Partial Fibulectomy Research Articles

Alternative Treatment of Gonarthrosis: Proximal Fibular Osteotomy.

Gonarthrosis is arthrosis of the knee joint, a chronic non-inflammatory disease manifested by progressive destruction of the intra-articular cartilage, accompanied by abnormal formation of the bones form the joint, changes in the synovial membrane and synovial fluid. Gonarthrosis is the most common type of arthrosis. Gonarthrosis can be treated conservatively and operatively. Among well-established surgical options for the treatment of medial gonarthrosis are high tibial osteotomy (HTO), unicompart-mental knee arthroplasty (UKA), and total knee arthroplasty (TKA). Proximal fibular osteotomy (PFO) or superior partial fibulectomy is a relatively recent procedure proposed to reduce knee pain in patients with medial compartment. Our study aims to demonstrate an alternative treatment for gonarthrosis with proximal fibular osteotomy and reduced knee pain in patients with medial compartment osteoarthritis of the knee. At the Department of Orthopedics and Traumatology at J.Z.U "Borka Taleski" Prilep in the period from 2018 to 2021, 14 cases were treated, of which 11 were female and 3 were male. All patients were aged between 62 and 82 years with a mean age of 71.3 years. Patients had a severe degree of gonarthrosis (III/IV) according to Kellgren-Lawrence classification. Arthroscopy was performed in 2 patients. The fibula osteotomy was 7 cm away from the fibular head, with 1 cm resected bone fragment from the fibula. The average duration of the surgery was 30 minutes. Patients were followed up on the 7th day, first month, 3 months and 6 months after surgery. The final evaluation of function was done after 6 months by examining the active and passive movements of the knee joint. In all 14 patients we have excellent results with pain reduction, improvement of movement and quality of life. Proximal fibular osteotomy is an option for medial compartment osteoarthritis of the knee. Current literature is limited to small case series which report good outcomes in pain reduction, including the correction of varus deformity in medial gonarthrosis. Further studies are needed to determine the place of the PFO in the medial gonarthrosis management algorithm before it can be recommended for routine clinical use.

Evaluation of lower limb function and gait characteristics after fibulectomy in adults

To explore the effects of fibulectomy on lower limb function and gait of adult patients through gait analysis, in order to provide guidance for clinical treatment. A clinical data of 24 patients who underwent fibulectomy and met the selection criteria between January 2017 and December 2022 was retrospectively analyzed. There were 12 males and 12 females with an average age of 25 years (range, 18-68 years). The length of fibulectomy was 10-19 cm, with an average of 15 cm. The patients underwent routine rehabilitation training after operation. The occurrence of postoperative complications was recorded, the pain degree of surgical incision was evaluated by visual analogue scale (VAS) score, and the residual fibular bone was reviewed by imaging. A gait test system was used before operation and at 6 months after operation to collect gait data of healthy and affected sides under slow, medium, and fast velocity conditions, including gait parameters (foot rotation angle, step length, support phase, swing phase, gait line length, single support line, maximum force 1, maximum force 2) and the tripod area parameters (maximum pressure, time maximum force, and contact time of forefoot, midfoot, and hindfoot). All incisions healed by first intention after operation. All patients were followed up 1-5 years, with an average of 3 years. The great dorso-extension muscle strength decreased in 3 cases, and the sensory defects in the operative area and distal part occurred in 5 cases. The VAS scores of incisions were 0-6 (mean, 4) at 6 months after operation and 0-5 (mean, 2) at last follow-up. During follow-up, imaging review showed that 5 cases had osteoporotic changes of distal residual bone of the fibula, and the residual segment was shorter and more significant; 3 cases had new bone formation. The results of gait test showed that the gait parameters and the tripod area parameters under the three gait speeds were consistent. There was no significant difference in the gait parameters and the tripod area parameters between the healthy side and the affected side before operation ( P>0.05). Compared with the healthy side, the foot rotation angle, the single support line, the maximum force 1, the maximum force 2, and the maximum pressures of the forefoot and midfoot of the affected side significantly decreased after operation ( P<0.05), and the step length, the time maximum force of midfoot and hindfoot, and the contact time of the forefoot and midfoot significantly increased ( P<0.05). Compared with preoperative conditions on the same side, the foot rotation angle, the gait line length of both sides significantly decreased ( P<0.05), and the maximum pressures of the forefoot, midfoot, and hindfoot and the time maximum force of the midfoot significantly increased ( P<0.05); the step length on healthy side significantly decreased, while the affected side significantly increased ( P<0.05); the maximum force 1 and the maximum force 2 on the healthy side significantly increased, while the affected side significantly decreased ( P<0.05); the single support line on the affected side significantly decreased ( P<0.05). Different degrees of clinical symptoms occurred, gait pattern changes, compensatory gait appears, gait stability decreases, and the risk of tumble increases in adult patients after partial fibulectomy. Therefore, it is recommended to walk slowly after fibulectomy.

