Fibular Strut Research Articles

The biomechanical effect of fibular strut grafts on humeral surgical neck fractures with lateral wall comminution

No studies have evaluated the effect of fibular strut augmentation on the stability of locking plate fixation for osteoporotic proximal humeral fractures with lateral wall comminution. The purpose of this study was to evaluate the stability of locking plate fixation with a fibular strut graft compared with locking plate alone in an osteoporotic two-part surgical neck fracture model with lateral cortex comminution. Ten paired fresh-frozen cadaveric humeri were randomly allocated into two groups, either the locking plate alone (LP group) or locking plate with fibular strut graft augmentation (LPFSG group), with an equal number of right and left osteoporotic surgical neck fractures with lateral wall comminution of the greater tuberosity. Varus, internal/external torsion, and axial compression stiffness as well as single load to failure were measured in plate-bone constructs, and the LPFSG group showed significantly greater values in all metrics. In conclusion, this biomechanical study shows that fibular strut augmentation significantly enhances varus stiffness, internal torsion stiffness, external torsion stiffness, and maximum failure load of a construct compared to locking plate fixation alone in proximal humeral fractures with lateral wall comminution.

Preventing varus collapse in proximal humerus fracture fixation: 90-90 dual plating versus endosteal fibular allograft strut.

Screw cut out and varus collapse arethe most common complication of locked plate fixation of proximal humerus fractures. The purpose of this study was to compare dual plating and endosteal fibular allograft struts as augmentation strategies to prevent varus collapse. A trapezoidal osteotomy was created at the metaphysis to create a 2-part proximal humerus model in 18 paired shoulder specimens. Each specimen was assigned to group A, B, or C and was fixed with either a lateral locking plate, a lateral locking plate and anterior one-third tubular plate in an orthogonal 90/90 configuration, or a lateral locking plate with intramedullary fibular strut, respectively. The specimens were stressed in axial compression to failure. Displacement, elastic limit, ultimate load, and stiffness were recorded and calculated. There was no difference in mean cyclic displacement between the three groups (0.71mm vs 0.89mm vs 0.61mm for Group A, B, C, respectively). Lateral plating demonstrated the greatest absolute and relative displacement at the elastic limit (5.3mm ± 1.5 and 4.4mm ± 1.3) without significance. The elastic limit or yield point was greatest for fibular allograft, Group C (1223N ± 501 vs 1048N ± 367 for Group B and 951N ± 249 for Group A) without significance. Dual plating of proximal humerus fractures in a 90-90 configuration demonstrates similar biomechanical properties as endosteal fibular strut allograft. Both strategies demonstrate superior stiffness to isolated lateral locked plating.

Preoperative Muscle Biopsy to Assess Motor End Plate Integrity as a Predictor for Successful Nerve Transfer: A Case Report.

A 60-year-old right-hand-dominant man was referred for persistent right deltoid weakness, lateral shoulder numbness, and severe functional deficit 3 months after undergoing proximal humerus open reduction and internal fixation with plate and fibular strut allograft. Deltoid muscle biopsy demonstrated motor end plate (MEP) degeneration. After partial radial-to-axillary nerve transfer, repeat deltoid muscle biopsy revealed successful regeneration of MEPs with reinnervation of deltoid confirmed with postnerve transfer electromyography. Selective nerve transfer can successfully rescue a denervated target muscle from further degeneration by restoration of healthy MEPs.

Study on role of fibular graft in non-union and complex fractures of long bone

Background: Road traffic injuries are the seventh most common cause of long bone fractures. Following high velocity limb trauma, the defects in the long bone are usually associated with appreciable soft-tissue losses. These open long bone injuries always require multidisciplinary managements to reconstruct the composite defects of bone and soft tissue. Aims and Objectives: The aim of the study was to find out radiological and clinical outcome, complications, and union time in complex and non-union fractures of long bone managed by fibular graft. Materials and Methods: Out of 50 cases, 40 cases were of complex fractures and ten cases were of non-union. We used Fibular strut grafts in reconstruction of bone defects and soft tissue injury. Results: Thirty (60.0%) had excellent functional outcome, 10 (20.0%) had good, 6 (12.0%) had satisfactory, and 4 (8.0%) patients had poor outcome. Main complications were non-union 2 cases and 3 cases of superficial wound infection, which subsided by wound dressing and intravenous antibiotic treatment. Conclusion: Free fibular grafting has been proven to be an ideal choice in the management of large segmental bone defects as well as in situations of biological failure of bone healing.

