Transfibular Approach Research Articles

Complications and outcomes of the transfibular approach for posterolateral fractures of the tibial plateau

ObjectiveEvaluate complication rates and functional outcomes of fibular neck osteotomy for posterolateral tibial plateau fractures. DesignRetrospective case series. SettingUniversity hospital. PatientsFrom January 2013 to October 2014, 11 patients underwent transfibular approach for posterolateral fractures of the tibial plateau and were enrolled in the study. All patients who underwent transfibular approach were invited the return to the hospital for another clinical and imaging evaluation. InterventionTransfibular approach (fibular neck osteotomy) with open reduction and internal fixation for posterolateral fractures of the tibial plateau. Main outcome measurementsComplications exclusively related to the transfibular approach: peroneal nerve palsy; knee instability; loss of reduction; nonunion and malunion of fibular osteotomy; and functional outcomes related to knee function. ResultsTwo patients failed to follow-up and were excluded from the study. Of the 9 patients included in the study, no patients demonstrated evidence of a peroneal nerve palsy. One patient presented loss of fracture reduction and fixation of the fibular neck osteotomy, requiring revision screw fixation. There were no malunions of the fibular osteotomy. None of the patients demonstrated clinically detectable posterolateral instability of the knee following surgery. American Knee Society Score was good in 7 patients (77.8%), fair in 1 (11.1%), and poor in 1 (11.1%). American Knee Society Score/Function showed 80 points average (60–100, S.D:11). ConclusionThe transfibular approach for posterolateral fractures is safe and useful for visualizing posterolateral articular injury. The surgeon must gently protect the peroneal nerve during the entire procedure and fix the osteotomy with long screws to prevent loss of reduction. Level of evidenceTherapeutic level IV.

A case report on trans-fibular approach to distal tibial giant cell tumor

Surgical excision of tumors of distal tibia situated specially in poster lateral aspect may be difficult to visualize in its entirety by antero-lateral approach. If posterior approach is chosen, the difficulty in positioning of the patient and important structures behind may cause hesitation in surgeons mind. The trans-fibular approach in selected cases may be indicated for full visualization of the tumor boundary in its entirety. We report one case of osteoclastoma of distal tibia in which osteotomy and subsequent replacement of distal fibula and fixation with a semitubular plate, allowed complete excision of tumor and satisfactory outcome. This procedure provides an alternative technique to the anterior approach.

Total ankle replacement through a lateral approach: surgical tips.

Purpose: Recently, the Zimmer Trabecular Metal Total Ankle Replacement (Zimmer TM TAR) was developed to be used through a lateral transfibular approach. The purpose of this paper is to describe the surgical technique and early outcomes of the TAR via the lateral approach using the Zimmer TM TARs. Methods: Sixty-seven patients underwent primary TAR using the Zimmer TM TAR between May 2013 and May 2015. Patients were clinically evaluated preoperatively and postoperatively at six and twelve months and annually using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot scores, visual analogue scale (VAS) pain score, and the Short Form Health Survey (SF-12) questionnaire. The minimum follow-up was 12 months. Results: The mean AOFAS hindfoot score increased from 32.8 preoperatively to 85.0 at the latest follow-up (p-value < 0.001). The mean VAS pain score decreased from 8.0 to 2.0 at the latest follow-up (p-value < 0.001). The Physical and Mental Health Composite Scale scores (PCS and MCS) of the SF-12 passed from a mean value of 30.2 preoperatively to 43.1 (p-value < 0.001) and from a mean value of 44.6 to 53.5 at the latest follow-up (p-value < 0.001), respectively. Conclusions: We present our surgical tips and the early results of this prosthetic design which are encouraging. They could be useful as an adjunct to the manufacturer’s surgical technique guidance for surgeons who utilize these implants.

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.

Ankle arthrodesis from lateral transfibular approach: analysis of treatment results of 23 feet treated by the modified Mann's technique.

The aim of the study was to analyze the results of treatment by ankle arthrodesis by modified Mann's technique. The study included 23 patients, and a total of 23 feet were treated. Stabilization of arthrodesis was performed by two screws going from the sinus tarsi to the talus and tibia. Lateral part of the fibula was fixed with one or two screws to the talus and tibia. No additional medial approach to the ankle was performed. In 16 feet, arthrodesis was done due to secondary posttraumatic osteoarthritis, in five due to paralytic drop foot and in two due to osteoarthritis of unknown etiology. In 18 patients, the purpose of arthrodesis was also to correct the malalignment. The average age at operation was 46 (range 19-74) years. The average follow-up was 32 (range 12-69) months. At follow-up, the average AOFAS score was 76 points and subjective scale result 7.9 points. The correct alignment was not achieved in three feet. In one foot, fusion was not achieved and the patient needed repeated operation. The study has confirmed the effectiveness of the technique.