Clinical outcomes following tibiotalocalcaneal arthrodesis with intramedullary nailing combined with partial fibulectomy and onlay bone graft.

Although intramedullary nailing is a popular method for tibiotalocalcaneal arthrodesis, nonunion is one of the most commonly reported complications. This study aimed to evaluate the fusion rate, improvement in functional outcomes, and occurrence of complications in tibiotalocalcaneal arthrodesis using retrograde intramedullary nailing with partial fibulectomy and onlay bone graft technique. Twenty-six consecutive patients using the proposed technique were retrospectively reviewed. For radiographic outcomes, the union rate, alignment, and any related complications were assessed. Functional outcomes were evaluated using the American Orthopedic Foot and Ankle Society hindfoot scale, Foot and Ankle Outcome Score, and visual analog scale, preoperatively and at the final follow-up. The mean follow-up period was 38.2months. The tibiotalar joint achieved complete union in 80.8% at six months postoperatively, while all the cases achieved complete union at 12months postoperatively. However, the subtalar joint achieved complete union in 26.9% at six months postoperatively, which gradually increased to 73.1% at 12months postoperatively, and 80.8% at the final follow-up without revision surgery. A subgroup analysis showed there was a trend of higher subtalar fusion rate when an additional screw for the subtalar joint fixation was placed (86.7% vs. 54.5%). The functional outcomes significantly improved at the final follow-up. A few minor complications occurred, including surgical site infection, irritational symptoms, and metal failure; however, they eventually resolved. Our technique of tibiotalocalcaneal arthrodesis with partial fibulectomy and onlay bone grafting could be a good option where both the tibiotalar and subtalar joints need to be fused.

Combined dynamized nailing with partial fibulectomy for aseptic diaphyseal tibial nonunion in adults

Abstract Background and aim of the study Mechanical stability of hypertrophic nonunion remains the goal for treatment leading to bony bridging and remodeling. Partial fibulectomy or dynamization was reported with a wide range of clinical and radiological results. This study aims at assessment of combined dynamically locked nailing with partial fibulectomy technique to reach biological and mechanical stability with shorter healing time. Patients and methods This study included seventeen skeletally mature patients with aseptic diaphyseal hypertrophic tibial nonunion after nailing or external fixator. Patients with infected nonunion, atrophic nonunion, skeletally immature, and those with incomplete follow-up were excluded. Included patients were allocated into two groups, and final functional and radiological outcome regards healing time, union, limb alignment and rotation, knee and ankle rage of motions were reported. Results The mean follow-up period was 33.3 ± 6.2months. All nonunions healed successfully within 11.9 ± 1.5weeks (range: 10–16 weeks). One patient had tibial plafond injury that necessitated nail removal. The mean angle of coronal angulation was 1.4 ± 1.4°. The rotational difference between both limbs as per the thigh-foot angle was 2.5 ± 1.7°. The average functional outcome as per the Karlström-Olerud scale score was 30.9 ± 3. A significant difference was evident between the external fixator group and the nailing group in terms of functional grading scale (P=0.03). Conclusion The combined dynamically locked nailing with partial fibulectomy technique is a biology-preserving technique that provides mechanical stability, allows early return to functional activity with complete bone healing and no need for further surgeries.

