The transfibular approach for distal tibial osteochondroma: An alternative technique for excision

Surgical excision of osteochondromata occurring at the lateral aspect of the distal tibia is hampered by the difficult access to this area. Current techniques use an anterior approach, but this makes access to the posterior aspect of the tibia difficult. The authors report on 2 cases in which removal, and subsequent replacement of distal fibula and fixation with a semitubular plate, allowed complete excision of a distal tibial osteochondroma and satisfactory outcomes. This procedure provides an alternative technique to the anterior approach previously described. The literature appears to contain no similar previous reports.     

Arthrodesis of the distal tibiofibular joint for a large osteochondroma in an adult.

A case of a large osteochondroma of the distal tibia with distortion of the distal tibiofibular joint is presented. This could not be managed by traditional means, as excision would have resulted in ankle and tibiofibular joint instability. The problem was overcome by performing an arthrodesis. Only enough bone from both the tibia and the fibula was excised to provide a host bed for bone graft. We believe that symptomatic osteochondromata should usually be excised. However, if this would result in damage, then the method described offers an alternative management strategy.     

Management of ankle deformities in multiple hereditary osteochondromata

Nine patients with multiple hereditary osteochondromata underwent ankle surgery for valgus deformity. The indications for operation included pain from trauma of the prominent masses, pain in the ankle joint associated with the deformity, limited ankle motion, and undesirable cosmesis. The procedures included excision of osteochondromata, fibular lengthening, and medial tibial hemiepiphyseal retardation by inserting staples. Excision of osteochondromata as an isolated procedure relieved pain and improved cosmesis but did not alter the tibiofibular length discrepancy or the ankle valgus. Lengthening of the fibula and medial tibial hemiepiphyseal stapling, alone or in combination, corrected the valgus deformity of the ankle. At final follow-up (mean 43 months), no patient had pain or functional impairment.     

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.     

Multiple hereditary osteochondromata

Multiple hereditary osteochondromata is a disorder consisting of multiple projections of bone (exostoses) capped by cartilage. The lesions are most numerous in the metaphyses of long bones but may appear on diaphyses of long bones and on flat bones and vertebrae. The transmission is autosomal dominant. Sarcomatous transformation is uncommon and probably occurs in fewer than 1% of patients. The more common indications for surgical excision of lesions are pain, growth disturbance, compromised joint motion, cosmesis, and secondary impingement of tendon, nerve, or vessel. Excision of the lesions is effective in relieving pain, improving cosmesis and joint motion, and removing secondary impingement of tendon, nerve, or vessel, and may retard or prevent progressive disturbance of osseous growth. Wrist and ankle deformities are often associated with relative shortening and bowing of the ulna and fibula, respectively; tilt and tapering of the distal radial and tibial epiphyses; and distal radioulnar and tibio-fibular diastasis. These deformities can be effectively treated by ulnar and fibular lengthening combined with hemiphyseal stapling of the distal radius and tibia. Progressive genu valgum is well corrected by placement of staples over the medial side of the physis of the distal femur or proximal tibia or both.     

Displaced Salter-Harris Type I Distal Fibula Fractures: Two Case Reports and a Review of the Literature

Salter-Harris type I (SH-I) fractures of the distal fibula are commonly encountered in pediatric orthopedics. We describe 2 unique cases of adolescents with completely displaced SH-I distal fibula fractures that were treated operatively. In the first case, a closed reduction attempt failed and the patient required open reduction and internal fixation of the distal fibula and syndesmosis. The syndesmotic ligaments were avulsed from the distal fibular metaphysis. In the second case, closed reduction of the distal fibula fracture was partially successful, but anatomic reduction could not be achieved without open reduction. The distal fibula fracture was fixed with an intramedullary screw. We believe this pattern of injury represents a variant of the adolescent transitional ankle fracture. Because the distal tibial physes were nearing complete closure in these patients, the energy propagated through the distal fibular physis. To the best of our knowledge, this combination of injuries has not been previously reported. This type of physeal fracture raises concern for premature physeal closure, fibular growth disturbance, syndesmotic instability, and medial (deltoid ligament) injury. Both patients had excellent outcomes after anatomic reduction and fixation of the displaced SH-I distal fibula fractures at 1 and 6 years of follow up, respectively.     

Radiographic Assessment of Fibular Length Variance: The Case for “Fibula Minus”

Given the high prevalence of ankle fractures and morbidity of malalignment after fixation, an appropriate anatomic relationship between the distal fibula and adjacent tibia and talus is important. The tip of the lateral malleolus of the fibula has often been described to be at the level of the lateral talar process. However, no studies to date have examined the relationship of the distal fibular tip to the lateral process of the talus. We assessed 66 weightbearing mortise radiographs for variability of the distal fibular tip in relation to the lateral process of the talus. The subjects were all skeletally mature, with a mean age of 45.3 ± 14.6 years. We used a paired t test with a null hypothesis that the true mean difference in the distance from the distal fibula to the lateral process was equal to 0. The mean distance of the distal tip of the fibula was 0.257?± 0.127 cm proximal to the tip of the lateral process of the talus. The 95% confidence interval was 0.226 to 0.288. Of the 66 subjects, 65 had the distal tip of the fibula proximal to the lateral process of the talus, corresponding to a negative fibular variance. In the remaining subject, the distal tip of the fibula was at the same level of the tip as the lateral process of the talus. The distal tip of the fibula is most commonly not at the level of the talus lateral process, as often described in published reports. Instead, it has a variance analogous to the relationship between the lengths of the ulna compared with the radius. The distal tip of the fibula in our study was more often proximal to the tip of the lateral process of the talus and can be described as a negative fibular variance, or “fibula minus.”     