A case study on recurrent giant cell tumor of distal end radius

Abstract Background: Based on location distal end radius is the second most common for giant cell tumors (GCTs) followed by the knee. Like at any other location, they are treated with extended curettage or resection but reports of recurrence are increasingly coming up. In this study, we aim to treat the recurrent distal end radius GCTs and their outcome after Index surgeries. Materials and Methods: This case report was done in the year 2022–2023 on a patient with recurrent distal end radius GCT of age of 30 years. Recurrence had occurred after curettage and even after resection as index surgery. The recurrent lesion was treated with resection, excisional biopsy, fibula strut grafting, and wrist arthrodesis. The follow-up period was 12 months. Results: In various studies, when the patients with joint preservation were treated with curettage and those with resection of soft tissue recurrences were done with salvage of joint had better functional outcomes with a mean musculoskeletal tumor society (MSTS) score. In our case with arthrodesis using fibular strut grafting had a low MSTS score. The overall functional outcome was satisfactory. Conclusions: We conclude that local recurrence of GCT after curettage in long bones if contained within the bone and/or extending into the soft tissue, can be successfully treated with further more extensive surgery in an attempt to obtain wide margins with minimal risk of increased morbidity. It does increase some morbidity but there is significant gain with respect to the cure of the disease.

Use of an Intramedullary Allogenic Fibular Strut Bone and Lateral Locking Plate for Distal Femoral Fracture with Supracondylar Comminution in Patients over 50 Years of Age.

Background and Objectives: Distal femoral fracture is a severe injury that makes surgery challenging, particularly comminuted fractures in the supracondylar region. This study aimed to evaluate the outcomes of distal femoral fracture treated with the application of an intramedullary fibular allogenic bone strut in open reduction and internal fixation (ORIF) with precontoured locking plates in patients over 50 years of age. Materials and Methods: The study retrospectively enrolled 202 patients over 50 years of age with traumatic comminuted distal femoral fracture (AO/OTA 33-A3, 33-C2 and 33-C3) treated with ORIF with a locking plate from January 2016 to December 2019. The two groups were divided into patients who received an intramedullary allogenic bone strut and those who did not. Patients were followed for at least 1 year, with their function scores and radiographic data recorded. Results: A total of 124 patients were recruited, comprising 60 men and 64 women with an average age of 62.4 ± 8.5 years. The 36 patients who had received an intramedullary allogenic fibular bone strut reported lower postoperative pain scores at 1 month and lower postoperative Knee Society Scores (KSS) at 3 months than the control group. The application of an intramedullary allogenic fibular bone strut appeared to be significantly correlated with better 3-month postoperative KSS. Conclusions: The ORIF of distal femoral comminuted fracture with an intramedullary allogenic fibular bone strut can reduce pain and improve knee function in the early stages of postoperative rehabilitation and may reduce the time to union in patients over 50 years of age.

How to improve the biomechanical stability of endosteal augmentation for proximal humerus fracture with osteopenia? A cadaveric study

BackgroundEndosteal augmentation enhances the stability of osteoporotic proximal humeral fracture fixation, but the optimal configuration is unknown. The purpose of this study was to compare the biomechanical properties of different lengths of fibula with or without calcar screw in osteoporotic proximal humeral fracture. MethodsThree-part proximal humeral fractures with osteopenia were created on 20 pairs of fresh-frozen humeri specimens and allocated to four groups: (1) locking plate with a 6-cm fibular strut allograft, (2) locking plate with a 6-cm fibular strut allograft and additional calcar screws, (3) locking plate with a 12-cm fibular strut allograft，and (4) locking plate with a 12-cm fibular strut allograft and additional calcar screws. Specimens were loaded to simulate the force at 25° abduction. Thereafter, an axial stiffness test and a compound cyclic load to failure test were applied. Structural stiffness, number of cycles loaded to failure and relative displacement values for 5000 cycles at predetermined measurement points were recorded using a testing machine and a synchronized 3D video tracking system. FindingsIn terms of initial stiffness, number of cycles loaded to failure, and relative displacement values, the groups with 12-cm fibular strut showed obvious improvement compared to the groups with 6-cm fibular strut irrespective of the influence of calcar screw implementation. Further, the groups implemented with calcar screws also showed promising biomechanical stability irrespective of fibular length. InterpretationLateral locking plate with longer endosteal fibular augmentation and calcar screw can significantly improve biomechanical stability for elderly proximal humeral fractures with posteromedial comminution.

