An imageology-based feasibility study of plating posterolateral tibial plateau fractures via an anterolateral trans-fibular-head approach.

BACKGROUND: There are many difficulties in the reduction and fixation of the tibial plateau fractures involving posterolateral quadrant using general plates via traditional approaches. By imaging the area above the fibulae capitulum, this study was performed to investigate the feasibility of the trans-fibular-head approach and to design an ideal anatomical plate. METHODS: MRI and CT scans of the knee joint were collected from 205 healthy volunteers (103 males, 102 females). Gender and height were used to divide the volunteers into groups separately: (1) A1 group and A2 group according to gender, (2) B1 group and B2 group according to height. Based on the images, several parameters were defined and measured to describe the space above the head of the fibula. In addition, differences in these parameters between genders and height were compared. RESULTS: The narrowest distance in the bony region was (10.96 ± 1.39) mm, (5.41 ± 0.97 mm) in the bone-ligament region. The narrowest distance of bony region in the A1 group was more than that in the A2 group (11.21 ± 1.62 mm, 10.85 ± 1.47 mm, p = 0.029). The narrowest distance of the bony region was (10.21 ± 1.42) mm and (11.65 ± 1.39) mm in the B1 group and B2 group, respectively (p = 0.002). The narrowest distance of the bone-ligament region was (5.39 ± 0.78) mm and (5.22 ± 1.21) mm in the A1 group and A2 group, respectively. No statistically significant differences were observed between the A1 group and the A2 group in terms of the narrowest distance of the bone-ligament region. In the B1 group, the narrowest distance of the bone-ligament region (5.18 ± 0.71 mm) was not significantly less than that (5.31 ± 0.91 mm) in the B2 group. CONCLUSION: The space above the fibular capitellum was ample enough to place the plate for treating tibial plateau fractures involving posterolateral quadrant. The divisions of the lateral tibial plateau by 3-dimensional CT and the parameters of each region were crucial for providing guidance for designing the anatomical plate for the trans-fibular-head approach.

The anteroposterior distance between the posterior edge of the medial tibial condyle and the posterior edge of the fibular head in the lateral view can be a reference in determining the axis perpendicular to the tibial anteroposterior axis.

BACKGROUND: Obtaining an accurate tibial lateral view is important during high tibial osteotomy. This study investigated whether the posterior edge of the medial/lateral tibial condyle (PEMTC/PELTC) and the posterior edge of the fibular head (PEFH) in a lateral view could be a reference for determining the accurate tibial lateral view. METHODS: A total of 75 lower limbs in 38 subjects were evaluated in this study. In order to target healthy knees, subjects undergoing primary total hip arthroplasty were selected. The MF/LF, comprising the anteroposterior distance between PEMTC/PELTC and PEFH, was measured on the lateral view of the tibial bone model based on the tibial anteroposterior (AP) axis (true lateral view: TLV). In addition, measurements were calculated in the model with a 10° external/internal rotation. Using these measurements, linear regression analysis was performed to predict the tibial rotation with MF/LF. RESULTS: The mean MF/LF was 0.9/4.6 mm (P < 0.001). MF and LF increased with incremental tibial rotation. Regression formulas were derived from these results as follows: Tibial rotation = (1) -1.01 + 1.06 × MF (R2 = 0.87, P < 0.001), (2) -8.70 + 1.86 × LF (R2 = 0.51, P < 0.001). The mean tibial rotation angle when MF was 0 mm was -0.9°. CONCLUSIONS: Based on formula (1) and actual measurements, the mean tibial rotation angle when MF is 0 mm is an internal rotation of about 1°. Therefore, a lateral view, in which PEMTC and PEFH are seen colinearly, can be the approximate TLV. The MF can be a suitable intraoperative reference in determining TLV.

Higher fibular head is a risk for lateral hinge fracture in medial open wedge high tibial osteotomy.