Optimal location for fibular osteotomy to provide maximal compression to the tibia in the management of delayed union and hypertrophic non-union of the tibia

BackgroundTibial shaft fractures are the commonest long bone fracture, with early weight-bearing improving the rate of bony union. However, an intact fibula can act as a strut that splints the tibial segments and holds them apart. A fibular osteotomy, in which a 2.5 cm length of fibula is removed, has been used to treat delayed and hypertrophic non-union by increasing axial tibial loading. However, there is no consensus on the optimal site for the partial fibulectomy. MethodsNine leg specimens were obtained from formalin-embalmed cadavers. Transverse mid-shaft tibial fractures were created using an oscillating saw. A rig was designed to compress the legs with an adjustable axial load and measure the force within the fracture site in order to ascertain load transmission through the tibia over a range of weights. After 2.5cm-long fibulectomies were performed at one of three levels on each specimen, load transmission through the tibia was re-assessed. A beam structure model of the intact leg was designed to explain the findings. ResultsWith an intact fibula, mean tibial loading at 34 kg was 15.52 ± 3.26 kg, increasing to 17.42 ± 4.13 kg after fibular osteotomy. This increase was only significant where the osteotomy was performed proximal to or at the level of the tibial fracture. Modelling midshaft tibial loading using the Euler-Bernoulli beam theory showed that 80.5% of the original force was transmitted through the tibia with an intact fibula, rising to 81.1% after a distal fibulectomy, and 100% with a proximal fibulectomy. ConclusionThis study describes a novel method of measuring axial tibial forces. We demonstrated that a fibular osteotomy increases axial tibial loading regardless of location, with the greatest increase after proximal fibular osteotomy. A contributing factor for this can be explained by a simple beam model. We therefore recommend a proximal fibular osteotomy when it is performed in the treatment of delayed and non-union of tibial midshaft fractures.

Comparative study between functional outcome of high tibial osteotomy and partial fibulectomy in isolated medial compartment osteoarthritis of knee

Purpose: To compare the results of high tibial osteotomy with partial fibulectomy in the surgical management of isolated medial compartment osteoarthritis of knee and to reduce pain and deformity. Methods: patients visiting the outpatient department of S.C.S.M.S.R. with complaints of knee pain. Patients who were found to have isolated medial compartment osteo-arthritis will be included in the study. 50 patients were subjected to high tibial osteotomy and 50 patients were operated with partial fibulectomy. Functional outcome of both the procedure were compared with WOMAC score. Patients were followed up at 3 months 6 months and 9 months and reassessed. Result: There were a total of 100 patients with clinically and X-ray confirmed medial compartment osteoarthritis of knee (41 males and 59 females) with most patient in 51-60 year age group. mean pre operative WOMAC score was 82.38 and mean post operative score at 9 Month follow up was 38.43(p value

Anatomical basis of the support of fibula to tibial plateau and its clinical significance

BackgroundThe fibula is only indirectly involved in the composition of the human knee joint and has therefore been neglected in the research on knee osteoarthritis. Nonuniform settlement of the proximal tibia plateau is clinically defined as when the height of the medial tibial plateau is lower than that of the lateral side in medial compartment knee osteoarthritis (KOA). The non-uniform settlement of the proximal tibia plateau may be caused by fibular support on the lateral side. Orthopedic surgeons practice partial fibulectomy based on the clinical manifestation of nonuniform settlement, and this technique has been shown to reduce pain and improve function in patients with medial compartment KOA. However, this hypothesis of the mechanism of nonuniform settlement lacks an anatomical basis.MethodsThe P45 polyester plastination technique was used to prepare sections of the proximal tibiofibular joint to investigate the distribution of the bone trabeculae in the region of the lateral tibial plateau.ResultsThere was uneven distribution of trabeculae in the lateral condyle of the tibia and the head and neck of the fibula. The fibula and the posterolateral cortex of the shaft of the tibia united to form an arch beam via the tibiofibular joint. Many thick, dense trabeculae were present in a longitudinal direction above the tibiofibular arch.ConclusionsThe fibula supports the lateral tibial plateau, and the trabeculae were concentrated above the tibiofibular arch.