What's New in Musculoskeletal Tumor Surgery.

What's New in Musculoskeletal Tumor Surgery.

Fixation of Fresh Femoral Neck Fractures Using Fibular Strut Graft Along with Cannulated Screws

Intracapsular femoral neck fractures can result from trivial trauma in the elderly or high-energy trauma in younger age-groups. In younger patients aged <60 years, the femoral head should be conserved to avoid the long-term complications of replacement arthroplasty. The options of osteosynthesis include closed/ open reduction and internal fixation with/without bone grafting. Internal fixation alone does not provide rigid fixation, owing to cavities in the posterior part of the femoral head and neck. Fibular grafts augment union and provide strength to the posterior cortex during reconstruction of the femoral neck. We evaluated the use of fibular grafting for fresh femoral neck fractures with posterior comminution. Between November 2019 and March 2022, 20 women and 12 men aged 20 to 60 years underwent osteosynthesis and fibular strut grafting supplemented with 7.0-mm cannulated hip screws for Garden grades III (n=19) and IV (n=13) femoral neck fractures. Clinical and radiological outcomes were evaluated. Patients were followed up for a period of 15 months. According to the Harris hip score, outcome was good to excellent in 23, fair in 7, and poor in 2. 30 of the 32 patients achieved bone union after a mean of 4.5 (range 3.5-5.5) months. In 2 patients, the bone was united with a mean of 10º of varus collapse. Two patients had non-union. Other complications included screw migration in the joint space (n=1) and screw pullout (n=2). No patient had avascular necrosis of the femoral head. Fixation with cancellous screws and fibular strut grafts for femoral neck fractures is cost-effective and technically less demanding, and associated with good outcomes.

Single-Stage Reconstruction with Innate Chimeric-Free Fibula Flap in Limb-Preserving Excision of Upper Limb Sarcomas

IntroductionThe limb-preserving excision is the standard of care in upper limb sarcoma management, but the resulting complex composite defects are exacting the expertise of the reconstructive surgeons. This study was done to evaluate a novel single-stage reconstruction of these defects using an innate chimeric-free fibula flap (a nonfabricated, anatomically available multiple tissue components harvested on independent perforators arising from the same peroneal source vessel). Patients and MethodsTwenty patients (16 male/4 female) with an average age of 29.5 years with upper extremity sarcoma (Enneking IIA/IIB) were treated by wide local excision and innate chimeric-free fibula flap reconstruction from March 2012 to March 2020. All the patients were followed for an average period of 18.3 months. At the end of the follow-up, the outcome was assessed by musculoskeletal tumor score (MSTS). ResultsThe flow-through flap was done in five patients. Muscle-tendon unit defects were reconstructed with a vascularized peroneus longus muscle-tendon unit in 15 patients. Nerve gap reconstruction using vascularized superficial peroneal nerve was done in eight patients. All patients had a segmental defect in the appendicular skeleton that was reconstructed with the vascularized fibular strut component. Soleus chimeric muscle component was used as a void filler and for covering the hardware in seven patients. The average size of the chimeric cutaneous component paddle was 30.7 cm2. The average length of fibula used for reconstruction was 16.6 cm. All flaps survived well, facilitating good hand function at the end of the follow-up. The average outcome score as per the MSTS was 22 (p = 0.035). ConclusionThe innate chimeric-free fibula flap provides all tissue components facilitating a good functional outcome. The advantage is the restoration of a functional hand in a single-stage reconstruction.

