The association between fibular status and frontal plane tibial alignment post-union in congenital pseudarthrosis of the tibia

PurposeControversy exists regarding fibular status related to tibial alignment after congenital pseudarthrosis of the tibia (CPT) achieves union. We aimed to determine whether fibular status affected frontal plane tibial alignment post-CPT union.MethodsBetween January 2010 and December 2013, we followed 36 patients treated using a combined surgical technique (mean 6.6 years (2.2 to 9.4)). Outcome measures comprised medial proximal tibial angle, tibial diaphyseal angulation, lateral distal tibial angle (LDTA), relative intramedullary rod length and relative fibula length discrepancy.ResultsThe frequency of proximal tibial valgus deformity and ankle valgus deformity were significantly lower in the fibular integrity group than in the fibular un-integrity group (proximal tibial valgus deformity: 2/17 versus 11/19; p = 0.006; ankle valgus deformity: 10/17 versus 18/19; p = 0.016). The mean LDTA was notably higher in the fibular integrity group than in the fibular un-integrity group (81.2° (sd 6.7°) versus 71.3° (sd 6.6°); p < 0.001). A statistically significant difference was observed in relative fibula length discrepancy between patients with fibular integrity (0.06 (0 to 0.11); Malhotra grade 0, n = 6; Malhotra grade I, n = 11) and those without (0.24 (0.01 to 0.36); Malhotra grade 2, n = 2; Malhotra grade 3, n = 17; p < 0.001). Ankle valgus deformity had a significant positive correlation with proximal tibial valgus deformity (r = 0.402; p = 0.015). Patients with an intact and normal length fibula had a lower frequency of ankle valgus deformity than those with an intact but shortening fibula (1/6 versus 9/11; p = 0.035).ConclusionShortening or pseudarthrosis of the fibula was associated with ankle valgus and proximal tibial valgus deformities post-CPT union.Level of evidenceIII     

Valgus Ankle Deformity After Vascularized Fibular Reconstruction for Oncologic Disease

Background  Previous studies highlight the risk of valgus ankle instability in children following vascularized fibular procedures. We have observed that persistent valgus instability results in valgus deformity in these ankles. The aim of this study was to explore the risk factors associated with valgus ankle deformity following vascularized fibular graft harvest. Methods  We present 31 patients with minimum follow-up of 2 years and maximum of 18 years. They underwent regular clinical evaluation of their ankles and routine radiological evaluation when valgus deformity became clinically apparent. Results  Five patients developed valgus ankle deformities. Risk factors for development of valgus deformity included age under 14 years (P = 0.02) and short [6 ± standard deviation (SD) 1 cm] residual fibular lengths (P = 0.02). Age-residual fibula index (age in years plus residual distal fibula length in centimeters) under 16 strongly predicted the development of ankle deformity (P = 0.0008). Short residual fibular lengths were not consistently associated with valgus deformity. Children developed focal lateral tibial epiphyseal atrophy and premature antero-medial fusion of the distal fibular physis resulting in a concave-anterior bowing of the fibula. Skeletally mature patients had congruent joints and posterior rotation of the proximal fibula without bowing. Conclusions  Mechanical causes cannot solely explain valgus ankle deformity following vascularized fibula harvest. Secondary changes due to growth arrest in the ankle significantly contribute to this deformity.     

Correction of ankle valgus by hemiepiphysiodesis using the tension band principle in patients with multiple hereditary exostosis

Background

Ankle valgus is a common deformity in patients with multiple hereditary exostoses (MHE) and a potential risk factor for early degenerative arthritis. In children, medial hemiepiphysiodesis of the distal tibia is a relatively simple surgical technique used to correct this deformity. We present here the first results of applying this procedure using the eight-Plate guided growth system (eight-Plate) for growth guidance.

Methods

Between 2006 and 2011 we performed hemiepiphysiodesis of the distal medial tibia in 30 ankles of 18 children with MHE using the eight-Plate. Weight-bearing total leg radiographs were obtained preoperatively, during follow-up and at the time of implant removal or when the distal tibial physis had closed. The lateral distal tibia angle (LDTA) was measured and fibular shortening assessed using the Malhotra classification. To evaluate the effect of hemiepiphysiodesis, we correlated the LDTA with age.