PURPOSE: To examine the association between the hinge position, fibular head position, and type III lateral hinge fracture (LHF) in patients with knee osteoarthritis (OA) who underwent medial open wedge high tibial osteotomy (MOWHTO). METHODS: This retrospective study examined patients who underwent MOWHTO. Radiographically, the Kellgren-Lawrence (K/L) classification, distance between the articular surface and the tip of the fibular head (fibular head position), hinge point (hinge position), type of LHF, and safe zone (within the proximal tibiofibular joint) outlier were evaluated. To determine the cut-off value of the hinge position and fibular head position associated with type III LHF, a receiver operating characteristic (ROC) curve analysis was performed. The odds ratio (OR) was calculated from the obtained cut-off values using logistic regression, which was adjusted by age, gender, body mass index, and opening distance. RESULTS: Among 132 knees in 120 patients, the radiographic severity of knee OA was 19 (14%), 73 (55%), and 40 (30%) of K/L grades 2, 3, and 4, respectively. LHF was observed in 40 knees (30%), including types I, II, and III fractures in 21 (16%), 5 (4%), and 14 (11%) knees, respectively. Hinge and fibular head positions were 16 and 10 mm, respectively, with significant correlation. Safe zone outlier was observed in 38 knees (29%). The hinge and fibular head positions with type III LHF were significantly higher (more cranial) than those with no fracture or other LHF subtypes. The ROC curve revealed that the cut-off value for the hinge and fibular head positions was 13.3 and 8.6 mm, respectively. The OR of the hinge and fibular head positions was 22.42 and 13.86, respectively. CONCLUSIONS: A higher hinge position was a risk factor for type III LHF and was associated with a higher fibular head in patients with knee OA who underwent MOWHTO. The hinge position should be placed at a certain distance from the articular surface to avoid type III LHF, especially in participants with higher fibular head position, even if the hinge position is located in the safe zone. LEVEL OF EVIDENCE: Retrospective cohort study, Level III.

Comparison of the intraarticular osteotomy and the "window" osteotomy in the treatment of tibial plateau fracture involving depressed posterolateral fragments.

OBJECTIVES: The methods of reduction of depressed posterolateral fragments in tibial plateau fracture through anterolateral approaches remain controversial. This paper aimed to compare the intraarticular osteotomy technique and the "window" osteotomy technique for the reduction of depressed posterolateral fragments through anterolateral approach. METHOD: From January 2015 to January 2022, we retrospectively reviewed the data on patients with tibial plateau fracture involving depressed posterolateral fragments treated with the intraarticular osteotomy or the "window" osteotomy. 40 patients underwent the intraarticular osteotomy were divided into group A, while 36 patients underwent the "window" osteotomy were divided into group B. The operative time, bone grafting volume, fracture healing time, complication, reduction quality and postoperative functional results were compared between the two groups. RESULTS: The average follow-up duration was 16.6 ± 3.7 months. The average bone grafting volume for all patients in group B was essential larger than group A (p = 0.001). Compared to group B, patients in groups A had significantly shorter fracture healing time (p = 0.011). The depth of depressed articular surface, PSA and the radiographic evaluation at 2 days and 6 months after surgery in group A were significantly lower than group B (p<0.05). Based on the HSS knee-rating score, no significant difference in function results was found between the two groups (p>0.05). No significant difference was found in operation time and blood loss between the two groups (p>0.05). CONCLUSION: The intraarticular osteotomy could obtain satisfactory clinical results in tibial plateau fracture involving posterolateral fragments.

Adjustable-loop cortical suspension device for posterolateral corner reconstruction in the setting of fibular avulsion fracture: a case series and novel technique description.

INTRODUCTION: A novel technique using an adjustable-loop cortical suspension toggle device for reduction of a fibular head avulsion fracture (arcuate fracture) in posterolateral corner (PLC) reconstruction is described. Results of clinical follow-up are presented. MATERIALS AND METHODS: 9 patients were retrospectively identified who underwent posterolateral corner reconstruction using an adjustable-loop cortical suspension toggle device. Radiographic examination was used to evaluate the successful healing of the avulsed fibular head fragments post-operatively. RESULTS: 7 patients reported satisfactory results with their clinical outcome with no feelings of knee instability or objective instability on exam at final follow-up. Post-operative radiographs obtained > 6 months following reconstruction demonstrated well reduced and healed fracture in 5 of 6 patients, with 1 patient demonstrating maintained reduction but incomplete fracture union at 6 months. CONCLUSION: This novel surgical technique for PLC reconstruction with an avulsed fibular head fracture is a viable alternative to previously described methods. The majority of patients report subjective satisfaction with a stable knee post-operatively. LEVEL OF EVIDENCE: IV.

