Distal Fibula Metastasis of Cholangiocarcinoma

Cholangiocarcinoma is a rare disease with a reported incidence in the United States of 1 to 2 cases per 100,000 population. These cancers have a high mortality rate because most are locally advanced at presentation. Cholangiocarcinoma most commonly advances locally and regionally by invading the lymph nodes. In rare cases, it has been noted that cholangiocarcinoma can metastasize to bone, with a preponderance for the axial skeleton. Herein, we describe what we believe to be the first clinical report of an acral bone metastasis from metastatic cholangiocarcinoma.     

Atypical Chronic Ankle Instability in a Pediatric Population Secondary to Distal Fibula Avulsion Fracture Nonunion

Chronic ankle instability is a disabling condition, often occurring as a result of traumatic ankle injury. A paucity of published data is available documenting chronic ankle instability in the pediatric population. Much of the data has been confined to the adult population. We present 2 cases of chronic ankle instability, 1 in a 12-year-old and 1 in a 9-year-old patient. Unlike the typical adult etiology, the cause of instability was a dysfunctional lateral ligamentous complex as a consequence of bony avulsion of the tip of the fibula. Both patients had sustained a twisting injury to the ankle. The fractures failed to unite. The nonunion resulted in dysfunction of the anterior talofibular ligament with consequent chronic ankle instability. At the initial clinical assessment, magnetic resonance imaging was requested for both patients. In patient 1 (12 years old), the fracture was fixed with 2 headless screws and was immobilized in a plaster cast for 6 weeks. In patient 2 (9 years old), because of the small size of the avulsed fragment, fixation was not possible. A modified Gould-Broström procedure was undertaken, facilitating repair of the avulsed fragment using anchor sutures.     

Osteotomy of the Distal Fibula for Correction of Posttraumatic Malunion

Objective Restoration of anatomic alignment of the lateral malleolus to delay or prevent development of posttraumatic osteoarthritis of the ankle joint. Indications Posttraumatic malunion of the distal fibula with shortening, often combined with external rotation and abduction of the lateral malleolus. Osteoarthritic changes may be absent, mild or moderate. Contraindications Severe, preexisting osteoarthritis of the ankle. Presence of a remote lateral pilon fracture with articular depression. Poor soft tissue conditions after infection or sympathetic reflex dystrophy. Surgical Technique Lateral approach respecting former incisions or wounds, if at all possible. Osteotomy of the fibula (horizontal, oblique or Z-shaped), resection of scar tissue, osteophytes and bony fragments in the fibular notch and freeing of the distal part of the fibula. Correction of any obstacle around the medial malleolus if indicated. Correction of length, rotation and abduction of the lateral malleolus, and fixation with a reconstruction or LC-DC plate. Fixation of the fibula in the fibular notch with two Kirschner wires. Results After a follow-up of 3.9 years, all eight patients were satisfied. In five of six patients, there was only a slight progression of arthritic changes radiologically already present before osteotomy. Two patients without any arthritic changes before the osteotomy did not develo such changes thereafter. Our results, confirmed by previous reports, indicate that the most important factor determining the final outcome is the presence of degenerative changes at the time of osteotomy. Lengthening of the fibula slowed down or even stopped progression of arthritis.     

胫腓骨中下段开放性骨折的手术方式及其疗效分析

目的 探讨胫腓骨中下段开放性骨折的手术方式并分析其临床疗效。方法 自1998年4月～2004年7月共手术治疗胫腓骨中下段开放性骨折146例149肢。Gustilo分类：Ⅰ型28例,Ⅱ型58例,Ⅲ型60例。其中使用交锁髓内钉治疗44例47肢（A组）,使用钢板内固定治疗46例（B组）,使用胫骨外固定架及腓骨1／3管型钢板治疗56例（C组）。平均随访27个月后分析各组骨折愈合时间及术后并发症并进行比较。结果 平均骨折愈合时间,A组5．1个月,B组5．6个月,C组7．9个月。术后并发症：A组：感染2例,无断钉,无畸形愈合。B组：感染及皮肤坏死11例,钢板断裂3例,畸形愈合2例。C组：感染1例,外固定架钉道感染松动3例,畸形愈合2例。结论 Ⅰ型、Ⅱ型均可使用交锁髓内钉治疗以使骨折达到一期愈合;所有胫腓骨中下段开放性骨折最好少用或不用胫骨解剖型钢板或窄加压钢板;外固定架及腓骨1／3管型钢板是治疗Ⅲ型损伤安全、简单的方法,可以考虑首选治疗措施。     