Tibiotalokalkaneare Korrekturarthrodese bei Charcot-Arthropathie des oberen Sprunggelenks mit dem retrograden Nagel

Involvement of the ankle joint in Charcot osteoarthropathy is most often associated with severe instability and fracture or collapse of the talus. Caused by malalignment, ulcerations over both malleoli are associated with increased risk of major amputation. The goal of the operation is to realign the hind foot, gain a stable osteosynthesis, and prevent major amputation. Charcot osteoarthropathy of the ankle joint with instability, with or without soft tissue involvement, failure of the primary arthrodesis of the ankle or subtalar joint. Acute osteitis/osteomyelitis, severe malalignment of the distal tibia, soft tissue infection close to the ankle joint. Realignment of the hind foot, preparation of the joint surfaces using a transfibular approach. Bone grafting of the defects, stable osteosynthesis with an anatomically shaped retrograde locking nail. Walker or cast for at least 12 weeks, 6 weeks no weight bearing. Partial weight bearing starting from week 7. X-ray control at 2, 6, and 12 weeks. After 12 weeks, walking in an ankle brace until fully consolidated.

The utility and limitations of the transfibular approach in ankle trauma surgery.

The commonly used extensive approaches to the distal tibia include the posteromedial and anterolateral approaches. The current report describes several cases performed using this technique establishing a rationale and safe zone for performing a transfibular approach to the distal tibia. The advantages of such approach are the excellent visualization of the lateral tibia and the articular space. The utilization of this approach involves the risk of injury to the anterior tibial vessels and to the superficial peroneal nerve as well as a requirement for syndesmosis reconstruction. The recommendation is to utilize this approach in cases of severe comminution of the lateral tibia with a relatively intact medial tibia.

Ankle Arthrodesis Outcomes in Ankle Osteoarthritis: Comparison between Anterior Approach and Transfibular Approach

Ankle Arthrodesis Outcomes in Ankle Osteoarthritis: Comparison between Anterior Approach and Transfibular Approach

Fashioning autologous bone graft from the fibula in the transfibular approach to open ankle arthrodesis.

Open ankle arthrodesis is one of the primary operations for disabling ankle arthrosis. The transfibular lateral approach to ankle fusion is a common approach for open ankle arthrodesis. Autologous bone graft can be harvested from the osteotomised fibula. We describe a safe technique of taking graduated slices of fibula bone graft, which allows optimal fibula length excision and are suitable in shape to pack into defects at the fusion site.

Anatomical Evaluation of Different Approaches for Tibiotalocalcaneal Arthrodesis

The transfibular approach is commonly used for tibiotalocalcaneal arthrodesis. However, the medial and the posterolateral approaches are available as alternatives. The present study was performed to assess the effects of the 3 approaches on the neurovascular structures encountered and to quantify the extent of cartilage in the different joint compartments that could be surgically debrided. This cadaver study was performed in 6 pairs of formalin-fixed legs (mean donor age: 80 years; 4 females, 2 males). For each approach, 4 specimens were selected. The neurovascular structures at risk and the debrided portions of the articular cartilage were compared. Arterial structures were least compromised by the transfibular approach. The posterolateral approach was particularly likely to damage the lateral malleolar branches of the peroneal artery. Venous structures were at risk mainly from the medial approach, which was also the most risk-bearing of the 3 approaches in terms of nerve damage. The proportions of cartilage-debrided joint surfaces of the tibia in the ankle joint, and of the talus and the calcaneus in the subtalar joint, did not differ notably. The proportions of debrided surfaces of the talus in the ankle joint differed notably among the 3 approaches. The medial approach could be a valid alternative to the lateral transfibular approach for tibiotalocalcaneal arthrodesis. Care should be taken, however, to prevent damage to the saphenous nerve and other neurological structures. Access morbidity and feasibility of adequate cartilage debridement are relevant to the clinical outcome of hindfoot arthrodesis.

Posterolateral and anterolateral approaches to unicondylar posterolateral tibial plateau fractures: A comparative study

BackgroundLateral tibial plateau fractures that are located posterolaterally are difficult to reduce through an anterolateral surgical approach because of the lack of direct visualisation of the fracture. This study compared the results of unicondylar posterolateral tibial plateau fractures in two patient cohorts: one treated through a posterolateral direct approach and the other through an anterolateral indirect approach. Patients and methodsAll nine patients admitted to our hospital, a tertiary care, urban, public hospital in Australia, from 2007 to 2010 with unicondylar posterolateral tibial plateau fractures were treated through a direct posterolateral transfibular approach and prospectively studied. All eight patients admitted from 2004 to 2007 with unicondylar posterolateral tibial plateau fractures were treated through an indirect anterolateral approach and retrospectively reviewed. Fracture reduction and maintenance of reduction were assessed radiographically over 2 years. Knee function was assessed clinically and using the Lysholm score. ResultsFractures managed through a direct posterolateral transfibular approach were reduced with no measurable articular step on standard radiography and had no loss of reduction over time. By contrast, fractures treated through an indirect anterolateral approach had a median postoperative articular step of 5.5mm (interquartile range=4.5). These displacements worsened over time in six of the eight patients. At 2 years, patients treated through a direct approach had significantly better Lysholm scores than those treated through an indirect approach. ConclusionThis study suggests that a direct posterolateral transfibular approach to unicondylar posterolateral tibial plateau fractures results in improved reduction, stabilisation and functional outcomes at early follow-up compared to an indirect anterolateral approach.