Management of early and late presenting tibial stress fracture with advanced osteoarthritis of the knee: A dilemma among arthroplasty surgeons in developing countries

BackgroundSingle-stage total knee arthroplasty (TKA) with long-stem is a viable option to treat proximal tibial stress fracture in advance knee osteoarthritis. However, in patients with old mal-united or non-united tibial fractures, treatment becomes complicated. Therefore, our aim in this study was to monitor clinical and radiological outcome in patients presenting early or late managed by single-stage long-stem TKA. MethodsThis retrospective study included 24 consecutive patients; all were female. Patients with recent and mobile stress fracture (Group A) were treated with close reduction and long-stem tibial component. However, in patients with old, sclerotic or mal-united fractures (Group B), open reduction, partial fibulectomy and plating with bone grafting was also performed. Outcome was monitored by tibiofemoral angle, functional Knee Society score and time taken for union. ResultsThe mean age of patients was 62.34 years. There were 13 patients in Group A and 11 in Group B. The mean follow up was 42.79 months (range, 18–72 months). Knee Society score improved from 29.83 ± 6.10 to 91.57 ± 4.89 in Group A and from 27.21 ± 3.32 to 89.87 ± 3.89 in Group B. Tibiofemoral angle improved from 20.57 ± 3.00° to 0.80 ± 0.46° in 21 varus knees, whereas it improved from 22.33 ± 4.61° to 0.83 ± 0.28° in three valgus knees. Iatrogenic perforation of tibial cortex occurred in one case. Union of stress fracture was achieved in all cases with a mean duration of 4.70 months. ConclusionExcellent results were obtained in both groups but were slightly lower in patients presenting late, therefore all efforts must be made to treat such cases as early as possible.

Tibia Stress Fracture and Subsequent Nonunion Associated With High Morbidity Following Vascularized Fibula Graft Harvest

There is little in the literature about tibial stress fracture after partial fibulectomy. As fibula strut grafting and vascularized fibula flap grafting becomes more common in the field of reconstructive surgery, the incidence of this complication will likely rise. The authors present the case of a 54-year-old woman with tibial stress fracture and subsequent nonunion following vascularized fibula graft harvest. The aim of this case report is to present a unique tibial stress fracture and nonunion following vascularized fibula flap for mandibular reconstruction and a discussion of the orthopedic management of this uncommon injury. The authors' goal is to educate both surgeons and patients about the altered biomechanics and subsequent risks associated with fibula strut graft harvest, from an orthopedic surgery perspective. By increasing physician awareness and obtaining better informed consent preoperatively, better health care outcomes associated with fibular graft harvesting can be obtained. [Orthopedics. 2021;44(2):e306-e308.].

Changes in patellar height and posterior tibial slope angle following uniplanar medial opening wedge high tibial osteotomy using a novel wedge-shaped spacer implanation concurrent with proximal partial fibulectomy.

The purpose of this study was to evaluate changes of patellar height and posterior tibial slope angle following uniplanar medial opening wedge high tibial osteotomy using a novel wedge-shaped spacer implanation concurrent with proximal partial fibulectomy. All patients who underwent uniplanar medial opening wedge high tibial osteotomy using a novel wedge-shaped spacer implanation concurrent with proximal partial fibulectomy between January 2017 and February 2019 were included and assessed retrospectively. Radiological assessment was made in terms of the changes in patellar height and posterior tibial slope angle between pre-operative and post-operative radiographs. Thirty-five patients (9 males and 26 females) with a mean age of 57.3 years (range 50.8-64.2 years) were enrolled in this study protocol and demonstrated decreased posterior tibial slope angle post-operatively (9.7° ± 2.5° pre-operatively and 7.3° ± 1.8° post-operatively, P < 0.001). Patellar height was unchanged significantly post-operatively (Caton-Deschamps: 0.83 ± 0.12 pre-operatively and 0.82 ± 0.09 post-operatively, P > 0.05). Uniplanar medial opening wedge high tibial osteotomy using a novel wedge-shaped spacer implanation concurrent with proximal partial fibulectomy can decrease posterior tibial slope and maintain the patellar height.

Comparison of Clinical and Biomechanical Outcomes between Partial Fibulectomy and Drug Conservative Treatment for Medial Knee Osteoarthritis.