Functional Outcomes of Patients Treated with Fibula Strut Graft and Double Plate in the Treatment of Recalcitrant Humerus Nonunions

Objective: Recalcitrant humerus nonunion is challenging to treat, and plate fixation is a common treatment choice. This study aimed to determine the efficiency of double plating combined with nonvascularized autologous fibular strut allograft in the treatment of atrophic and defective humerus nonunions.Methods: Fourteen patients were surgically treated for recalcitrant humerus malunions. Demographic data (age, gender, dominant side), clinical features, and previous surgical records of the patients were recorded preoperatively. Preoperative Visual Analogous Scale (VAS) and Constant-Murley scores of the patients were recorded before the surgery.Results: 10 (71.4%) of the patients were female, and 4 (28.5%) were male. The mean age was 53.07±9.69 (range, 39-67). 9 (64.3%) of the patients had nonunions on the dominant side. The mean follow-up was 11.14±1.9 months. The complete union was observed in all patients, and the mean union time was 5.1±0.63 months (range, 4.2-6.0). The mean preoperative VAS score was 7.29 ± 0.91 (range, 6-9), and the mean postoperative VAS score was 0.93 ± 0.92 (range, 0-3). VAS scores improved after the surgery (p<0.001). The mean preoperative Constant-Murley score was 53.57 ± 12.17 (range 34-72), and the mean postoperative Constant-Murley score was 86.00 ± 9.21. Constant-Murley scores improved after the surgery (p<0.001). Gender (p=0.635), dominant side involvement (p=0.112), and age (p=0.925) did not correlate with union time.Conclusion: Double plating with autologous nonvascularized fibular grafts is a successful treatment option for recalcitrant humerus atrophic nonunions, especially with bony defects.

Results of using intramedullary autogenous fibular strut graft as an adjunct to dynamic plating in atrophic non-union of humeral mid-shaft fracture

Introduction: Atrophic nonunion of the humerus is rare and complex condition to treat. Several surgical techniques have been used for the treatment of non-union, which include compression plating, intramedullary nailing and use of external fixators, with or without bone grafts. Use of autogenous fibular as a strut graft is proposed to achieve good union and functional recovery. The aim of this study was to assess the clinical result of the intramedullary fibular graft adjunct to dynamic plate fixation in diaphyseal atrophic non-union of the humerus.Methods: The present prospective study was carried out within the period of January 2019 to December 2021 in the Department of Orthopedic Surgery of Bangabandhu Sheikh Mujib Medical University. Fifteen patient (09 male and 06 female) with atrophic non-union of the humerus midshaft fracture within the age range of 41-60 years were selected. All the case had non-union of the fracture of the middle third of humerus with a delay in commencement of specific treatment. The clinical and radiological outcome of Surgery has been assessed using definite recommendation. Statistical results were obtained by using the SPSS program.Result: The mean union time was 5.65 months. Post-operative complications were noticed in 3 patients, infection in 01 patient and 02 patients had persistent pain due to failure of union. Regarding the final outcome, satisfactory results were found in 86.66% case and unsatisfactory result in 13.33% case.Conclusion: The intramedullary fibular auto graft with dynamic plating results in satisfactory clinical outcome in atrophic osteoporotic diaphyseal non-unions of the humerus.

Assessment of management of fracture neck of femur with internal fixation alone or with fibular graft

Background: Intracapsular femoral neck fractures are commonly seen in the elderly population after a trivial fall. The present study was conducted to assess management of fracture neck of femur with internal fixation alone or with fibular strut graft. Materials & Methods: 52 patients of fracture neck of femur treated by close / open reduction and internal fixation using cannulated cancellous screws along with strut fibular graft of both genders were enrolled. Parameters such as mode of injury, range of movement and complications were recorded. Results: Out of 52 patients, males were 32 and females were 20. Mode of accident was RTA in 28, fall in 16 and domestic violence in 8 cases. Range of motion flexion > 100 degrees was seen in 40 and < 100 degrees in 12 cases. Extension > 10 degrees was seen in 38 and < 10 degrees in 14 cases. Abduction > 25 degrees was seen in 44 and < 25 degrees in 8 cases. Complications observed were swelling in four, shortening of the affected limb in two and superficial infection in case. Conclusion: Management of fracture neck of femur with cancellous cannulated screw and fibular strut graft is a reliable method of fixation.