R-T1.2 A new plate for the treatment of Lisfranc's fracture

Introduction: In 1986 Jean Martin Charcot describes an unusual hypertrophic destruction of the ankle joint. As of today one third of all diabetics bare the risk of developing the Charcot neuropathic osteoarthropaty. The tibial compartment instability usually has 3 staged progressive collapse: arthrosis of the hind-foot, talar valgisation and medial instability (Myerson et al). The clinical evaluation includes evolution of the pain, soft tissues condition and the neurovascular status. Materials and Methods: Between 2007–2011 (5 years period) we had operated 10 patients (4 male, 6 female), mean age of 57.5 years. Posttraumatic arthrosis was found in 6 cases, 2 had open fractures, 1 had previous screw arthrodesis and 1-diabetic arthropathy. The surgical technique used was as follows: supine position of the patient, transfibular approach, resection of the joint surfaces (distractor can be used as well), the medial malleolus has to be saved (not so only when medial shift exists), the foot must be positioned in 5° of dorsiflexion (neutral) and 5° of valgus (usually the anterior tibial border points towards the second toe). Results: We have achieved arthrodesis in all cases. There were no non-unions, vascular or neurological compromise. We have observed the following mistakes: wrong proximal locking in 1 case and medial maleollus fracture in 1 case. Conclusion: As a final outcome we have achieved pain-free ankle joint. Both the pantallar and tibio-talo-calcanear arthrodesis have good results and better advantages, compared to the amputation. The IM nail secures the rigidity of the fixation when compared to the crossed screw placement. The postero-anterior positioning of the screws in the calcaneus after direct compression is applied, increases the tosrional resistance by 40% (Mann MR, Parks BG, Pak SD, Miller SD). The complication and revision procedures rate is very low as well.

Tibiotalocalcaneal Arthrodesis with Combined Retrograde Intramedullary Nail and Lateral L-plate

Achieving stable fixation when performing tibiotalocalcaneal or tibiocalcaneal arthrodesis can be challenging. Patients undergoing these procedures often have osteopenia, poor bone stock, fragmentation of the bones of the foot and ankle, joint subluxation, or even dislocation. The author describes a technique of tibiotalocalcaneal arthrodesis with intramedullary nail fixation augmented by lateral plating through the transfibular approach. This can provide excellent exposure of the ankle and subtalar joints, morselized bone for grafting, and better construct stability.

Tibiocalcaneal arthrodesis using retrograde insertion of a compression nail

OPERATION GOAL: Arthrodesis of the upper and lower ankle joint because of problematic bone positioning or failed arthrodesis. Osteosynthesis procedure using a retrograde compression nail. To achieve stable, fully weight-bearing osteosynthesis for early, pain-free mobilization. Rearthrodesis because of failure of the conventional arthrodesis technique and development of osteoarthritis of the lower ankle joint. Painful osteoarthritis of the upper ankle joint because of inadequate perfusion or a major bone defect because of sclerosis or necrosis. Primary arthrodesis because of facture of the lower leg (pilon tibial) with joint involvement and preexisting osteoarthritis. Acute osteitis/osteomyelitis, sclerosis in the marrow of the distal tibia, malalignment of the distal tibial shaft and local soft tissue inflammation. Preparation of the articular surface of the upper and lower ankle for arthrodesis using a transfibular approach. If necessary, correction of bone defects with iliac crest spongiosa. Stabile osteosynthesis by retrograde insertion of a compression nail. A split lower leg cast on the 2nd postoperative day, mobilization of the patient with underarm crutches with floor contact for 2weeks, then with application of a lower leg walking cast for 8weeks with partial weight-bearing for 4weeks and full weight-bearing for the last 4weeks of cast fixation. X-ray controls immediately postoperatively, then after 6 and 12weeks. From 2006 to 2008, 12patients (7men, 5women; mean age 59years) with various indications were treated with retrograde insertion of a compression nail. All patients were routinely controlled radiologically and clinically after 2, 4, 8 and 12weeks. Follow-up was carried out at 6, 12 and 24months. All arthrodeses showed osseous consolidation 16 weeks postoperatively. Tenpatients were able to use full weight-bearing without pain after 12 weeks. Twopatients reported experiencing pain after walking for 2h. In total three complications occurred: one hindfoot healed with varus malalignment; one patient fell, fracturing the lower leg above the nail; one distal locking screw loosened.

