Digital analysis of the human maxilla to enable semistandardized template tool reconstructions with free fibula transplants.

OBJECTIVES: This study analyzed the human maxilla to support the development of mean-value-based cutting guide systems for maxillary reconstruction, bridging the gap between freehand techniques and virtual surgical planning (VSP). MATERIALS AND METHODS: This retrospective cohort study used routine CT scans. DICOM data enabled 3D modelling and the maxilla was divided into four regions: paranasal (R1), facial maxillary sinus wall (R2), zygomatic bone (R3) and alveolar process (R4). Surface comparisons were made with a reference skull. Statistical analyses assessed anatomical variations, focusing on mean distance (Dmean), area of valid distance (AVD), integrated distance (ID) and integrated absolute distance (IAD). The study addressed hemimaxillectomy defects for two-segmental reconstructions using seven defined bilateral points to determine segmental distances and angles. RESULTS: Data from 50 patients showed R2 as the most homogeneous and R4 as the most heterogeneous region. Significant age and gender differences were found in R3 and R4, with younger patients and females having more outliers. Cluster analysis indicated that males had R1 and R3 positioned anterior to the reference skull. The mean angle for segmental reconstruction was 131.24° ± 1.29°, with anterior segment length of 30.71 ± 0.57 mm and posterior length of 28.15 ± 0.86 mm. CONCLUSIONS: Anatomical analysis supported the development of semistandardized segmental resection approaches. Although gender and anatomical differences were noted, they did not significantly impact the feasibility of mean-value-based cutting-guide systems. CLINICAL RELEVANCE: This study provides essential anatomical data for creating cost-effective and efficient reconstruction options for maxillary defects, potentially improving surgical outcomes and expanding reconstructive possibilities beyond current techniques.

Case report: Individualized 3D-printed uncemented distal fibular prosthesis preserving the lateral malleolus for repair of distal fibular defects.

Background: Involvement of the distal fibula by alveolar soft-part sarcoma is rare. Extensive resection or amputation may be needed; however, distal fibula resection can disrupt foot and ankle biomechanics, leading to ankle joint instability. Reports on joint preservation for maintaining optimal ankle joint function are scarce. Computer-aided design and individualized three-dimensional (3D)-printed uncemented implants represent an evolving solution for reconstructing the distal fibula. Case presentation: A 34-year-old woman was diagnosed with alveolar soft-part sarcoma in the right lower leg involving the cortical bone of the fibula. After anlotinib treatment, the tumor size decreased, and the tumor response rate was a partial response (PR); however, the patient continued to experience adverse reactions. With multiple disciplinary team discussions, surgical resection was deemed appropriate. Due to the extensive defect and ankle joint instability after resection, a custom-made 3D-printed prosthesis was designed and fabricated to reconstruct the defect, preserving the lateral malleolus. During the follow-up, the patient achieved favorable ankle function, and no prosthesis-related complications were observed. Conclusion: 3D-printed personalized uncemented implants constitute a novel approach and method for addressing the reconstruction issues of the distal fibula and ankle joint. Through the personalized design of 3D-printed prostheses, the lateral malleolus can be preserved, ensuring the normal anatomical structure of the ankle joint. They achieve a well-integrated interface between the prosthesis and bone, ensuring satisfactory postoperative function. Additionally, they offer valuable insights for reconstructing distal bone defects near joints in the extremities. However, confirming these findings requires extensive cohort studies.

Osteosynthesis for mandibular reconstruction with fibula free flap: Which type and why? A French national survey.