Mechanical Evaluation of Salvage Fixation Techniques for a Lateralized Fibular Tunnel in Posterolateral Corner Reconstruction of the Knee.

Background: Posterolateral corner (PLC) reconstruction of the knee involves precise drilling of a single tunnel from anterolateral to posteromedial in the fibular head (FH) to ensure adequate graft fixation. Misplacement of the tunnel in a too lateral or too superior trajectory can lead to cortical breach and inadequate graft fixation. Purpose: To (1) determine the mechanical consequence of a lateralized FH tunnel in PLC reconstruction and (2) compare the mechanical strength of 3 salvage fixation techniques for a lateralized FH tunnel. Study Design: Controlled laboratory study. Methods: Sawbones models of a uniform density were utilized. FH tunnels (7-mm diameter) were drilled from anterolateral to posteromedial in positive controls (lateral cortex thickness, 7.6 ± 0.7 mm) to represent an improperly placed FH tunnel at risk of lateral cortical breach. For negative controls and salvage experimental groups, FH tunnels were drilled from anterolateral to posterolateral (lateral cortex thickness, 2.7 ± 0.9 mm). Three salvage fixation techniques were compared: suture anchor fixation, tunnel redrilling, and nitinol staple fixation. Samples (n = 5 per group) underwent uniaxial tension testing, and the ultimate tensile strength (UTS) and mode of failure were recorded. Data were analyzed using the 1-sample t test and nonparametric 1-sample Wilcoxon signed-rank test. Results: The negative control group had a 4-fold lower mean UTS relative to the positive control group (1.49 ± 0.17 vs 6.25 ± 1.98 MPa; P < .01) and exhibited failure through the lateral cortex and tunnel. Nitinol staple fixation improved the mean UTS by >16 times compared with the negative control group (24.06 ± 6.49 vs 1.49 ± 0.17 MPa; P < .01). Suture anchors and tunnel redrilling exhibited similar UTS and mode of failure to those of negative controls. Conclusion: Reinforcement of a thinned lateral FH cortex with a single nitinol staple improved graft fixation strength in a sawbones model. Clinical Relevance: A lateralized FH tunnel can be a common intraoperative pitfall during PLC reconstruction. Salvage of a thinned lateral FH cortex with a single nitinol staple may reduce the risk of cortical breach and graft failure.

Analysis of the relationship between the morphology of the proximal tibiofibular joint and lateral hinge fracture in open wedge high tibial osteotomy.

BACKGROUND: One of the complications of open wedge high tibial osteotomy is lateral hinge fracture, which causes delayed bone healing. In this study, we focused on the morphology of the proximal tibiofibular joint to clarify the influence of this morphology on the occurrence of lateral hinge fracture in open wedge high tibial osteotomy. METHODS: The proximal tibiofibular joint of 58 knees in 55 patients who underwent open wedge high tibial osteotomy was classified as either horizontal or oblique, depending on the morphology of the fibular head. Lateral hinge fracture of Takeuchi classification type II or III was defined as unstable lateral hinge fracture. We analyzed whether patient background and bone morphological factors, including the morphology of the proximal tibiofibular joint, were associated with the occurrence of unstable lateral hinge fracture. RESULTS: The horizontal and oblique types were found in 34 and 24 knees, respectively. There was no difference in the percentage of hinge points within the safe zone between the horizontal and oblique types; however, there was a significant difference in the unstable lateral hinge fracture incidence between the two groups. Unstable lateral hinge fracture occurred in seven knees, mostly in patients with an oblique proximal tibiofibular joint. The factors associated with the occurrence of unstable lateral hinge fracture were analyzed using logistic regression analysis; the fibular head of the oblique type was a significant factor. CONCLUSION: Open wedge high tibial osteotomy for oblique-type proximal tibiofibular joints may be more likely to cause unstable lateral hinge fracture than the horizontal type.

Relationship between the height of fibular head and the incidence and severity of knee osteoarthritis.