Background Upper partial fibulectomy has been preliminarily proved to have the efficacy for pain alleviation and improvement of function in patients with mild to moderate medial compartment knee osteoarthritis (KOA). However, the previous studies lack the control group with other treatments. The aim of this prospective, randomized controlled study is to compare the clinical and biomechanical effects between upper partial fibulectomy and drug conservative treatment on improvement of clinical pain, function, and gait for patients with mild to moderate medial knee osteoarthritis (KOA) and further discuss its biomechanical mechanism. Methods From August 2016 to February 2017, 49 and 48 patients with mild to moderate medial KOA were allocated to fibulectomy and drug groups. We assessed the patients' visual analog scale (VAS) pain score, Hospital for Special Surgery (HSS) knee score, limb alignment, passive flexion/extension range of motion (ROM) of the knee, and 3D gait kinematics and kinetics parameters before and after intervention. Repeated-measures ANOVA with Dunnett's post hoc assessment and multivariate analysis of variance were applied for intragroup and intergroup comparisons, respectively. Results The improvement in the fibulectomy group on the VAS pain score, HSS knee score, walking speed, and walking knee range of motion (ROM) was statistically better than that in the drug group. The decreased overall peak knee adduction moment (KAM) (decreased by 16.1%) and hip-knee-ankle (HKA) angle (decreased by 0.99° from a more varus alignment to a more neutral alignment) of the affected and operated side 1 year after surgery were observed in the fibulectomy group. Conclusion This research demonstrated that as a biomechanical intervention, upper partial fibulectomy can be a better choice in pain relief and function and gait improvement than drug conservative treatment for patients with early-stage knee OA. The long-term clinical outcomes, indication, and rationale for the improvement in clinical symptoms should be investigated further.

Anatomical Adaptation of Fibula and its Mechanism of Proximal Partial Fibulectomy Associated with Medial Compartment Knee Osteoarthritis.

ObjectivesTo reveal the anatomical adaptation of the fibula and its relations to age and settlement of the medial tibial plateau, and to explore the mechanism of proximal partial fibulectomy in treating medial compartment knee osteoarthritis (OA).MethodsA retrospective study was performed in the Third Hospital of Hebei Medical University. Weight‐bearing full‐leg anteroposterior (AP) radiographs of 280 adults (560 knees) obtained from 1 January 2018 to 31 October 2018 were enrolled according to our inclusion and exclusion criteria, including 157 men and 123 women, with an average age of 50.3 ± 14.8 years (range, 19–80 years). Radiographic severity of knee OA was assessed using Kellgren and Lawrence (K–L) grading. The settlement of the medial tibial plateau was evaluated using the medial proximal tibial angle (MPTA). Curvatures of the tibia and the fibula were measured as proximal tibial curvature (PTC), distal tibial curvature (DTC), proximal fibular curvature (PFC), and distal fibular curvature (DFC). Two orthopaedic surgeons performed all the radiological measurements for 30 randomly selected patients, and repeated the measurements 1 week later. Based on the satisfactory intra‐observer and inter‐observer reliabilities (ICC > 0.9), each parameter was analyzed in this study. Multivariable linear regression models were used to examine relations between radiological measurements and age.ResultsThe mean MPTA, PTC, DTC, PFC, and DFC were 85.4° ± 2.8°, 176.2° ± 1.9°, 176.8° ± 1.8°, 176.8° ± 1.9°, and 177.0° ± 2.0°, respectively. Ninety‐three knees of K–L grade I were categorized as non‐knee OA, and 467 knees of K–L grades II–IV were categorized as knee OA. The MPTA, PTC, and PFC of the knee OA group were significantly smaller than those of non‐knee OA group (P < 0.05). The K–L grade of knee OA significantly increased with age (χ 2 = 182.169, P < 0.01). The multivariate linear regression analysis indicated that the MPTA and fibular curvatures were negatively correlated with age (the regression equation is age = 561.165–0.945 MPTA‐0.937 PFC‐0.959 DFC, P < 0.05), and the MPTA was negatively correlated with PFC (the regression equation is MPTA = 7.827 + 0.099 DFC, P < 0.05).ConclusionsThe proximal curve of the fibula increased in patients with medial compartment knee OA, and this change was positively correlated with age and settlement of the medial tibial plateau. This anatomical adaptation of the fibula was associated with greater fibular axial load and the pulling from the peroneus longus. The proximal partial fibulectomy procedure effected a receptive foot pronation to reduce KAM and rebalance the biceps‐proximal fibula–peroneus longus complex, consequently achieving medial compartment unloading.