We explored the most suitable osteosynthesis type for mandibular reconstruction using fibula free flap (FFF) given the lack of robust data available. For this, an anonymous survey was e-mailed to 853 head-and-neck surgeons (France) asking about their practices and criteria guiding their osteosynthesis material and method choices. Questions assessed: (1) the most frequently used osteosynthesis type, (2) the explanatory variables related to surgeon career status/surgical specialty, and (3) justifications for osteosynthesis type (scientific, technical, "misuse"). Multivariate logistic regression was performed to test for associations of explanatory variables with plate type or misuse. Overall, 118 (13.8%) surgeons responded, among which flexible non-locking osteosynthesis was preferred (59%). Career status and surgical specialty were significantly associated with material choice. University professors/senior lecturers (OR 5.96 vs academic clinical associates; p = 0.02), but not ear-nose-throat/reconstructive plastic surgeons (OR 0.22 vs maxillofacial surgeons; p = 0.04), were more likely to opt for rigid locking osteosynthesis. Private practitioners preferred flexible non-locking osteosynthesis (OR = 5.03; p = 0.04). Only 18% of surgeons scientifically justified their choices. We considered misuse among 65% of surgeons and this was significantly associated with irregular practice of FFF surgery (OR 2.28 vs > 10 surgeries/year; p = 0.04). Overall, >50% of surgeons mainly rely on habits without scientific arguments assisting in decision-making.

Enchondroma in the Fibular Diaphysis: A Case Report.

Chondroma is a benign tumor formation that occurs through the proliferation of cartilaginous tissue. It can be located centrally (enchondroma) or peripherally, often appears between 10-30 years of age, and is commonly discovered incidentally. This case report describes a 46-year-old woman presenting with pain in the left calf and partial functional impotence. The onset of her symptoms was affirmatively marked by a mild skiing-related trauma. Following protocol, X-ray imaging (antero-posterior and lateral views) of the calf was performed, with the only finding being a solitary bony lesion, with internal calcifications, sclerotic margin and radiolucent internal matrix. Facing the uncertainty of diagnosis from a clinical and radiographic standpoint, it was decided to admit the patient for further evaluation and start the standard protocol of imaging investigations - computed tomography, magnetic resonance imaging, and bone scintigraphy - and determine the subsequent therapeutic behavior. Differential diagnosis between enchondroma and low-grade chondrosarcoma can be difficult due to their histopathological similarity. The therapy of choice in enchondroma comprises non-surgical treatment (observation) if the lesion remains unaltered in imaging, or curettage/filling with bone substitutes/allografts, but considering the advanced age and interruption of the bone cortex in our case, we opted for curative surgical treatment.

Magnetic Resonance Imaging Has Utility in Clinical Decision-Making for Children and Adolescents With Symptomatic Subfibular Ossicles.

Treatment of children with chronic ankle pain, lateral instability, and the presence of a subfibular ossicle (SO) can be challenging. When will these patients respond to nonoperative management, and when will they require surgery? The purpose of this study was to investigate the utility of magnetic resonance imaging (MRI) in clinical decision-making for patients with symptomatic SOs. METHODS: We performed a retrospective study of pediatric patients with lateral ankle pain, recurrent sprains, and radiographs showing SOs who had undergone an MRI as part of their diagnostic work-up. We identified 22 patients from the senior author's registry of pediatric patients with lateral ankle injuries. Eleven were girls, and 11 were boys, ages ranging from five to 19 years. Eleven involved the left ankle; 11 involved the right. Positive MRIs showed a high-intensity signal between the SO and the distal fibular epiphysis; negative MRIs had a low-intensity signal. The main outcome measure was operative versus non-operative treatment. RESULTS:  Sixteen of the 22 patients had positive MRIs, and six had negative MRIs. Twelve of the 16 patients with positive MRIs had undergone an operation. All six patients with negative MRIs responded to nonoperative management. CONCLUSIONS: MRI has utility in clinical decision-making for symptomatic patients with SOs. Patients with negative MRI sequences responded to nonoperative management. Most patients with positive MRI sequences will require surgery to alleviate their symptoms and return to full activities. LEVEL OF EVIDENCE: IV.

Comparative study of CAD/CAM reconstruction and miniplates for patient-specific fixation in LCL-type mandibular reconstruction.