Outcome of Ankle Arthrodesis Using a Transfibular Approach

Variable union rates in ankle arthrodesis using different surgical techniques have been reported in the biomedical literature. However, the advantages of a transfibular approach with sagittal splitting of the fibula have not been widely reported, even though the technique is well known and even described in surgical textbooks. We analyzed outcomes in our practice for all patients who underwent ankle arthrodesis. Over a 5-year period, 2 surgeons using the same transfibular approach performed 26 ankle arthrodeses in 25 patients. The medical records and radiographs of the patients were reviewed for duration of hospital admission, time to union, and complications. All (100%) of the ankle fusions progressed to solid union in a mean postoperative duration of 4.5 ± 1.8 months (range, 2-10 months), and the only clinically significant complication involved 1 patient with suspected complex regional pain syndrome, who responded to treatment and recovered fully.

Technical Guide: Transfibular Ankle Arthrodesis with Fibular-Onlay Strut Graft

A wide range of techniques have been described for ankle arthrodesis, and although all of these have been shown to provide stability, few have been shown to achieve a solid construct in patients at risk of nonunion. In this technical guide, we describe a modified transfibular approach to ankle arthrodesis that uses a fibular-onlay strut graft for use in patients at high risk for nonunion. In our experience, the technique has been effective and reliable.

Popliteal block with transfibular approach in ankle arthrodesis: a case series

IntroductionAnkle arthrodesis is primarily undertaken to control severe pain in the ankle joint. Immediate postoperative pain is usually treated using oral analgesics, intravenous opiates and regional anaesthesia. The outcomes of ankle fusion, including patient satisfaction studies, are well documented in the literature. However, the advantage of popliteal block in the management of early postoperative pain after ankle fusion for osteoarthritis has not been widely reported. This study aims to determine the role of popliteal block using ankle fusion in the management of ankle osteoarthritis.Case presentationAnkle arthrodeses were performed in 27 patients over a five-year period. Eighteen patients were males (one had bilateral arthrodesis) and eight were females. Their mean age was 56 years and they were all Caucasians. The notes and radiographs of the patients were reviewed in retrospect for the duration of their hospital admission, time to union and complications.ConclusionPopliteal block is a safe and effective technique for postoperative analgesia in ankle arthrodesis. By using this technique, we achieved a significant reduction in the duration of hospital stay for our patients after ankle arthrodesis. The resultant cost saving was GBP717 for each patient.

An Enlarging Distal Tibia Osteochondroma in the Adult Patient

The extensive enlargement of a solitary osteochondroma in a skeletally mature patient is rare and might result from malignant transformation. Excision of such a lesion in the distal and lateral aspect of the tibia is difficult because of the risk of injury to the neurovascular structures and the possible functional consequences with respect to ankle stability. We present a case of an active osteochondroma arising from the posterolateral distal tibia in an adult patient. The tumor was successfully excised by using a transfibular approach with fibular reconstruction. No signs of recurrence were noted 2 years after surgery.

Femoral Head Allograft for Large Talar Defects

Large talar body defects after total or subtotal talectomy present a difficult treatment dilemma for the reconstructive foot and ankle surgeon. Treatment of these defects includes tibiocalcaneal fusion, but this leaves the patient with significant limb shortening. Tibiotalocalcaneal fusion can be done if there is a subtotal talectomy with the talar head and neck remaining. This technique is done with some form of structural or cancellous graft with internal or external fixation. These fusions are technically challenging and often involve harvesting large autografts from the iliac crest. The technique described involves a less complex reproducible 1-stage reconstruction for large talar defects using a transfibular approach with placement of a femoral head allograft in a fusion bed prepared by acetabular reamers.

Fibular Rotational Osteotomy for the Treatment of Distal Tibial Osteochondroma: A Technical Modification for Deformity Correction and Improved Outcomes

The technique of choice for excision of osteochondromas located in the lateral aspect of the tibia is a transfibular approach to expose the lesion for resection. A drawback of this approach is that removal of the lesion leaves a void that may cause a visible deformity and adversely affect long-term function. Fibular rotational osteotomy followed by fibular graft may minimize the resultant deformity, producing a more satisfactory functional and cosmetic result. The authors report a retrospective case series consisting of 5 cases in which a fibular graft rotation was performed after rotational osteotomy via a transfibular approach. Retrograde intramedullary fixation by means of a Kirschner wire, in combination with the design of the fibular osteotomy, provided rotational graft and fibular stability until healing occurred.