High Fibular Fracture in Association with Triplane Fracture: Reexamining This Unique Pediatric Fracture Pattern

A case of a high fibular fracture in association with a triplane fracture in a 12-year-old boy is presented and this unique fracture pattern examined. Whether from blunt trauma or an external rotation mechanism, it appears that trans-syndesmotic fixation is not needed to satisfactorily repair this injury. Because of the rarity of the condition, there is limited previously published information describing this particular injury, although surgeons should be aware of it and the underlying mechanism of the fracture.     

腓骨内固定在治疗胫腓骨骨折中的作用

目的 探讨腓骨内固定在治疗胫腓骨骨折中的作用。方法 50例胫腓骨骨折，采用腓骨内固定、胫骨闭合手法复位加外固定方法治疗。其中闭合性骨折28例，开放性骨折12例，Pilon骨折10例；粉碎性骨折28例，斜形骨折12例、螺旋形骨折10例。结果 50例均达临床愈合。平均临床愈合时间为5个月，骨折位置良好，关节功能恢复正常，无皮肤坏死及感染发生。结论 腓骨固定适合于胫前皮肤条件不好的闭合性或开放性胫腓骨骨折和胫骨下1/3粉碎性骨折合并腓骨骨折的治疗。     

Stress Fracture of the Proximal Fibula in Military Recruits

Background

We wanted to report on stress fracture of the proximal fibula and to suggest the pathomechanism of this fracture.

Methods

Between April 2004 through April 2005, the military recruits who complained of leg pain during the 6 weeks basic training in the Republic of Korea Marine Corps education and training group were evaluated according to their clinical manifestations and plain radiographs.

Results

Twelve recruits of 635 recruits who complained leg pain were diagnosed as having fibular stress fracture. Eleven cases (10 recruits) appeared at the junction of the proximal and middle 1/3 of the fibula and 2 cases (2 recruits) were in the middle 1/3 of the fibula, as assessed radiologically. Tenderness was the most reliable clinical manifestation. All the fractures occurred after repetitive walking or jumping in a squatting position. Conservative treatments that included bed rest, immobilization and non-steroidal anti-inflammatory drugs administration according to the symptom severity were satisfactory.

Conclusions

Proximal fibular stress fracture is not rare in military recruits. The shearing force on the proximal fibula and the repetitive stress by walking or jumping in a squatting position contribute to the stress fracture of the proximal fibula.     

Comparison of Locking Versus Nonlocking Plates for Distal Fibula Fractures

Locking plates might offer a biomechanical fixation advantage for distal fibula fractures with comminution or osteoporotic bone. In January 2011, our unit introduced a bone-specific locking plate for the distal fibula. The aim of the present study was to compare it against more conventional plating system implants for lateral malleolar fixation in terms of outcomes, crude costs, and complications. We retrospectively reviewed a consecutive cohort of patients with closed ankle fractures who presented within a 24-month period. The clinical and radiographic outcomes were compared among conventional plating using a one-third semitubular plate, a 3.5-mm limited-contact dynamic compression plate, and a 2.7-mm/3.5-mm locking compression distal fibula plate. A total of 145 patients with ankle fractures underwent surgical fixation: 87 (60.0%) with the semitubular plate, 22 (15.2%) with the limited-contact dynamic compression plate, and 36 (24.8%) with the locking compression distal fibula plate. A greater proportion of patients with established osteoporosis or osteoporosis risk factors were in the locking compression distal fibula plate group (27.8% versus 2.3% and 0%). Four patients (2.8%) required washout for infection. No significant differences were found between the sex distribution within the 3 groups (p?=?.432). No significant difference was found in the complication rate (p?=?.914) or the reoperation rate (p?=?.291) among the 3 groups. Although costing >6 times more than a standard fibula fixation construct (implant cost), bone-specific locking compression distal fibula plates add to the portfolio of implants available, especially for unstable fractures with poor bone quality.     

