symptomatic incomplete union or nonunion despite appropriate management, and later require operative intervention to eliminate pain. A retrospective review of 17 referred patients with rotational fibular fractures between August 1999 and July 2003 identified six persistently symptomatic distal fibular fractures after an adequate trial of conservative treatment. Due to their persistent localized pain and difficulty with ambulation, five patients underwent operative treatment of the nonunion with autologous bone grafting with plate and screw osteosynthesis. The sixth patient has refused operative intervention despite persistent symptoms. All six of these patients were identified as low risk for nonunion. Two fibular nonunions were found to be complete and four were partial nonunions. One hundred percent of these patients presented with a chief complaint of pain, had reproducible tenderness with palpation directly at the fracture site, and exhibited a persistent antalgic gait pattern. Four of six patients who underwent surgery noticed complete resolution of their pain and return of their normal gait within an average of 2.3 months postoperatively, with an average follow-up of 19.5 months (range, 2-53 months). Distal fibula nonunion appears to be a relatively common cause of persistent lateral ankle symptoms in patients who do not enjoy a satisfactory recovery after appropriate conservative treatment. The authors believe that the persistent lateral pain in such patients results from micromotion strain at the incomplete fracture union site. Surgical stabilization of fibular nonunion seems to be a reliable means of resolving these symptoms when conservative measures fail.

Hypertrophic nonunion of the distal fibula after reduced triplane fracture of the distal tibia in a child

Ankle fractures in children are a common injury and most heal uneventfully. Nonunion is unusual in children with otherwise normal bone, particularly following ankle fracture. We report the exceptional case of a hypertrophic fibular nonunion in a healthy 13 year old girl.

Closed interlocking nailing for fibular nonunion

The majority of fibular fractures occur in conjunction with fractures of the tibia. While most of these fibular fractures heal without consequence, a few go on to cause problems. Recent evidence suggests that the incidence of nonunion of the fibula has risen with the advent of interlocked intramedullary nailing of the tibia. However, painful nonunion of a fibular fracture requiring surgical intervention is still a rare complication. We present a case of painful fibular nonunion which was treated successfully with closed locked intramedullary nailing.

External fixation of tibial plafond fractures: is routine plating of the fibula necessary?

To determine the advantages and disadvantages of plating an associated fibula fracture in tibial plafond fractures treated with external fixation that spans the ankle. Retrospective clinical review. The incidence of treatment complications and the outcomes achieved were compared between two groups of patients with tibial plafond fractures and associated fractures of the fibula. Both groups were treated by a uniform technique of monolateral external fixation. One group, consisting of twenty-two patients with twenty-two fractures, had plate fixation of the distal fibula and the other group, thirty-one patients with thirty-two fractures, had no fibular fixation. The demographics of the two groups, including sex, fracture classification, and number of open fractures, were similar. The outcome of the two groups for radiographic arthrosis and clinical ankle score, measured at minimum two-year follow-up, showed no statistically significant difference. The total numbers of complications were not statistically different between the two groups (p = 0.15), but the types of complications varied. Group I had eight complications: five fibular wound infections, two fibular nonunions, and one angular nonunion. Group II had seven complications: six angular malunions and one tibial wound infection. Open reduction and internal fixation of the fibula fracture in tibial plafond fractures treated with external fixation that spans the ankle is associated with a significant rate of complications, and good clinical results may be obtained without fixing the fibula.

Ankle fractures involving the fibula proximal to the distal tibiofibular syndesmosis.

Thirty-two cases of ankle fractures associated with fibular fractures above the distal tibiofibular syndesmosis were studied. All were treated with open reduction and internal fixation. The average follow-up was 25 months. The results of the postoperative evaluation were rated, based on subjective clinical criteria, as good, fair, and poor. According to the Lauge-Hansen classification, there were 17 (53%) cases of supination-external rotation injury (2 stage 2 and 15 stage 4), 9 (28%) cases of stage 3 pronation-abduction injury, and 6 (19%) cases of pronation-external rotation injury (3 stage 3 and 3 stage 4). All cases could be classified as Weber type C or as suprasyndesmotic, fibular diaphyseal fracture (44-C) according to the Orthopaedic Trauma Association classification. In 18 (56%) cases, the fracture was associated with ankle dislocation. There were seven (22%) open fractures, (two grade I, four grade II, and one grade IIIA). Syndesmotic screws were used in 23 (72%) cases (12 supination-external rotation injury, 6 pronation-external rotation injury, and 5 pronation-abduction injury). The syndesmotic screw was removed after an average of 9 weeks. Four (13%) nonunions and two (6%) delayed unions of the fibula were treated with bone grafting and/or hardware revision and eventually healed. Three of the nonunions had poor clinical results because of degenerative ankle joint arthritis in two (one of them ended in arthrodesis) and deep infection, which was eventually cured, in the third. The fourth nonunion had a fair result. One of the delayed unions had a fair result (an obese patient) and the other had a good result. Two patients developed deep infections; one ended in gangrene and amputation in a diabetic patient, and the other was a patient with fibular nonunion that eventually healed. Three patients had superficial infections that were treated successfully. Of the 32 cases, 23 (72%) showed good results, 4 (13%) showed fair results, and 5 (16%) showed poor results. The cases with poor results included three fibular nonunions, one deep infection, and one recurrent superficial infection and wound dehiscence after hardware removal. A syndesmotic screw is usually needed in cases of fracture-dislocations. Two patients with occult fibular nonunions developed diastasis of the syndesmosis after removal of the syndesmotic screw. It was found that reduction and temporary pinning of the distal tibiofibular joint helps achieve fibular length, which is crucial to restoring the biomechanics of the ankle joint. It seems advisable not to remove the syndesmotic screw until there are signs of healing of fibular fracture to avoid diastasis of the distal tibiofibular joint. Bone grafting should be considered in high energy fractures with comminution. These complex injuries are associated with higher rates of complications. Poor results can be attributed to fracture factors, e.g., open fractures, infections; patient factors, e.g., obesity, lowered immunity as in diabetes, and noncompliance; and iatrogenic factors, e.g., early removal of syndesmotic screws.

Fibular nonunion in combination with fractures of the tibia.

Seventeen cases of fibular nonunion or delayed union were seen in our institution from 1985 to 1990. All but one of these cases were associated with nonunion of the tibia which was diagnosed radiologically and/or surgically. The fibula characteristically heals before the tibia; therefore, if the fibula is slow in healing or showing nonunion, more intensive investigation of the tibia for occult nonunion, or delayed union, should be done to determine whether early surgical intervention would be necessary to avoid prolonging the course of treatment. Nonunion of the fibula may indicate instability of the fractured tibia. The authors have examined the relationship of this mutual nonunion and recommend careful observation of the fibular healing in associated fractures of the tibia and fibula.

Fibular Nonunion After Fixation of the Tibia in Lower Leg Fractures

In 335 extraarticular tibial-fibular fractures treated by open reduction of the tibia, nonunion of the fibula was noted in 15 cases (4.5%). Four of these cases were symptomatic, but resection of the hypertrophic nonunion provided relief of pain. Fixation of the fibula is not necessary in primary treatment of extraarticular lower leg fractures.