Objective: Miniplates offer superior clinical handling and facilitate postoperative removal after mandibular reconstruction but unfavorable load distribution under high stress has been shown. This study aimed to compare the clinical outcome of patient-specific 3D-printed (PS-3D) titanium miniplate with reconstruction plate fixation in three-segmental LCL-type reconstructions for the first time. Methods: Patients undergoing three-segmental LCL-type mandibular reconstruction after malignant tumor resection between April 2017 and July 2023 were analyzed in a retrospective single-center study. Inclusion criteria were primary reconstruction using a fibula free flap and PS-3D titanium mini- or reconstruction plate fixation. Complication rates were recorded and analyzed within 6 months after surgery using the N - 1 Chi2- and unequal variance t-test. Results: 38 patients (10 females, 28 males; mean age 61.4 ± 7.6 years) met the inclusion criteria. In 14 patients (36.8%) miniplates were used in the anterior region. Rates of fixation failure, plate exposure, incomplete osseous union, wound infection, soft tissue, and overall complications did not differ significantly between the two plate systems. Conclusion: Complication rates did not differ significantly between PS-3D mini- and reconstruction plates in three-segmental LCL-type mandibular reconstructions. Given their advantages in clinical handling and postoperative removal, PS-3D miniplates can be a viable alternative also in larger mandibular reconstructions.

Autologous non-vascularized fibula with compression plating in the management of aseptic complex non-union of long bones.

BACKGROUND: The surgical treatment of non-union of long bones are challenging especially when bones are osteoporotic or there is a large bone gap due to repeated surgeries and implant failures. Plate with intramedullary fibula provides a stable construct as fibula acts as a second implant with better anchorage and high pull-out strength. The aim of our study is to present our experience of treating complex non-union of long bones using compression plating (LCPs/DCPs) in combination with autologous non-vascularized fibular graft (ANVFG). MATERIAL AND METHODS: 10 cases of complex non-union of long bones (tibia, femur, humerus) treated with debridement, decortication followed by intramedullary fibular strut grafting and rigid osteosynthesis by LCPs/DCPs were included in this study. DASH score and LEFS score was used for upper limb and lower limb functional assessment. RESULTS: All patients had clinico-radiological union with a mean time of 11.4 months. Pre-operative mean DASH and LEFS score was 45.9±2.1 and 20.6±2.03 At the last follow-up, mean DASH and LEFS score was 19.8±1.1 and 60.6±2.6. CONCLUSION: Compression plating with ANVFG is a viable option for treating complex non-union of long bones. Intramedullary fibula acting as a second implant provides mechanical stability and support biological healing with its osteogenic property at the non-union site.

Prosthodontic rehabilitation with all-on-four implant treatment combined CAD/CAM prosthesis in an oral cancer patient: a case report.

BACKGROUND: The microvascular free fibula (MFF) flap is a reliable treatment modality for mandibular reconstruction and is suitable for dental implant placement after oncologic surgery. The most common issue with the MFF flap is its limited bone height, which typically results in excessive interarch space and complicates prosthodontic therapy. Overcoming the physical limitations from tumor excision and reducing the treatment time for prosthodontic rehabilitation to improve quality of life are critical clinical challenges. CASE PRESENTATION: A 64-year-old male with lower left gum and bilateral buccal cancer received a single-layer microvascular MFF flap to reconstruct a mandibular defect post-tumor excision. He underwent a bilateral modiolus Z-plasty combined with a skin flap debulking procedure to relieve oral contracture, achieving adequate mouth opening for prosthodontic rehabilitation. Scar tissue bands on the bilateral cheeks significantly affected retention and stability, hampering dental impression performance. The patient sought prosthodontic rehabilitation to enhance his chewing function and quality of life promptly. Prosthodontic rehabilitation with all-on-4 implant therapy, utilizing computer-aided design and computer-assisted manufacturing (CAD/CAM), was completed within one month. CONCLUSION: This case utilized the all-on-4 implant system to address the insufficient fibular height for conventional dental implant placements. Dental CAD/CAM was employed to mill custom prosthetic abutments and a large titanium framework for the implant bar overdenture, compensating for the excessive interarch space between the grafted fibula and maxilla. This treatment approach successfully shortened the prosthodontic rehabilitation time and overcame anatomical limitations.

Graft Infections in Biologic Reconstructions in the Oncologic Setting: A Systematic Review of the Literature.