Supramalleolar osteotomy for treatment of post-traumatic angular tibial deformities affecting the ankle joint

Background Angular deformities of the leg resulting from malunion of distal tibial fractures or physeal arrest in skeletally immature patients are usually associated with ankle and foot pain secondary to disturbed mechanics and joint overload and could inevitably lead − if uncorrected − to degenerative arthritis. This prospective, case series study aims to evaluate the functional and radiological outcomes of supramalleolar corrective osteotomies for treating symptomatic angular deformities of the tibia and to assess its role in preventing or postponing degenerative arthritis of the ankle joint. Patients and methods This study included 18 patients presented with symptomatic angular tibial deformities secondary to malunion of previous distal tibial fractures or post-traumatic physeal arrest. Twelve patients had varus deformities of the ankle, while six patients had valgus deformities. Partial fibulectomy proximal to the level of the planned osteotomy was initially done in all patients; varus deformities were corrected with medial opening-wedge osteotomy and bone grafting with or without tibial fixation, while valgus deformities were corrected with medial closing-wedge osteotomy fixed by plates and screws. The ankle–hindfoot scale of the American Orthopaedic Foot and Ankle Society was used for evaluating the functional results preoperatively and postoperatively. Results The mean age of the patients at presentation was 17.6±5.9 years (ranged from 10 to 44 years). All the osteotomies united in an average duration of 10±4.8 weeks (ranged from 7 to 15 weeks) with no reported surgery-related complications apart from delayed wound healing in two cases. The deformity was clinically improved in all the 18 patients, while the radiological parameters were satisfactory in 16 patients with statistically significant improvement (P Conclusion Supramalleolar osteotomy is an effective procedure for treating symptomatic angular deformities of the tibia. Supramalleolar osteotomies − not only − correct the deformity and improve the functional outcome, but also represent a joint-preserving surgery protecting the articular cartilage through correcting the mechanics and equally redistributing the joint loads thus preventing progressive degenerative arthritis.

Evidence and mechanism by which upper partial fibulectomy improves knee biomechanics and decreases knee pain of osteoarthritis.

To investigate the change in short-term clinical outcomes and biomechanical properties of the knee in response to upper partial fibulectomy and to probe into the biomechanical mechanism underlying the clinical benefits of upper partial fibulectomy for medial compartment knee osteoarthritis (KOA). A total of 29 patients with medial compartment KOA underwent upper partial fibulectomy. Visual analog scale (VAS) pain, the hospital for special surgery knee score (HSS), hip-knee-ankle (HKA) angle (measured in the frontal plane), and flexion/extension range of motion of the knee were assessed before and up to 6 months after surgery. Patients and 20 healthy controls were evaluated by 3D gait analysis and dynamic lower limb musculoskeletal analysis. Both VAS pain and HSS score were significantly improved (p < 0.001) one day after surgery and steadily improved during the subsequent 6 months. HKA angle improved (p = 0.025) immediately and remained stable by 3 months after surgery. The decreased overall peak KAM (decreased by 11.1%) and increased HKA angle (increased by 1.80 degrees from a more varus to more neutral alignment) of affected and operated side by 6 months after surgery were observed. Muscle activity of biceps femoris caput longum of affected and operated side increased immediately and was equivalent to healthy controls by 6 months after surgery (p = 0.007). This pilot study provides biomechanical evidence of benefit from partial upper fibulectomy and indicates a plausible rationale for the improvement in clinical symptoms. Long-term clinical outcomes and precise biomechanical mechanism of partial upper fibulectomy should be further investigated. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 9999:1-10, 2018.