Intramedullary Screw Fixation Versus Traditional Plating for Distal Fibula Fractures

The traditional method of treating fibular fractures in unstable ankle injuries involves open reduction and internal fixation with a plate and screw construct. Less invasive percutaneous fixation techniques with intramedullary fibular screws have been utilized for many years to reduce wound and implant complications while maintaining a stable ankle mortise. However, there have been no direct case-control studies comparing percutaneous intramedullary fibular screw fixation to the traditional open reduction and internal fixation with plates and screws. In our study, we compared radiographic and clinical outcomes for unstable ankle fractures in which the fibula fracture was treated with either a percutaneous intramedullary screw or by open reduction and internal fixation with a plate and screw construct. We retrospectively reviewed 69 consecutive patients from 2011 to 2019 with unstable ankle fractures treated with intramedullary fibular screws and compared them to 216 case-control patients treated with traditional plate and screw construct over the same time period. The average follow-up for the intramedullary screw group was 11.5 months and 15.2 months for the plate and screw group. We collected general demographic data, measured intraoperative and final follow-up talocrural angles, Kellgren-Lawrence osteoarthritis grade, union rates, implant removal rates, infection rates, and American Orthopedic Foot and Ankle Society ankle-hindfoot scores. The intramedullary screw group had a statistically significant lower rate of delayed implant removal (8.7% vs 23.6%) and there was no detectable difference in other measures.     

开放性胫腓骨骨折治疗回顾

目的探讨开放性胫腓骨骨折治疗的体会。方法回顾性分析采用钢板、交锁髓内钉、外固定架治疗78例81肢的临床资料。结果随访时间6~33个月,按Johner-w ruh标准评定疗效,钢板内固定组优12肢,良7肢,中5肢,差1肢,优良率76%;交锁钉固定组优14肢,良8肢,中2肢,优良率91.6%;外固定架组优12肢,良9肢,中8肢,差3肢,优良率65.6%。结论早期清创,良好复位和坚强固定,G ustiloⅡ度以下行钢板或交锁钉内固定,Ⅲ度以应用外固定架治疗为宜。     

开放性胫腓骨骨折治疗的若干问题探讨

我院自1991～1997年共收治开放性胫腓骨骨折患者57例,现就治疗中的若干问题,进行探讨。1　临床资料　　本组57例,男36例,女21例;年龄24～58岁,平均41岁;均为直接暴力外伤所致。4～12小时急诊处理45例,1～3天内处理12例,其中3例外院行钢板固定,感染、骨折端外露而转入我院。本组均有不同程度的皮肤软组织损伤,皮肤缺损面最小2ｃｍ×5ｃｍ;最大10ｃｍ×16ｃｍ。合并创伤性休克5例;合并多发性损伤12例;有胫前、后动脉损伤3例;合并腓总神经或胫后神经损伤2例。2　治疗方法　　伤口用3%双氧水、1‰新洁尔灭消毒液和生理盐水反复、大量的冲洗;清除…     

锁骨外端移位骨折的生物性内固定

目的 :研究新型生物性内固定手术方法治疗锁骨外端移位骨折。方法 :根据肩部的解剖生理和生物力学设计锁骨外端移位骨折的内固定手术新方法。先切开复位 ,然后采用生物可吸收缝合线或粗丝线经锁骨近折段和喙突穿孔 ,顺喙锁韧带纤维走向修复韧带以重建锁骨在垂直方向的稳定 ,最后在锁骨远折段钻骨孔 ,经孔缝合结扎固定 ,保证锁骨骨折有良好对位并恢复在水平方向的稳定。结果 :14例病人术后随访 6～ 2 4个月 ,骨折愈合良好 ,内固定稳定 ,不影响肩锁关节的活动 ,无明显并发症 ,避免了金属内固定的二次拆除手术 ,全部病例肩关节活动度恢复正常 ,疗效优良。结论 :应用生物可吸收缝线或丝线 ,按解剖结构和生物力学原理重建喙锁韧带治疗锁骨外端移位骨折 ,固定确切 ,疗效满意 ,不需二次手术。     