Results

The mean age at time of surgery was 12.6 (range 9.5–15.0) years, and the mean preoperative LDTA was 76.9° (range 68.5°–83.5°). During follow-up, the implant was removed in 12 extremities and the physis had closed in 18 extremities. The mean LDTA at the time of implant removal or at closure of the physis was 83.6° (range 76.5°–90.0°). Mean correction of LDTA was 6.9° after a mean follow-up period of 22 (range 3–43) months. During follow-up, no changes in the Malhotra classification were found in any of the patients. Correction of the valgus deformity of the ankle was significantly correlated (r = ?0.506) (p = 0.004) with age in all patients.

Conclusion

Temporary medial hemiepiphyseodesis of the distal tibia seems to be an effective strategy for correcting ankle valgus in children with MHE. Timing of the intervention is, however, of importance. Hemiepiphyseodesis alone has no effect on the Malhotra classification.

Level of evidence

IV, retrospective review.

     

The regeneration at non vascularized fibular harvest site and development of ankle valgus in donor leg-investigations done over two time points

IntroductionWe retrospectively observed the fibular regeneration in non vascularized harvest in children and development of ankle valgus at 2 time points to find any possible relationship between them.Material and methodsA 6 month period was chosen as the first time frame to assess regeneration and ankle valgus. Radiographs at this time and a subsequent follow up were studied for regeneration, lateral distal tibial ankle (LDTA) and fibular station. The donor sites were divided into complete and incomplete regeneration groups and compared statistically.ResultsThere were 12 patients with 18 harvested fibulae. Ten out of 18 fibulae (56%) had complete longitudinal regenerate at 6 months. Two fibulae underwent delayed union. Of 8 incomplete regenerates at 6 months, 6 (75%) were also incomplete beyond a follow up of 2.75 years. Incomplete group had radiological ankle valgus in 6 legs (75%) at 6 months increased to 7 at follow up. Further, LDTA for incomplete group was significantly lower than complete group (p = 0.025) at 6 months.ConclusionsMore than half of harvested legs (56%) had complete longitudinal fibular regeneration at 6 months. Of incomplete regenerates at 6 months, three fourth remained so beyond 2.5 years. Ankle valgus was found strongly related to long standing fibular non regeneration. Radiological ankle valgus developed early in the incomplete regenerate group.     

Is the Fibular Station on Lateral Ankle Radiographs Symmetric? A Retrospective Observational Radiographic Study

BackgroundPrecise reduction of a syndesmosis after disruption is critical to improve patient physical function. Intraoperative lateral radiographs of the unaffected ankle are often used in clinical practice as a template for anatomic syndesmotic reduction because sagittal plane malreduction is common. However, there is little data to suggest fibular station, or the position of the fibula in the AP plane on the lateral radiograph, is symmetric side-to-side in patients.Questions/purposes(1) Is the position of the fibula in the AP plane (fibular station) on lateral ankle radiographs symmetric in an individual? (2) Do the measurements used to judge the position of the fibula on lateral radiographs have good inter- and intraobserver reliability?MethodsOver the period from August 2016 to October 2018, we identified 478 patients who presented to an orthopaedic clinic with forefoot and midfoot complaints. Skeletally mature patients with acceptable bilateral lateral ankle radiographs, which are common radiographs obtained for new patients to clinic for any complaint, were included. Based on that, 52% (247 of 478 patients) were included with most (22%, 107 patients) excluded for poor lateral radiographs. The most common diagnosis in the patient cohort was midfoot OA (14%, 35 patients). The median (range) age of the included patients was 54 years (15 to 88), and 65% (159 of 247) of the patients were female. Fibular station, defined as the position of the fibula in the AP plane, and fibular length were measured using a digital ruler and goniometer on lateral radiographs. A paired t-test was used to determine if no difference in fibular station existed between the left and right ankles. With 247 paired-samples, with 80% power and an alpha level of 0.05, we could detect a difference between sides of 0.008 for the posterior ratio, 0.010 for the anterior ratio, and 0.012 for fibular length. Two readers, one fellowship-trained orthopaedic traumatologist and one PGY-4, measured 40 patients to determine the inter- and intraobserver reliability by intraclass correlation coefficient (ICC).ResultsThe posterior fibular station (mean right 0.147 [σ = 0.056], left 0.145 [σ = 0.054], difference = 0.03 [95% CI 0 to 0.06]; p = 0.59), anterior fibular station (right 0.294 [σ = 0.062], left 0.299 [σ = 0.061], difference = 0.04 [95% CI 0 to 0.08]; p = 0.20), and fibular length (right 0.521 [σ = 0.080], left 0.522 [σ = 0.078], difference = 0.05 [95% CI 0.01 to 0.09]; p = 0.87) ratios did not differ with the numbers available between ankles. Inter- and intraobserver reliability were excellent for the posterior ratio (ICC = 0.928 and ICC = 0.985, respectively) and the anterior ratio (ICC = 0.922 and ICC = 0.929, respectively) and moderate-to-good for the fibular length ratio (ICC = 0.732 and ICC = 0.887, respectively).ConclusionThe use of lateral radiographs of the contralateral uninjured ankle appears to be a valid template for determining the position of the fibula in the sagittal plane. However, further prospective studies are required to determine the efficacy of this method in reducing the syndesmosis over other methods that exists.Level of EvidenceLevel III, diagnostic study.     