Kienb?ck's disease and multiple hereditary osteochondromata: a case report.

A case of bilateral forearm localization of multiple hereditary osteochondromata and unilateral Kienb?ck's disease is reported. Ulnar minus variance is frequent in both diseases. Carpal slip is often found in multiple hereditary osteochondromata. In this case, the extremity having both multiple hereditary osteochondromata and Kienb?ck's disease had no carpal slip. This might have produced an excess load on the lunate, which might have provoked Kienb?ck's disease.     

Biomechanical study on the load-bearing characteristics of the fibula and the effects of fibular resection.

The objective of this research was to investigate the load-bearing function of the fibula in relation to donor leg morbidity in patients who have had fibular resections. Biomechanical loading experiments were performed on ten anatomic specimens. Force transducers were mounted in place of resected tibial and fibular segments to allow load transmission to be measured. Load transmission through the fibula varied with ankle position. With the ankle at neutral position, the load distribution to the fibula averaged 7.12% of the total force transmitted through the tibia and fibula. Maximum loads occurred at full dorsiflexion and eversion. Resection of the proximal fibula results in a significant reduction of load through the distal fibular remnant. The values varied between 0.62% and 0.81% of the total force transmitted. When a cortex screw was introduced to anchor the distal fibula remnant to the tibia, the load distribution to the distal fibula remnant was partially restored with values ranging from 1.71% to 5.14% of the total force transmitted depending on the different ankle positions. These observations suggest that more consideration of the loading characteristics of the fibula should be taken into account in planning resection operations.     

Management of a Rare Case of Closed Pilon Fracture With Fibula Displaced in the Foot

Pilon fractures are intra-articular injuries involving the tibial plafond and have a wide range of complexity. The timing and type of fixation in these injuries is dictated by soft tissue status and energy imparted to the distal tibial plafond. We had a unique clinical situation in which axial loading of the talus caused severe comminution of the tibial plafond and fracture of the distal third of the fibula. Further action of these forces caused displacement of the fibular segment into dorsum of the foot along with part of the articular surface of the tibial plafond without causing any external wound. This case was challenging because displacement of the distal fibula resulted in disruption of important syndesmotic and lateral ankle ligaments. Fibular segment was without any soft tissue attachment and was reimplanted in the ankle mortise like a free fibula graft. Near normal ankle biomechanics were achieved in this case through anatomic reduction of the articular surface, reimplantation of the fibula in the ankle mortise, and repair of syndesmotic and lateral ankle ligaments. There was satisfactory clinical and radiological outcome on follow-up of more than 4 years. To our knowledge, this is the only case in Standard English literature where in the case of pilon fracture, the fibula had displaced in the foot without external wound.     

Peroneus brevis rotation flap: anatomic considerations and clinical experience

BACKGROUND: Large soft tissue defects of the distal third of the leg are common occurrences at trauma centers. Massive defects often require vascularized free tissue transfer for coverage; however, smaller defects may frequently be closed by rotation of local tissue. The peroneus brevis muscle is ideally located to provide coverage of the exposed distal fibula. METHODS: An anatomic dissection of the peroneus brevis muscle and its vascular pedicles was performed in 10 fresh cadaveric leg specimens. Patients who underwent this procedure at our institution were retrospectively reviewed. RESULTS: Each dissected muscle had an average of 3.5 vascular pedicles (range, 2-6), which arose from the peroneal artery in all but two cases. The average distance of the distal pedicle from the tip of the lateral malleolus was 6.7 cm (range, 3.5-12.0 cm). The muscle belly ended an average of 6.0 mm proximal to the tip of the lateral malleolus. Half of the specimens had muscle bellies that extended to or past the tip of the lateral malleolus. This rotation flap has been successful in covering four wounds with exposed distal fibula in four patients. CONCLUSION: The anatomic characteristics of the peroneus brevis muscle are ideal for soft tissue coverage of the distal fibula. Ease of elevation and reliability have made this rotational flap the procedure of choice for small soft tissue defects over the distal fibula at our institution.     