Aggressive giant cell tumour of the talus: a rare case report and challenges faced during its management

&lt;p&gt;Giant cell tumour (GCT) of the bone is a locally aggressive benign tumour that commonly occurs in the epiphyseal ends of long bones. Its occurrence in the small bones of the foot like the talus is rare. In this case report we described a case of aggressive GCT of the talus (Campanacci grade 3) in a twenty-one years old male diagnosed by the presence of a well-defined osteolytic lesion seen involving the talar body with cortical breach and soft tissue extension confirmed to be a GCT by closed needle biopsy. The patient was managed surgically by excision of the tumour mass in-toto along with the talus followed by tibio-calcaneal fusion using free fibular strut graft and Ilizarov frame. At 3 months follow up no evidence of fusion was seen and therefore secondary augmentation with a cortico-cancellous graft from the iliac crest was done to aid fusion and Ilizarov fixator was removed 6 months after the surgery. The patient at one year follow up had shown no signs of recurrence of the tumour and has a pain free, stable fused tibiocalcaneal joint with a bipedal unassisted gait. Our case report found excision of talus combined with tibio-calcaneal fusion using free fibular strut graft along with cortico cancellous iliac bone graft to have a good outcome in terms of aiding tibio-calcaneal arthrodesis and thereby providing pain relief and providing a stable foot to the patient.&lt;/p&gt;

The effect of onlay cortical fibula strut grafts on biomechanical features of Vancouver type B1 periprosthetic femoral fractures.

This study aimed to investigate biomechanically the effects of onlay fibula grafts on Vancouver Type B1 Periprosthetic Femoral Fractures (PPFs). Vancouver Type B1 PFF models were created in 25 fourth-generation synthetic femurs and fixed with locking plates using bicortical, unicortical screws, and cables. While no graft was used in group 1, onlay fibula grafts were placed anteriorly in group 2 and medially in group 3. In group 4, the cortical strut allograft was placed on the medial femoral cortex, and a locking compression plate (LCP) was applied to the lateral femoral cortex. In group 5, the strut allograft was placed over the anterior cortex of the femur and fixed with the same technique as in group 4. All models were then subjected to rotational and axial cyclical stiffness tests and load to failure to measure and compare the mechanical strengths of the constructs. The mean stiffness values of group 4 with medial allograft, before and after cyclical loading, were higher than all other groups, under both rotational and axial forces. The mean stiffness values of fibula autografts (groups 2 and 3) were similar to that of anterior allografts (group 5) in each test except that the mean initial axial stiffness of group 5 was higher than group 2. Failure loads were also not different between the groups. Although the rigidity of Vancouver type B1 periprosthetic femur fractures is highest if allografts are placed medially, fibula autografts can also provide similar fixation strengths to allografts if locking plates with unicortical and bicortical screws and cables are used.

Endosteal plating in proximal humerus fractures: a novel technique and alternative to fibular strut allograft for medial column support

The purpose of this retrospective study is to investigate the clinical and radiographic outcomes associated with the use of a standard metal plate as an endosteal implant in combination with a lateral locking plate to treat 4 patients with displaced proximal humerus fractures. A retrospective case series study design was utilized, and the medical records of 4 patients with displaced, 3-part proximal humerus fractures treated using this technique between January 2019 and July 2021 were reviewed for this study. The mean age was 52 years (range, 44-57 years). The radiographic outcome of interest was humeral neck-shaft angle preoperatively, intraoperatively, and at the latest follow-up. The average follow-up duration was 62 weeks (range, 12-161 weeks). All fractures healed without loss of reduction or neurovascular deficits. Avascular necrosis was not observed in the 2 patients with sufficient follow-up time to make such an evaluation. The average neck-shaft angles preoperatively, intraoperatively, and at the latest follow-up were 104.8°, 139.8°, and 137°, respectively. Locking plate technology augmented with an endosteal plate provided stable reduction and restoration of physiologic alignment in a small number of patients with displaced proximal humerus fractures. This construct creates a second column of fixation, providing medial column support, and could be removed in the event of a future revision to a reverse shoulder arthroplasty.

Revision total elbow arthroplasty using intramedullary strut allograft for aseptic loosening of the humeral stem

Total elbow arthroplasty (TEA) has become a well-accepted treatment option for many pathologies of the elbow joint. Its use in distal humerus fractures in elderly patients has become increasingly popular and has good clinical results. However, with the aging population and the increasing number of TEAs performed, so comes the potential for an increasing number of revision TEA cases. Revision TEA can be extremely challenging. In addition to the technical difficulties of safe exposure and implant removal, reimplantation of a cemented humeral component with loss of bone stock can be a challenging step in this procedure. The purpose of this article was to describe a novel technique to address aseptic loosening of the humeral stem and loss of humeral bone stock with revision of the humeral component using a long-stemmed cemented implant and intramedullary allograft fibular strut bone grafting.