Fibular position in individuals with self-reported chronic ankle instability

STUDY DESIGN: Case control study. OBJECTIVES: The purpose of this study was to assess the position of the distal fibula in individuals with chronic ankle instability (CAI). BACKGROUND: Recent literature has suggested that a positional fault of the fibula on the tibia may contribute to CAI; however, there is a lack of objective scientific evidence to support this claim. METHODS AND MEASURES: Thirty subjects with unilateral CAI (mean +/- SD age, 20.3 +/- 1.3 years) and 30 subjects with no previous history of ankle injury (mean +/- SD age, 21.3 +/- 3.8 years) participated in this study. Subjects completed a pair of subjective functional scales and fluoroscopic lateral images of both the right and left ankles were recorded. The distance from the anterior margin of the distal tibia to the anterior margin of the distal fibula was measured in millimeters. Nonparametric statistics were used to assess the relationship between fibular position and CAI status. RESULTS: There were significant differences between the CAI and control group ankles (P = .045) and within the involved and uninvolved sides of the CAI group (P = .006). Those with CAI had a significantly more anterior fibular position on their involved ankle in relation to their uninvolved limb, and the ankles of the control group. CONCLUSIONS: The fibula was positioned significantly more anterior in relation to the tibia in subjects with unilateral CAI. It is unclear if repetitive bouts of ankle instability caused the anterior fibular position or if the more anterior position was a predisposing factor to injury.     

髓内钉治疗胫腓骨中下1/3骨折腓骨固定与否的疗效比较

《寰枢椎脱位中西医结合诊疗指南》由中国中西医结合学会脊柱医学专业委员会遵照循证医学原则和专家共识制定,为骨科医师提供AAD临床诊疗的学术性指导意见。主要内容包括AAD的诊断标准、中医辨证、临床分型、治疗策略和方法。     

Biomechanical analysis of different internal fixation methods for special Maisonneuve fracture of the ankle joint based on finite element analysis

ObjectiveThe objective of this study was to evaluate the biomechanical properties of different internal fixation methods for Maisonneuve fractures under physiological loading conditions.MethodsFinite element analysis was used to numerically analyze various fixation methods. The study focused on high fibular fractures and included six groups of internal fixation: high fibular fracture without fixation + distal tibiofibular elastic fixation (group A), high fibular fracture without fixation + distal tibiofibular strong fixation (group B), high fibular fracture with 7-hole plate internal fixation + distal tibiofibular elastic fixation (group C), high fibular fracture with 7-hole plate internal fixation + distal tibiofibular strong fixation (group D), high fibular fracture with 5-hole plate internal fixation + distal tibiofibular elastic fixation (group E), and high fibular fracture with 5-hole plate internal fixation + distal tibiofibular strong fixation (group F). The finite element method was employed to simulate and analyze the different internal fixation models for the six groups, generating overall structural displacement and Von Mises stress distribution maps during slow walking and external rotation motions.ResultsGroup A demonstrated the best ankle stability under slow walking and external rotation, with reduced tibial and fibular stress after fibular fracture fixation. Group D had the least displacement and most stability, while group A had the largest displacement and least stability. Overall, high fibular fracture fixation improved ankle stability. In slow walking, groups D and A had the least and greatest interosseous membrane stress. Comparing 5-hole plate (E/F) and 7-hole plate (C/D) fixation, no significant differences were found in ankle strength or displacement under slow walking or external rotation.ConclusionCombining internal fixation for high fibular fractures with elastic fixation of the lower tibia and fibula is optimal for orthopedic treatment. It yields superior outcomes compared to no fibular fracture fixation or strong fixation of the lower tibia and fibula, especially during slow walking and external rotation. To minimize nerve damage, a smaller plate is recommended. This study strongly advocates for the clinical use of 5-hole plate internal fixation for high fibular fractures with elastic fixation of the lower tibia and fibula (group E).     