Changes in tibiofibular relationships due to growth disturbances after ankle fractures in children

We analyzed the longitudinal growth of the distal tibial and fibular physes and the longitudinal displacement of the distal metaphysis and epiphysis of the fibula relative to the distal metaphysis and epiphysis of the tibia during growth using a roentgenstereophotogrammetric technique in eight children: six with a traumatic growth disturbance in one or both of the distal tibial and distal fibular physes and two with a normal ankle. In the normal ankles the distal fibular metaphysis moved distally in relation to the distal tibial metaphysis and the growth in the distal fibular physis was slower than that in the distal tibial physis. Growth arrest in the distal fibular physis and continued growth in the distal tibial physis resulted in distal displacement of the fibular metaphysis relative to the tibial metaphysis, probably due to traction on the distal ligaments of the fibula or more rapid growth in the proximal fibular physis than in the proximal tibial physis, or both. Valgus deformity of the ankle developed when the growth of the distal tibial physis exceeded the distal sliding of the fibula, as shown by the stereophotogrammetric analyses and orthoroentgenograms. Growth arrest in the distal tibial physis and continued growth in the distal fibular physis resulted in proximal sliding of the fibula, as shown by the roentgenstereophotogrammetric analyses and serial orthoroentgenograms. This mechanism compensated to some extent for the overgrowth of the fibula. Simultaneous growth arrest in both the distal tibial and the distal fibular physis was associated with movement of the distal end of the fibula in a distal direction relative to the tibia, probably due to the more rapid growth in the proximal fibular physis than in the proximal tibial growth plate. Therefore, growth arrest of the distal tibial or fibular physis may result in either proximal or distal sliding of the fibular metaphysis in relation to the tibial metaphysis. Probably growth arrest in the distal fibular physis has a less favorable prognosis than arrest in the distal tibial physis, because after tibial arrest proximal sliding of the fibula may compensate for overgrowth of the fibula better than distal sliding of the fibula can compensate for fibular arrest and overgrowth of the tibia.     

Transfibular excision of distal tibial interosseous osteochondroma with reconstruction of fibula using Sofield's technique – A case report

Osteochondromas arising from the interosseous border of the distal tibia and involving distal fibula are uncommon. Considering its proximity to the ankle joint, early excision of this deforming distal tibial osteochondroma is done to avoid the future risk of pathological fracture of the distal fibula, ankle deformities and syndesmotic complications. We present a 16-year-old young girl with thinning and deformed distal fibula, secondary to an osteochondroma arising from the distal tibia which was managed with transfibular excision of mass and reconstruction of distal fibula using square nail by shoefields technique.     

Prosthetic reconstruction for tumours of the distal tibia and fibula.

We have carried out prosthetic reconstruction in six patients with malignant or aggressively benign bone tumours of the distal tibia or fibula. The diagnoses were osteosarcoma in four patients, parosteal osteosarcoma in one and recurrent giant-cell tumour in one. Five tumours were in the distal tibia and one in the distal fibula. The mean duration of follow-up was 5.3 years (2.0 to 7.1). Reconstruction was achieved using custom-made, hinged prostheses which replaced the distal tibia and the ankle. The mean range of ankle movement after operation was 31 degrees and the joints were stable. The average functional score according to the system of the International Society of Limb Salvage was 24.2 and five of the patients had a good outcome. Complications occurred in two with wound infection and talar collapse. All patients were free from neoplastic disease at the latest follow-up. Prosthetic reconstruction may be used for the treatment of malignant tumours of the distal tibia and fibula in selected patients.     

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.     

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.     

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.     

Distal fibula reconstruction using a frozen allograft: a case report

We report the case of a 25-year-old woman who developed recurrent chondromyxoid fibroma involving the distal portion of the right fibula. This patient had been treated two years earlier with curettage without grafting. The treatment associated en bloc resection of the distal 12 cm of the fibula and reconstruction with a cryopreserved allograft fixed with a lateral plate and pin associated with a syndesmodesis screw for six weeks. The lateral collateral ligament and the tibiofibular ligaments were also repaired. At two years, the patient has no sign of recurrence and the ankle motion is satisfactory. The ankle is stable and pain free with an esthetic aspect similar to the healthy side. Allograft reconstruction is a novel alternative for reconstruction of the distal fibula. We have found only one other case reported in the literature.     

Distal tibial aneurysmal bone cyst treatment by using a proximal fibular autologous bone graft: a case report

A case of an aneurysmal bone cyst that involved the distal tibia and medial malleolus with erosion of the medial cortex in a 22-year-old woman is presented. The patient was surgically treated by curettage and bone grafting along with reconstruction of the distal tibia by using ipsilateral proximal fibula. At the 2-year follow-up, the patient had full, painless range of motion and complete incorporation of the fibular graft. The authors discuss the different treatment options for benign tumors of the distal tibia and the advantages of using proximal fibula as an autologous bone graft in the reconstruction of medial malleolus.     

Saving the ankle in distal fibular giant cell tumour – A case report

Distal Fibula Giant cell tumour (GCT) is a rare condition. The described methods of treatment for distal fibula GCT include excision of tumour and ankle arthrodesis, replacement of distal fibula with ipsilateral proximal fibula and autograft or allograft reconstruction. This case report describes treatment of distal fibula grade 3 GCT with involvement of syndesmosis with tumour excision, proximal fibular slide and reconstruction of ankle joint. With this technique the ankle joint movements are preserved and stability is maintained.