Upper partial fibulectomy improves knee biomechanics and function and decreases knee pain of osteoarthritis: A pilot and biomechanical study

To investigate the change in clinical outcomes and biomechanical properties of the knee in response to upper partial fibulectomy. Sixteen patients with medial compartment knee osteoarthritis (KOA) underwent upper partial fibulectomy. Visual analog scale (VAS) pain, the hospital for special surgery knee score (HSS), hip-knee-ankle (HKA) angle (measured in the frontal plane), and flexion/extension range of motion of the knee were assessed before and up to 6 months after surgery. Patients were evaluated for gait parameters and overall peak knee adduction moment (KAM). Patient-specific finite element knee models were developed to investigate changes in load in response to fibulectomy. Both VAS pain and HSS score were significantly improved (P < .001) one day after surgery and steadily improved during the subsequent 6 months. HKA angle improved (P = .006) immediately and remained stable by 3 months after surgery. A significant inverse relationship (R = −0.528, P = .012) between the overall peak KAM (decreased by 19.1%) and the HKA (increased by 1.24° from a more varus to more neutral alignment) angle was observed. The minor load supported by the fibula preoperatively was spread post-operatively over the cortical bone of the tibial shaft. The mean stress in the medial tibial plateau was significantly decreased (P < .001), with a portion of the stress transferred to the posterior-lateral region of the tibial plateau after upper partial fibulectomy. This pilot study provides objective 3D gait and plausible biomechanical evidence for the improvement in clinical symptoms from partial upper fibulectomy.

Poster 289: Utility of Dynamic Sonographic Examination and Intervention in the Management of Proximal Tibiofibular Joint Osteoarthritis in the Context of Partial Fibulectomy: A Case Report

PM&RVolume 9, Issue 9S1 p. S223-S223 MSK & Sports Medicine Poster Hall: Case Report Poster 289: Utility of Dynamic Sonographic Examination and Intervention in the Management of Proximal Tibiofibular Joint Osteoarthritis in the Context of Partial Fibulectomy: A Case Report Allison N. Schroeder, Allison N. Schroeder University of Pittsburgh Medical CenterSearch for more papers by this authorKentaro Onishi DO, FAAPMR, Kentaro Onishi DO, FAAPMR University of Pittsburgh Medical CenterSearch for more papers by this author Allison N. Schroeder, Allison N. Schroeder University of Pittsburgh Medical CenterSearch for more papers by this authorKentaro Onishi DO, FAAPMR, Kentaro Onishi DO, FAAPMR University of Pittsburgh Medical CenterSearch for more papers by this author First published: 19 September 2017 https://doi.org/10.1016/j.pmrj.2017.08.228Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume9, Issue9S12017 AAPM&R Annual Assembly AbstractsSeptember 2017Pages S223-S223 RelatedInformation

A Novel 'Transfibular Approach' for the Nonunion of a Tibial Shaft Fracture with Poor Anteromedial Soft Tissue Cover.

The need for an ideal approach for the nonunion of the tibial shaft with anteromedial soft tissue scarring has long baffled surgeons. Many different approaches have been suggested in the past, but all those approaches were haggled by a multitude of problems. We have described a novel 'transfibular approach' for this selective situation. An appropriate patient with a mid-shaft tibial non-union was selected. After preoperative workup, the patient underwent an open reduction internal fixation (ORIF) with lateral tibial plating, bone grafting, and partial fibulectomy. In this new approach, the plane between tibialis anterior and extensor hallucis longus was used combined with a conventional posterolateral approach using the same incision. Subsequently, the patient was followed up for adequacy of the fixation and wound-related problems with a convincing outcome.

Results of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunions.