The purpose of this study was to investigate the correlation between fibular head height and the incidence and severity of osteoarthritis associated with varus knee deformity. The fibular head height, joint line convergence angle (JLCA) and medial proximal tibial angle (MPTA) were measured in a three-dimensional model. Ordinal multivariate logistic regression was used to analyze the correlation between fibular head height and Kellgren-Lawrence (K-L) grade. Pearson correlation was used to analyze the correlation between fibular head height and K-L grade. A total of 232 patients (232 knees) were finally included in the study. There were significant differences in JLCA and hip-knee-ankle angle (P < 0.05), and both JLCA and hip-knee-ankle angle increased with severe aggravation of K-L grade. Both fibular head height and MPTA decreased as the K-L grade was severely aggravated. There was a significant negative correlation between K-L grade and fibular head height (r = -0.812, P < 0.001). Furthermore, there was a significant negative correlation between fibular head height and hip-knee-ankle angle (r = -0.7905, P < 0.001). In addition to body mass index, fibular head height is a risk factor for the pathogenesis of osteoarthritis associated with varus knee deformity; the smaller the fibular head height, the more severe the degree of varus deformity.

Snapping of bilateral biceps femoris tendons: A case report and brief review.

Snapping of the biceps femoris tendon is a rare cause of lateral knee pain often due to multiple factors including fibular head deformity and thickening of the anterior band of the biceps femoris tendon inserting on the tibia. Understanding the complex and poorly understood anatomy of the biceps femoris tendon is crucial and essential for proper diagnosis of its snapping. In this report, we describe the rare entity of bilateral biceps femoris tendon snapping in a young man using a multimodality diagnostic approach.

The treatment of posterolateral tibial plateau fracture with a newly designed anatomical plate via the trans-supra-fibular head approach: preliminary outcomes.

BACKGROUND: There are no ideal plates or approaches for anatomical restoration and rigid fixation of posterolateral tibial plateau fractures. This study aimed to evaluate the short-term preliminary outcomes of our novel anatomical plate placed via the trans-supra-fibular approach to treat posterolateral tibial plateau fractures. METHODS: From May 2016 to May 2018, 23 consecutive patients with posterolateral tibial quadrant fractures underwent open reduction with internal fixation via the trans-supra-fibular-head approach with our newly developed plate. The tibial plateau-tibial shaft angle (TPTSA), lateral posterior tibial slope angle (LPSTA), step-off, and condylar widening were measured on radiological images pre-operatively, 3 days post-operatively, 3 months post-operatively, and at the final follow-up examination. The radiological Rasmussen score was calculated, and the Hospital for Special Surgery (HSS) knee score was assessed to evaluate the functional outcomes. RESULTS: The LTPSA, TPTSA, step-off, and condylar widening at 3 days post-operatively, 3 months post-operatively, and at the final follow-up were significantly different (p = 0.001) compared with those pre-operatively, as was the radiological Rasmussen score (p = 0.001). The HSS score at the final follow-up was 89.10 ± 5.94 (range, 78-98), which was significantly higher than that at the 3-month follow-up 84.36 ± 6.76 (range, 74-96); p = 0.001). CONCLUSIONS: Our newly designed anatomical plate placed via the trans-supra-fibular approach can effectively treat posterolateral tibial plateau fractures. We noted minor trauma, stable fixation, and satisfactory clinical results.

A reproducible reference point for the common peroneal nerve during surgery at the posterolateral corner of the knee: a cadaveric study.

BACKGROUND: This is an experimental study conducted to assess whether the fibular head is a reliable reference point to identify the position of the common peroneal nerve at the posterolateral corner of the knee. MATERIALS AND METHODS: Twelve cadaveric knees were dissected through the lateral approach. The common peroneal nerve was identified and traced. The location where the common peroneal nerve crossed the posterior border of the biceps femoris and the posterior border of the fibular neck were designated as points B and N, respectively. The tip of the fibular head was designated F. Distances FB and FN were measured and the triangular area FBN was calculated at various degrees of knee flexion. RESULTS: During knee motion, distance FN showed minimal change and was not affected by variation in degrees of knee flexion (p = 0.131). Distance FB and distance BN were affected by variation in degrees of knee flexion (p < 0.001). Triangular area FBN increased in size up to 60° of knee flexion measuring 621.22 mm2 and subsequently decreased with further knee flexion. CONCLUSION: The common peroneal nerve can consistently be found at approximately 20.7 ± 1 mm on the fibular neck with respect to the tip of the fibular head. The tip of the fibular head is a consistent landmark that can be used to predict the position of the exit point of the common peroneal nerve at the posterolateral corner of the knee.