The Corkscrew Technique for Removing a Fibular Strut Allograft From the Proximal Humerus

A fibular strut allograft is a reliable option for augmentation in open reduction internal fixation (ORIF) of proximal humerus fractures, but techniques to remove a fibular strut during revision shoulder arthroplasty are limited. Currently published techniques on extracting fibular strut grafts from humeral shafts include using a Midas burr, flexible osteotomes, humeral shaft osteotomy, and reaming. To our knowledge there has not been a technique that uses a corkscrew to remove the fibular strut from the proximal humerus in preparation for revision shoulder arthroplasty. This is a case report and description of a simple and reproducible technique that can be implemented in the setting of conversion from a proximal humerus lateral locking plate with fibular strut allograft to shoulder arthroplasty.

Real-time intraoperative computed tomography can accurize virtual surgical planning on the double-barrel fibular flap for mandibular reconstruction

Real-time intraoperative computed tomography created the accuracy of less than 1 mm deviation in virtual surgical planning double barrel fibular flap for mandibular reconstruction-the symbiosis of intelligent technology in a digital OR. BackgroundWith the intelligent technology of virtual surgical planning, CAD/CAM, and intraoperative CT(iCT) in a digital OR, the secondary mandibular defect or primary amelobalstoma mandibulectomy can be restored using double barrel fibula and be achieved precision medicine purpose. Material and MethodA series of 7 patients underwent free flap for oral cancers who sustained 5 osteoradionecrosis, 2 segmental mandibular defect, and 2 ameloblastoma. They received 9 double barrel fibula flap and 2 free skin flaptransfers. The fibula flap were reconstructed using a virtual surgical planning including CAD/CAM for simulation 3D model, cutting guides for recipient sites and fibulas osteotomy, and iCT for image fusion in a digital OR. ResultThe mandibular defect was 5–16 cm (average: 9.56 cm), and 2–5 fibular struts for double barrel fibula (average: 3.67 struts) image fusion. One vein graft for artery was required and all 11 flaps were transferred successfully without reexploration. Six patients had intraoperative revision of the fibula and plate to improve the onlay image fusion volume from 74.71 to 82.57%. The postoperative inter-incisor midline deviation was less than 2 mm in 5 patients, and well reduction image in 4 edentulous patients. Five landmarks including bilateral condyles, bilateral gonions, and gnathion demonstrated deviation less than 1 mm in average. ConclusionCAD/CAM can allow a practical virtual surgery to restore mandibular defect reconstruction using a double barrel fibula. The symbiosis of intelligent technology in a digital OR, the iCT can promote the accuracy of mandibular spatialframework and occlusion plain.

Use of an intramedullary fibular strut allograft and dual locking plate in periprosthetic fractures above total knee arthroplasty: new application of a well-known treatment method in trauma.

Augmenting fracture fixation with intramedullary fibular graft has seen several applications such as in comminuted proximal humerus fractures, and femoral neck and shaft nonunion. The purpose of this study was to report the first case series demonstrating the novel application of an intramedullary fibular allograft strut and dual locking plates on complicated periprosthetic fracture of distal femur. The patient demographics, weight-bearing status, and radiographic and clinical outcomes of six patients, who were treated for periprosthetic distal femur fractures using an intramedullary fibular allograft strut and dual locking plate, between January 2018 and April 2020 were analyzed. Postoperative range of knee motion showed median 10' (range 10-20) of flexion contracture and 90' (range 80-110) of further flexion. Postoperative joint function was assessed according to the Kolmert functional criteria, with "excellent to good" in angular deformity and "Good to fair" result in range of motion and pain. RUSH score was assessed, and median score was 24 (range 18-26). All patients were able to ambulate without assistance 6months after surgery. In summary, the application of fibular strut graft and dual locking plate might be an option in complicated distal femur fracture above total knee arthroplasty. Albeit with an available number, such application showed promise as an intramedullary and cortical support for both reduction and maintenance of correction alignment, length, and prevention of further angular deformity. Surgical technique and Cases-series.