The purpose of this study was to evaluate the effectiveness of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunion. Retrospective cohort. Tertiary referral center. Forty-six aseptic tibial nonunion sites in 40 patients (2 bilateral and 4 segmental) who presented with an intramedullary nail on an average of 16 months after the initial treatment were presented in this study. Insertion of an exchange nail of at least >2-mm diameter than the prior nail using a different manufacturer's nail, static interlocking, partial fibulectomy in a select group of patients, and correction of underlying metabolic and endocrine abnormalities. Union rate, time to union. Forty-five of 46 tibial nonunion sites (98%) healed at an average of 4.8 months. Patient selection criteria and a systematic approach to exchange nailing for tibial nonunion is highly successful. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

An operative approach to address severe genu valgum deformity in the Ellis-van Creveld syndrome

BackgroundThe genu valgum deformity seen in the Ellis-van Creveld syndrome is one of the most severe angular deformities seen in any orthopaedic condition. It is likely a combination of a primary genetic-based dysplasia of the lateral portion of the tibial plateau combined with severe soft-tissue contractures that tether the tibia into valgus deformations. Progressive weight-bearing induces changes, accumulating with growth, acting on the initially distorted and valgus-angulated proximal tibia, worsening the deformity with skeletal maturation. The purpose of this study is to present a relatively large case series of a very rare condition that describes a surgical technique to correct the severe valgus deformity in the Ellis-van Creveld syndrome by combining extensive soft-tissue release with bony realignment.MethodsA retrospective review examined 23 limbs in 13 patients with Ellis-van Creveld syndrome that were surgically corrected by two different surgeons from 1982 to 2011. Seven additional patients were identified, but excluded due to insufficient chart or radiographic data. A successful correction was defined as 10° or less of genu valgum at the time of surgical correction. Although not an outcomes study, maintenance of 20° or less of genu valgum was considered desirable. Average age at surgery was 14.7 years (range 7–25 years). Clinical follow-up is still ongoing, but averages 5.0 years (range 2 months to 18 years). Charts and radiographs were reviewed for complications, radiographic alignment, and surgical technique. The surgical procedure was customized to each patient’s deformity, consisting of the following steps: Complete proximal to distal surgical decompression of the peroneal nerveRadical release and mobilization of the severe quadriceps contracture and iliotibial band contractureDistal lateral hamstring lengthening/tenotomy and lateral collateral ligament releaseProximal and distal realignment of the subluxed/dislocated patella, medial and lateral retinacular release, vastus medialis advancement, patellar chondroplasty, medial patellofemoral ligament plication, and distal patellar realignment by Roux-Goldthwait technique or patellar tendon transfer with tibial tubercle relocationProximal tibial varus osteotomy with partial fibulectomy and anterior compartment releaseOccasionally, distal femoral osteotomyResultsIn all cases, the combination of radical soft-tissue release, patellar realignment and bony osteotomy resulted in 10° or less of genu valgum at the time of surgical correction. Complications of surgery included three patients (five limbs) with knee stiffness that was successfully manipulated, one peroneal nerve palsy, one wound slough and hematoma requiring a skin graft, and one pseudoarthrosis requiring removal of hardware and repeat fixation. At last follow-up, radiographic correction of no more than 20° of genu valgum was maintained in all but four patients (four limbs). Two patients (three limbs) had or currently require revision surgery due to recurrence of the deformity.ConclusionThe operative approach presented in this study has resulted in correction of the severe genu valgum deformity in Ellis-van Creveld syndrome to 10° or less of genu valgum at the time of surgery. Although not an outcomes study, a correction of no more than 20° genu valgum has been maintained in many of the cases included in the study. Further clinical follow-up is still warranted.Level of evidenceIV.

Partial fibulectomy for treatment of tibial nonunion

BackgroundDespite the improved rate of union reported in tibial shaft fractures, there continues to be a small number of patients with delayed union and nonunion who present a dilemma to the surgeons. Because the spectrum of injuries to the tibia is so great, many methods of treatment are available to treat tibial nonunions.AimThe aim of the study was to evaluate partial fibulectomy as an easy, simple, and effective treatment option in the treatment of certain types of tibial nonunions.Patients and methodsThis prospective study included 20 patients with established tibial nonunion. All patients were evaluated clinically in laboratory and radiologically before surgery and followed up until after complete union of the tibial fractures.ResultsAll fractures were united at an average duration of 15 weeks (range 10-19 weeks) after partial fibulectomy, with acceptable alignment in the coronal and sagittal planes. There were no neurovascular complications, no limitation of joint motion, and no problems at the fibulectomy site.ConclusionThe results were very satisfactory and were significantly in favor of using this easy, simple procedure in the treatment of certain patients of tibial nonunions.