Lower limb alignment in patients with primary valgus ankle arthritis: A comparative analysis with patients with varus ankle arthritis and healthy controls

BackgroundWhile it is commonly acknowledged that the combined effect of lower limb orientation and ankle and hindfoot alignment play a fundamental role in ankle arthritis, supramalleolar/lower limb alignment has received less attention in valgus ankle arthritis. The purpose of this study was to analyze the lower limb alignment of patients with valgus ankle arthritis with primary origin, compared to that of varus ankle arthritis and normal controls. We hypothesized that patients with valgus ankle arthritis would have the opposite pattern of lower limb alignment as those with varus ankle arthritis.MethodsA retrospective radiographic analysis was performed on 61 patients (62 ankles, mean age, 59.3 ± 12 years) with primary valgus ankle arthritis. On preoperative radiographs, seven parameters, including talar tilt angle, medial distal tibial angle (MDTA), talar center migration, anterior distal tibial angle, talo-first metatarsal (Meary's) angle, hindfoot moment arm (HMA), and mechanical axis deviation (MAD), were measured and compared to those of primary varus ankle arthritis (n = 55; mean age, 59.7 ± 8.1 years) and control patients (n = 59; mean age, 29.3 ± 7.3 years).ResultsThe valgus group had a significantly lower mean MDTA than the control group (p < 0.0001), indicating a varus distal tibial plafond in comparison to the control group. Meary's angle and HMA were significantly lower in the valgus group compared to the varus group (p < 0.05 and p < 0.0001, respectively), indicating a lower medial longitudinal arch and valgus hindfoot alignment. On whole limb radiographs, the valgus group showed a greater MAD than the control group, indicating varus lower limb alignment (p < 0.05). However, the MAD did not differ significantly between the valgus and varus groups (p = 0.7031).ConclusionOur findings indicate that a significant proportion of ankles with primary valgus arthritis have a varus tibial plafond and a varus lower limb mechanical axis. This study contributes to our understanding of primary valgus ankle arthritis and suggests that lower limb alignment should be analyzed and considered throughout valgus ankle arthritis realignment procedures.     

Reconstruction of a missing or insufficient distal fibula in the setting of a total ankle replacement: The Milanese technique

BackgroundThe presence of an intact distal fibula is reported as a prerequisite when considering total ankle replacement and its lack is usually considered a contraindication. The purpose of the study was to describe the results of a surgical technique to reconstruct the distal fibula (Milanese fibular reconstruction technique) in the setting of a total ankle replacement and insufficient fibula.MethodsRetrospective analysis of 15 patients (15 ankles) who underwent rotational fibular reconstruction technique with minimum follow-up of 24 months. Patients were evaluated preoperatively and at the last follow-up with AOFAS Ankle and Hindfoot score, VAS pain scale, SF-12 and range of motion. Standard weightbearing radiographs were used for radiographic assessment.ResultsThe average of all clinical scores significantly improved (P < .001). The average radiographic parameters showed a neutral alignment. No cases of reabsorption of the new lateral malleolus were observed even in cases with complications that accounted for 2 superficial wound infection and 2 deep infections.ConclusionsThe Milanese fibular reconstruction technique can successfully reestablish a lateral strut and in the setting of an ankle prosthesis in patients with an insufficient fibula.     