Background: Biologic graft infection (BGI) is one of the main complications in graft reconstructions. However, very little evidence exists regarding the epidemiology of BGI, as most of the data come from sparse reports. Moreover, most of the series did not detail the treatment and outcome of graft infections. The aim of this systematic review of the literature is to provide a comprehensive data collection on BGI after oncologic resections. Methods: Three different databases (PubMed, Scopus, and Web of Science) were searched for relevant articles, and further references were obtained by cross-referencing. Results: 139 studies met the inclusion criteria. A total of 9824 grafts were retrieved. Among these, 684 (6.9%) were in the humerus, 365 (3.7%) in the pelvis, 2041 (20.7%) in the femur and 1660 (16.8%) in the tibia. Most grafts were osteoarticular (2481, 26.7%) and intercalary 2112 (22.7%) allografts. In 461 (5.0%), vascularized fibula grafts (VFGs) were used in combination with recycled autografts. Recycled grafts were reported in 1573 (16.9%) of the cases, and allograft-prosthetic composites in 1673 (18.0%). The pelvis and the tibia had the highest incidence of BGI (20.4% and 11.0%, respectively). The most reported first treatment was debridement and implant retention (DAIR) in 187 (42.8%) cases and two-stage revision with graft removal in 152 (34.8%). Very little data are reported on the final outcome specified by site or type of graft. Conclusions: This systematic review of the literature confirms a high incidence of infections in biologic reconstructions after resections of primary bone tumors. Despite DAIR being a viable attempt, in most cases, a two-stage approach with graft removal and reconstruction with endoprosthesis presented the highest chance to overcome infection, guaranteeing a reconstruction. We emphasize the need for future multicentric studies to focus on the management of infections after biological reconstructions in bone sarcomas.

Segmental mandibulectomy and microvascular reconstruction with fibula free flap: Comparison between intraoral and extraoral approaches.

BACKGROUND: Segmental mandibulectomy and reconstruction of resulting defect can be performed via intraoral approach (IOA) or extraoral approach (EOA). Both approaches have advantages, disadvantages, indications, and contraindications to consider during their selection. OBJECTIVE: To compare IOA vs EOA of segmental mandibulectomy and microvascular reconstruction with fibula free flap (FFF). METHODS: We conducted a retrospective cohort study in which 51 patients who underwent segmental mandibulectomy and microvascular reconstruction with FFF from 2020 to 2024 were included, especially 17 patients by IOA and 34 patients by EOA, representing both groups of this study. Clinical characteristics, surgery parameters, and patients' prognosis were evaluated. Patients' satisfaction and Derriford Appearance Scale (DAS59) were assessed during follow-up. RESULTS: Ameloblastoma was the most frequent diagnosis (52.9% managed by IOA vs 70.6% by EOA); FFF was frequently positioned as double barrel (94.1% managed by IOA vs 88.2% by EOA). Compared with EOA group, IOA group had less intraoperative blood loss (mean difference [MD] = -112.2, 95% confidence interval [CI]: -178.9 to -45.5, p = 0.001), higher satisfaction score (MD = 1.3, 95% CI: 0.9 to 1.7, p ˂ 0.001), and lower DAS59 score (MD = -0.5, 95% CI: -0.7 to -0.2, p ˂ 0.001). CONCLUSION: Both IOA and EOA were found safe and feasible, presenting similar perioperative features and postoperative outcomes. Patients managed with IOA were more satisfied with aesthetic outcomes than patients managed with EOA. In the absence of simultaneous immediate implant during mandibular FFF reconstruction, after stability of FFF on the defect site, patients should always be referred to an implantologist and/or prosthodontist for teeth restoration to improve functional and aesthetic outcomes.

How Effective is Fibula Pro Tibia Plating in Treatment of Distal Tibial Fractures: A Pilot Study.