酒精灭活再植并游离腓骨植入治疗股骨远端恶性肿瘤

目的　探讨酒精灭活再植并游离腓骨植入治疗股骨远端恶性肿瘤的可行性。方法　我们回顾了自1999年6月至2 0 0 2年5月以来在我科诊治的10例股骨远端恶性骨肿瘤病例。手术方法采用瘤段酒精灭活,腓骨填充再植术。结果　平均随访3年4个月(11个月～6年)。8例无复发,7例膝关节活动范围达6 0°～90°,1例发生感染。结论　结果提示本保肢手术在治疗恶性骨肿瘤中是切实可行的,并可达到较高的成功率。     

Distal Clavicle Fracture as a Complication of Arthroscopic Distal Clavicle Resection

Arthroscopic resection of the distal clavicle has been advocated as a surgical treatment option for acromioclavicular (AC) joint pathology. To our knowledge, iatrogenic fracture of the distal clavicle during distal clavicle resection has never been reported. This report describes distal clavicle fracture as a complication of misidentification of the AC joint and subsequent aggressive burring of the distal clavicle during shoulder arthroscopy. This case is further complicated by the development of symptomatic delayed union and adhesive capsulitis. Ultimately, a revision distal clavicle resection was performed, underscoring the fact that special care must be taken to properly identify the AC joint and rule out pre-existing distal clavicle stress fracture or osteolysis before performing the arthroscopic Mumford procedure.     

影像学检查在胫骨三平面骨折诊断与治疗中的价值分析

目的：探讨各项影像学检查在胫骨三平面骨折的诊断与治疗中的作用与价值。方法：回顾分析17例三平面骨折的影像学资料。通过影像学观察计算出该项影像学检查的真阳性率；根据各项影像学检查提供的有价值信息累计评分，推算出该项影像学检查所提供信息占所需总信息量的百分比。结果：正侧位、正侧及斜位X线片，CT平扫及3D—CT作为影像学诊断工具的真阳性率分别为41．2％，77．8％，0，100％；正侧位、正侧及斜位X线片，CT平扫结合X线片及3D—CT为治疗提供的信息占总信息量的百分比约为52．8％，51．4％，83．8％，100％。结论：(1)正侧及斜位X线平片应作为诊断三平面骨折常规首选的影像学检查；单纯CT平扫不能作为诊断工具；(2)3D—CT不仅可以确定诊断，而且还可为治疗提供全部有价值信息；(3)提出针对三平面骨折诊断与治疗合理的影像学检查方案。     

Efficacy of Pie-Crusting Technique on Soft Tissues in Distal Tibia and Fibula Fractures

Distal tibia and fibula fractures are challenging injuries to treat as evidenced by the high rates of wound complications because of vulnerable soft tissue coverage. The aim of this study was to examine the effect on soft tissue complications of the pie-crusting technique when applied between 2 incisions in distal tibia and fibula fractures treated with open reduction and internal fixation. We reviewed 34 patients with distal tibia and fibula fractures treated between September 2014 and March 2017. The pie-crusting technique was performed during wound closure in 16 (47.06%) fractures (group 1) and classic wound closure was done in 18 (52.94%) fractures (group 2). The primary outcome was evaluated as the presence or absence of soft tissue complications such as superficial skin necrosis, deep skin necrosis, and deep infection. The mean age was 50.44 ± 13.51 (range 23 to 65) years in group 1 and 51.67 ± 14.49 (range 18 to 68) years in group 2. The mean follow-up time was 27.35 ± 9.02 (range 16 to 46) months. The mean surgery time after injury was 5.88 ± 3.5 (range 1 to 14) days in group 1 and 7.32 ± 4.25 (range 1 to 16) days in group 2. No soft tissue complications were seen in any patient in group 1. Five (27.77%) occurrences of superficial skin necrosis were observed in group 2. In 2 (11.11%) patients in group 2, deep necrosis and wound dehiscence occurred, and subsequent deep infection developed in 1 (5.55%) of these patients. The overall complication rate was higher in group 2 (p = .005). We believe that the pie-crusting technique is beneficial for wound closure in distal tibia and fibula fractures, because it reduces the tension of the skin and allows leakage of subcutaneous fluids.