Radiological assessment of ankle syndesmotic reduction

IntroductionThe intraoperative assessment of adequacy of syndesmotic reduction is challenging. The aim of this study was to develop a radiographic measure based on the lateral ankle view to assess both the normal and abnormal relationship between the tibia and fibula after simulated syndesmotic malreduction and to evaluate the effect on commonly used mortise measurements.MethodsMortise and talar dome lateral radiographs were obtained in eight fresh-frozen cadaveric specimens before and following syndesmosis division and posterior fibular displacement of 2 mm increments. Using the technique described, on the lateral radiograph the anterior fibular line ratio (AFL ratio) and posterior fibular line distance (PFL distance) were measured. Both measures were based on the anterior and posterior distal tibia articular margins and flat borders of the fibula.ResultsInter- and intraobserver reliability of the AFL ratio and PFL distance measured almost perfect agreement. In all uninjured specimens the AFL lay just anterior to the midpoint of the tibia and the PFL intersected the posterior tibia articular margin or lay just anterior to it, not posterior. At 2, 4 and 6 mm of posterior fibular displacement the decrease in AFL ratio and PFL distance showed significant differences between all pairwise comparisons.ConclusionThe proposed new measures of syndesmotic reduction are reproducible and capable of detecting from 2 mm of sagittal fibula displacement and can be useful adjuncts in the assessment of syndesmotic reduction.     

Altered fibular growth patterns after tibiofibular synostosis in children

BACKGROUND: Iatrogenic synostosis of the tibia and fibula following an operation on the leg in a child has been reported rarely in the literature, and the effects of this complication on future growth, alignment, and function are not known. This is a retrospective case series, from one institution, of crossunions of the distal parts of the tibia and fibula complicating operations on the leg in children. The purpose is to alert surgeons to this possible complication. METHODS: The senior author identified eight cases of iatrogenic tibiofibular synostosis seen in children since 1985. The patients had various diagnoses and were from the practices of four pediatric orthopaedic surgeons. Synostosis developed in six patients after osteotomies of the distal parts of the tibia and fibula, in one after internal fixation of distal tibial and fibular metaphyseal fractures through a single incision, and in one after posterior transfer of the anterior tibialis tendon through the interosseous membrane combined with peroneus brevis transfer to the calcaneus. Medical records were reviewed, and preoperative and follow-up radiographs were analyzed for changes in the relative positions of the proximal and distal tibial and fibular physes and in the alignment of the ankle. RESULTS: Five patients were symptomatic after crossunion; they presented with prominence of the proximal part of the fibula, ankle deformity, or ankle pain. Three patients were asymptomatic, and a synostosis was identified on routine follow-up radiographs. Intraoperative technical errors caused two of the crossunions; the cause of the others was unknown. Following tibiofibular synostosis, growth disturbances were noted radiographically in every patient. The normal growth pattern of distal migration of the fibula relative to the tibia was reversed, resulting in a decreased distance between the proximal physes of the tibia and fibula as well as proximal migration of the distal fibular physis relative to the distal part of the tibia. Shortening of the lateral malleolus led to greater valgus alignment of the ankle. CONCLUSIONS: Tibiofibular synostosis can complicate an operation on the leg in a child. After crossunion, the normal distal movement of the fibula relative to the tibia is disrupted, resulting in shortening of the lateral malleolus and ankle valgus as well as prominence of the fibular head at the knee. The synostosis also interferes with the normal motion that occurs between the tibia and fibula with weight-bearing, potentially leading to ankle pain.     

Simulating clamp placement across the trans-syndesmotic angle of the ankle to minimize malreduction: A radiological study