Introduction: Despite recent advances, management of distal tibial fractures is challenging, with high rate of complications. Fibula pro tibia plating technique fixes fibula and tibia together, via laterally placed fibular plate without disturbing the tibial soft tissue sleeve. We contemplated this pilot study to assess effectiveness of fibula pro tibia plating in management of distal tibia fibula fractures. Materials and Methods: A total of 30 patients with distal tibia fibula fractures with fracture line extending within 5cm from tibial plafond were managed with fibula pro tibia plating, with or without minimal articular fixation. Outcome evaluation was done by union, union time, alignment and functional outcome as assessed by AOFAS score. Results: Mean age in the series was 39.4 years with male to female ratio of 3:2. Mean duration of surgery, blood loss and C arm exposure were 79 minutes (range 52 to 98min), 80ml (range 62 to 102ml) and 48 shoots (range 36 to 81 shoots), respectively. All fractures united in mean union time of 10.2 weeks (range 9 to 14 weeks) with acceptable alignment in all the patients except one. Mean AOFAS score was 86.3 (range 70 to 93) with 29 patients having good to excellent outcome. One patient had varus malunion and in one case infection was seen. Conclusion: Fibula pro tibia plating can be successfully used to manage complex distal tibia fractures which leaves the soft tissue and periosteal sleeve undisturbed, thus avoiding wound related problems and leading to early union.

Prone position fibula nail and tibia buttress plate for large Volkmann fracture-dislocations technical note and preliminary results on a short case series.

Large posterolateral tibial fragments, known as Volkmann fractures, are common in ankle fracture-dislocations and typically require open reduction and fixation with interfragmentary screws and often buttress plates using a prone posterolateral approach. In this setting, fibula plating often necessitates dissection of the lateral window between the peroneal tendons and the skin, increasing wound-related complications. In recent years, intramedullary nailing of fibula fractures has gained popularity as a minimally invasive technique that allows load-sharing stabilization. However, this procedure has traditionally been performed in the supine position, which can pose challenges if a Volkmann-type fracture is present, requiring repositioning and losing access to the fibula through the posterolateral approach. Our objective is to describe a technique for fixing ankle fracture-dislocations with large posterolateral fragments using tibial buttress plates and fibula nails through a prone posterolateral approach without dissecting the lateral window. Additionally, we will present a case series with preliminary results.

Immediate inferior alveolar nerve reconstruction: Improving warfighter quality of life following mandibulectomy or traumatic avulsion of the mandible.

BACKGROUND: Mandibular reconstruction has historically been challenging due to the complex, highly functional, and esthetic nature of the anatomy. The most common etiologies of these defects requiring resection include trauma, benign tumors, and malignant pathology. Mandibular defects have been treated with little consideration for neural reconstruction, leaving patient's orally incompetent with associated social stigma. Although recent advances in reconstructive techniques improve oral rehabilitation, immediate inferior alveolar nerve (IAN) reconstruction has not been widely adapted. OBJECTIVE: Here-in we seek to discuss the innovations of neural reconstruction of large segment mandibular defects and associated IAN defects and present an example case performed at Naval Medical Center San Diego (NMCSD). METHODS: Pertinent literature discussing maxillofacial reconstruction and nerve repair using autogenous nerve harvest and allograft was queried from available online resources. RESULTS: Six patients have received immediate reconstruction of the IAN using processed nerve allograft over the past three years. All obtained sensation to S3 within six months of surgery. CONCLUSION: IAN repair using nerve allografts in conjunction with free flap reconstruction for large mandibular defects is a viable treatment and should be the new paradigm in maxillofacial reconstruction as it provides substantial quantifiable and qualitative improvements in social, functional, and esthetic outcomes of care.

Non-vascularised fibula as an adjuvant in the management of diaphyseal humerus non-union- A meta-analysis and systematic review.