BackgroundAnkle fractures associated with syndesmotic injury have a poorer prognosis than those without such an injury. Anatomic reduction of the distal tibiofibular joint restores joint congruency and minimizes contact pressures, yet operative fixation of syndesmotic ankle injuries is frequently complicated by malreduction of the syndesmosis. Current methods of assessing reduction have been shown to be inadequate. As such, additional methods to judge the accuracy of syndesmotic reduction are required.Questions/PurposesThe purposes of our study were (1) to determine the anatomic axis of the syndesmosis, or the trans-syndesmotic angle (TSA), and (2) to describe the intraoperative fluoroscopic appearance of syndesmotic clamp reduction oriented along the anatomic syndesmotic angle.MethodsComputed tomography (CT) scans of 45 uninjured adult ankles were analyzed to measure the TSA, defined as the angle between the plane of a lateral ankle radiograph and a line drawn perpendicular to the fibular incisura. Three-dimensional reconstructions of CT scans were then used to demonstrate clamp placement collinear with the TSA as would be seen on an intraoperative lateral ankle radiograph.ResultsThe average TSA measured 21 ± 5° anterior to the plane of a lateral radiograph. When a simulated reduction clamp tine was placed on the fibular ridge and the clamp oriented along the TSA, the medial tine, as seen on a lateral radiograph, was within the anterior one-third of the tibia 93% of the time. It was, on average, 23 ± 7% of the distance from the anterior to the posterior tibial cortex, with tine placement occurring in this range in 73% of ankles. The medial tine rested 53 ± 17% of the distance between the anterior cortices of the tibia and fibula, with 71% of tines placed in this range.ConclusionsReduction clamp placement oriented along the TSA has a predictable appearance on lateral ankle imaging and can guide clamp positioning during syndesmotic reduction. With one tine placed on the fibular ridge, placing the medial clamp tine in the anterior third of the tibia, or halfway between the anterior cortices of the tibia and fibula is the most accurate position for reduction in line with the TSA.Level of evidence2 (Retrospective diagnostic).     

Vascularised fibular graft for the treatment of congenital pseudarthrosis of the tibia: long-term complications in the donor leg

Treatment of congenital pseudarthrosis of the tibia is still controversial, and vascularised fibula graft is a reliable method for consolidation, although complications can occur in the donor leg after fibula grafting. This study evaluates 16 patients with congenital pseudarthrosis of the tibia (CPT) treated with contralateral fibular graft, with regard to complications in the donor leg, and assesses the influence of distal tibiofibular joint arthrodesis in these complications. All patients with CPT were consecutively submitted to surgical treatment with contralateral fibular graft. The mean follow-up was 94 months, varying from 44 to 162 months. The long-term effects in the donor leg were determined, and 12 cases with distal tibiofibular arthrodesis (group 1) were compared with a group without arthrodesis (group 2). Half of the patients had proximal migration of the lateral malleolus. Eight patients had ankle valgus. Group 1 had an average valgus tilt angle of 5.8°, while group 2 had an average angle of 1.5°. There was no significant difference between the patients with or without distal tibiofibular joint arthrodesis. The patients with a distal fibula remnant smaller than 5 cm had greater valgus tilt angle measurements. Distal tibiofibular arthrodesis was not effective in preventing all the complications in the donor leg; however, it can lessen the severity of the complications. Our results show that a distal fibular remnant greater than 5 cm should be retained to prevent ankle valgus.     

Assessment of the role of fibular fixation in distal-third tibia–fibula fractures and its significance in decreasing malrotation and malalignment

Background

In the treatment of distal-third tibia/fibula fractures treated by interlocking nailing, the role of fibular fixation is not clearly defined. This study aimed to assess the benefits of fibular fixation in such fractures.

Methods

Sixty patients with fractures of the lower third of the leg were enrolled into the study and divided into two groups based on whether the fibula was fixed (group A) or not (group B). Fracture tibia was treated with interlocked intramedullary nailing and fibular fixation was done using a 3.5-mm Limited Contact Dynamic Compression Plate (LC-DCP). The two groups were compared for differences in rotation at ankle, angulation at the fracture site, time of union and complications. Clinical and functional outcomes were assessed regularly. Merchant–Dietz criteria were used to assess ankle function.

Results

The demographics of the two groups were similar. Average valgus angulation was significantly less in group A (average 5°) versus group B (average 9°). The degree of rotational malalignment at the ankle in group A was average 7° versus average 15° in group B. The outcome of two groups for clinical ankle score, time of union and complications showed no significant differences.

Conclusion

Fixation of the fibula along with interlocking nailing of the tibia decreases the malalignment of the tibia and malrotation of the ankle in distal-third fractures of the tibia and fibula as compared with only interlocking nailing.     