Introduction: There is no standard protocol for managing non-union of diaphyseal humerus bone, with several authors reporting their results using various techniques and methods for its management. No meta-analysis has reported the results of managing these cases with non-vascularized fibula grafting as an adjuvant for osteosynthesis. Materials and methods: This meta-analysis was performed to estimate the pooled data for calculating the union rates in diaphyseal humerus fractures managed with non-vascularized fibula grafting. Risk of Bias was computed using the Joanna Briggs Institute appraisal tool. Results: A total of 5 studies, comprising 102 patients, were included. The pooled estimate demonstrated that 94 patients achieved bone union with intramedullary fibular strut grafting. The pooled union rate (per 100 events) was 90.59 (95 % CI, 82.86-95.04, I2 = 0). The present meta-analysis also showed a significant improvement in DASH scores following the use of a non-vascularized fibula graft with a common effects model (SMD = 4.08; 95%CI: 3.44; 4.72; p < 0.01 I2 = 19 %, p-value for Q test = 0.29). Conclusion: Non-vascularized fibula grafting is an excellent adjuvant for the internal fixation of non-union diaphyseal humerus fractures. Although there is limited literature, further studies should highlight and assess the treatment of these uncommon but disabling conditions.

Comparative Study of Degree of Great Toe Movement after Complete and Partial Flexor Hallucis Longus Harvest in Free Fibula Flap.

Background The flexor hallucis longus (FHL) muscle is crucial in fine motor control of the great toe but the muscle is often sacrificed in free fibula flap (FFF) reconstruction. The aim of this study was to compare great toe movement between complete and partial FHL resection during FFF harvest to see if FHL can be left behind (without undergoing fibrosis) in situ when bulk is not required at the recipient site. Methods A prospective, cross-sectional, observational study was performed including patients undergoing FFF harvest over a 2-year period. Movement of great toe interphalangeal joint was recorded of operated and unoperated legs in patients undergoing partial and complete FHL harvest and data analyzed. Results There was a statistically significant ( p < 0.05) difference between the two groups of patients. Conclusion FHL can be safely left in situ in patients not requiring bulk at the recipient site as blood supply, nerve supply, and muscle function are not compromised in partial FHL harvest. Further image-based and dye-based studies are warranted.

Persistent Challenges: A Recurrent Adamantinoma - Case Report.

Introduction: Adamantinoma is a rare, locally aggressive bone tumor that primarily affects the long bones, with a predilection for the tibia. Although considered a low-grade malignancy, adamantinoma is notorious for its high propensity for recurrence, which poses significant clinical challenges in the management of affected individuals. This case report aims to explore the intricacies of recurrent adamantinoma of the tibia, shedding light on its clinical presentation, diagnostic modalities, treatment strategies, and prognostic factors. Objective: This case report aims to evaluate surgical and functional outcomes of post-excision and reconstruction in recurrent adamantinoma. Case Report: This retrospective case report includes the patient who presented in Shaukat Khanum Memorial Cancer Hospital and Research Center Lahore with recurrent adamantinoma. Data were collected after patient's written and informed consent, and a retrospective analysis of the patient's demographics was done with the Statistical Package for the Social Sciences using the information in the Hospital Information System with a predesigned pro forma. Histology slides were collected from the Department of Pathology. Variables that were included are categorized into demographics, history and examination findings, site, and size of the primary tumor, radiological findings, histological type, stage, and resection margins. The patient underwent wide margin excision and reconstruction with free vascularized fibula graft and his functional outcome was evaluated using the musculoskeletal tumor society score which showed good functional outcome. Conclusion: Despite therapeutic challenges, wide excision of the tumor followed by free vascularized fibula grafting for reconstruction is a viable option to treat such patients where advanced prosthesis and allografts are not available.

Use of locking fibular plates versus non-locking dual plate fixation: A biomechanical study.

Introduction: Distal fibula osteoporotic comminuted fractures are challenging to treat and are often treated with periarticular locking plates. This study examined the biomechanical difference between locked plating and dual non-locked one-third tubular plating. Methods: Using an osteoporotic Sawbones fibula model, simulated fracture were fixated with one-third tubular dual plating and locked periarticular plating. The samples were then torqued to failure and peak torque, stiffness, and displacement were recorded. Results: The peak torque of the dual plating group was found to be statistically higher than the periarticular locked plating group (0.841 Nm and 0.740 Nm respectively; p = 0.024). However overall stiffness calculated at each 10° increment of displacement was noted to have no significant difference between the two constructs. Conclusion: Dual non-locked plating of distal fibula osteoporotic comminuted fractures is biomechanically equivalent to locked periarticular plating.