Comparison of mid-term clinical results between lag screw fixation and Kirschner wire fixation after close reduction in adolescent triplane distal tibia epiphyseal fracture

ObjectiveTo compare the mid-term clinical results of lag screw and Kirschner wire fixation(KWF) for close reduction in triplane distal tibia epiphyseal fracture.MethodsA retrospective analysis of 25 cases of triplane fractures of the distal tibia treated in our department from Jan 2017 to Dec 2019 was performed, Lag screw fixation(LSF) was used in 14 cases and Kirschner wire fixation in 11 cases, the clinical results were evaluated by premature epiphyseal closure(PPC) rate, the American Orthopaedic Foot and Ankle Score (AOFAS) Ankle-hindfoot foot scoring system, the lateral distal tibial angle (LDTA) from X-ray.ResultsAll the 25 children were followed up for a mean of 34(ranging 26–52) months. AOFAS scores improved from a mean of 33(ranging 29–43) pre-op, to 82(ranging 77–88) at three month follow up, to 92 (ranging 88–98) at last follow-up in all 25 cases. Till last follow up there was no cases premature physeal closure in LSF group but 4 cases in KWF group, LDTA in both groups at last follow up shows no ankle varus or valgus deformity, and the ankle joint function was not limited in all cases.ConclusionLag screw and Kirschner wire fixation methods can both achieve good clinical effects for triplane distal tibia epiphyseal fracture. Lag screw fixation provide lower PPC rate but Kirschner wire fixation save one anesthesia and surgery.     

Fibular lengthening by Ilizarov method secondary to shortening by osteochondroma of distal tibia

Osteochondroma is the most common benign bone tumour. They most commonly affect the long tubular bones and almost half of osteochondromata are found around the knee. Osteochondroma arising from the distal metaphysis of the tibia typically result in a valgus deformity of the ankle joint secondary to relative shortening of the fibula. This case describes the use of Ilizarov technique for fibular lengthening following excision of a distal tibial osteochondroma. A 12-year-old girl presented with a 3-year history of a large swelling affecting the lateral aspect of the right distal tibia. Plain radiographs confirmed a large sessile osteochondroma arising from the postero-lateral aspect of the distal tibia with deformity of the fibula and 15 mm of fibular shortening. The patient underwent excision through a postero-lateral approach and subsequent fibular lengthening by Ilizarov technique. The patient made excellent recovery with removal of frame after 21 weeks and had made a full recovery with normal ankle function by 6 months. The Ilizarov method is a commonly accepted method of performing distraction osteogenesis for limb inequalities; however, this is mainly for the tibia, femur and humerus. We are unaware of any previous cases using the Ilizarov method for fibular lengthening. This case demonstrates the success of the Ilizarov method in restoring both fibular length and normal ankle anatomy.     

Osteochondromas of the distal aspect of the tibia or fibula. Natural history and treatment

BACKGROUND: There is little information on the natural history or treatment of osteochondromas arising from the distal aspect of either the tibia or the fibula. It is believed that there is a risk of deformation of the ankle if these exostoses are left untreated or if the physis or neurovascular structures are injured during operative intervention. METHODS: We reviewed the records of twenty-three patients who had been treated for osteochondroma of the distal aspect of the tibia or fibula between 1980 and 1996. Four of the patients had hereditary multiple cartilaginous exostoses. There were seventeen male and six female patients, and the average age at the time of presentation was sixteen years (range, eight to forty-eight years). RESULTS: Preoperative radiographs showed evidence of plastic deformation of the fibula in eleven patients who had a large osteochondroma. Four patients elected not to have an operation. The tumor was excised in nineteen patients. Postoperatively, all nineteen patients had a Musculoskeletal Tumor Society score of 100 percent for function of the lower extremity with pain-free symmetrical and unrestricted motion of the ankle at the latest follow-up examination. Partial remodeling of the tibia and fibula gradually diminished the asymmetry of the ankles in all nineteen operatively managed patients; however, the remodeling was most complete in the younger patients. Pronation deformities of the ankle did not change after excision of the tumor. Complications of operative treatment included four recurrences (only three of which were symptomatic), one sural neuroma, one superficial wound infection, and one instance of growth arrest of the distal aspects of the tibia and fibula. CONCLUSIONS: Osteochondromas of the distal and lateral aspects of the tibia were more often symptomatic than those of the distal aspect of the fibula; they most commonly occurred in the second decade of life with ankle pain, a palpable mass, and unrestricted ankle motion. Untreated or partially excised lesions in skeletally immature patients may become larger and cause plastic deformation of the tibia and fibula and a pronation deformity of the ankle. Ideally, operative intervention should be delayed until skeletal maturity, but, in symptomatic patients, partial excision preserving the physis may be necessary for the relief of symptoms and the prevention of progressive ankle deformity. However, partial excision is associated with a high rate of recurrence, so a close follow-up is required. Skeletally mature patients who are symptomatic may require excision of the tumor.     

Growth arrest and its risk factors after physeal fracture of the distal tibia in children and adolescents

Background. This study performed to investigate the incidence of growth arrest such as leg length discrepancy (LLD) and ankle joint angular deformity and its risk factors after physeal fracture of the distal tibia in children and adolescents.Materials and Methods. Consecutive 78 patients (mean age 11.4 ± 2.0 years; mean follow-up period 2.0 ± 1.2 years) treated for the distal tibia physeal fracture were included. All patients underwent preoperative ankle radiographs, three-dimensional computed tomography (CT) scans, and postoperative follow-up teleradiogram. Patients were divided into two groups according to the LLD and the difference of lateral distal tibial angle (LDTA) with the contralateral limb as follows: Group 1 (growth arrest), patients with LLD ≥ 1cm or difference of LDTA ≥ 5°; Group 2 (normal growth), patients with LLD < 1cm and difference of LDTA < 5°.Results. The overall incidence of growth arrest was 12.8% (10 of 78). The mean displacement measured using CT scan was 4.4 ± 3.2 mm (range, 0.8-14.9). Of the total 78 fractures, 65 were treated surgically and 13 fractures were treated conservatively. The initial fracture displacement was significantly different between the two groups (p<0.001). However, there were no statistically significant differences between the two groups with respect to other factors. Initial displacement was the only significant risk factor for growth arrest (p<0.003). The cutoff values of initial displacement between the two groups were 5.2mm.Conclusions. This study showed that degree of initial displacement was the only significant risk factor for growth arrest after physeal fracture of the distal tibia in children and adolescents. Therefore, physicians should consider the possibility of growth arrest for patients with severely displaced physeal fractures of the distal tibia.     

螺钉固定与Tight-rope固定治疗下胫腓前联合损伤的初步有限元分析

目的 :建立下胫腓前联合损伤(anterior inferior tibiofibular syndesmosis injuries,AITSI)螺钉固定及Tightrope固定(TR)模型,比较其受力及位移情况,为临床诊治提供依据。方法 :选取1例正常人的踝关节CT图像建立3D模型。然后建立AITSI损伤模型,对损伤模型置入螺钉得到螺钉固定模型,使用Tight-rope固定得到TR模型。分析各模型单脚站立时的中立位、踝关节内旋以及外旋3种受力情况,观察胫腓骨及距骨关节面应力变化,以及胫腓骨远端位移情况。结果:AITSI导致胫腓骨及距骨关节面受力增加,胫腓骨位移增加。使用螺钉固定及TR均能有效减少AITSI导致的胫腓骨远端过度位移,但在螺钉固定模型中,胫腓骨位移明显小于正常模型,且胫腓骨远端及距骨关节面受力增大,螺钉受力集中。螺钉固定模型中的胫骨及腓骨最大受力为TR模型的1.3倍以上,距骨关节面接触力为1.8倍,螺钉固定模型中下胫腓前韧带胫骨附着点位移约为正常模型的0.6倍,而TR模型中该数据约为正常模型的1.1倍,但TR对于腓骨位移控制欠佳。结论:严重的下胫腓前联合损伤将改变踝关节受力及位移情况,应该行内固定治疗。下胫腓联合螺钉及TR都能有效地治疗下胫腓前联合分离,Tight-rope固定相较于螺钉固定在骨骼受力、踝关节微动及内固定物断裂方面具有优势,但存在腓骨旋转控制欠佳的劣势。伴有Weber C型踝关节骨折以及肥胖的患者更适合螺钉固定。