[Application of modified anterolateral supra-fibular-head approach in treatment of tibial plateau fractures involving posterolateral column].

OBJECTIVE: To explore effectiveness of reduction and internal fixation via modified anterolateral supra-fibular-head approach in treatment of tibial plateau fractures involving posterolateral column. METHODS: Between January 2016 and September 2018, 19 patients diagnosed as tibial plateau fractures involving posterolateral column were treated with reduction and internal fixation via modified anterolateral supra-fibular-head approach. There were 11 males and 8 females with an average age of 43.2 years (range, 28-65 years). The causes of tibial fracture were traffic accident (12 patients), falling injury (5 patients), and falling from height (2 patients). According to the Schatzker typing, the tibial fractures were rated as type Ⅱ in 9 cases, type Ⅲ in 4 cases, type Ⅴ in 4 cases, and type Ⅵ in 2 cases. The time from injury to operation was 5-13 days (mean, 8.5 days). There were 2 patients with osteoporosis. The operation time, intraoperative blood loss, and postoperative complications were recorded. The knee X-ray film was reviewed regularly to observe the fracture healing. At last follow-up, the fracture reductions were evaluated by Rasmussen radiological score. The knee joint function was evaluated by Hospital for Special Surgery (HSS) score system. RESULTS: The average operation time was 95 minutes (range, 65-130 minutes). The average intraoperative blood loss was 220 mL (range, 150-350 mL). All incisions healed by first intention. No complications such as infection or deep venous thrombosis occurred. All patients were followed up 12-20 months (mean, 15.4 months). X-ray films showed that the fractures healed with the healing time of 12-20 weeks (mean, 14.5 weeks). No complications such as loosening or breakage of internal fixation occurred. At last follow-up, according to the Rasmussen radiological score, the fracture reductions were evaluated as excellent in 13 cases, good in 4 cases, fair in 1 case, and poor in 1 case. HSS scores of knee joint function were excellent in 14 cases, good in 3 cases, fair in 1 case, and poor in 1 case. The knee joint range of motion was 90°-135°, with an average of 113.4°. CONCLUSION: Application of modified anterolateral supra-fibular-head approach in reduction and internal fixation for tibial plateau fractures involving posterolateral column has the advantages of full exposure, less trauma, safety, and reliable reduction and fixation.

Good functional outcome evaluation of free vascularized fibular head graft (FVFHG) as treatment after resection of giant cell tumor (GCT) campanacci 3 at proximal humerus: A case report.

INTRODUCTION: Giant cell tumor (GCT) is benign aggressive tumors with a high rate of recurrence and capacity to metastasize. Wide resection is the treatment of choice, but this creates a flaw at the proximal end of the humerus. There are various methods exist as the treatment option to fixed this problem. PRESENTATION OF CASE: We here present our experience on wide resection and free vascularized autogenous fibula head grafting for GCT at the proximal humerus of a 32 years old male. We performed free vascularized fibular head graft (FVFHG) as a reconstruction method followed by sling procedure and used the long head of biceps tendon. Evaluation of anatomical, functional, and radiological outcomes of this management was performed. After 3 years, the patient has a good outcome. DISCUSSION: Free vascularized fibula graft is the most favored as a treatment after resection of a tumor on the proximal humerus. The advantages are can be harvested without many difficulties and rapid healing. In our case, we used a free vascularized fibular head graft (FVFHG) for proximal humerus reconstruction after resection giant cell tumor (GCT) on the right proximal humerus. We use the peroneal artery as vascular pedicle due to well vascularity to the peripheral part of fibula. There is no fibula head reabsorption after three years post-operation. CONCLUSION: FVFHG for reconstruction modality as the treatment after resection of GCT grade Campanacci 3 on proximal humerus shows satisfactory result following long term evaluation.

Displaced osteochondral fracture of the posterolateral tibial plateau associated with an acute anterior cruciate ligament injury.

An osteochondral fracture of the posterolateral tibial plateau associated with an anterior cruciate ligament (ACL) injury in a 24-year-old boy is reported. Anterior cruciate ligament rupture is accompanied by bone contusions resulting from the impact of the posterolateral tibial plateau on the anterior part of the lateral femoral condyle. The osteochondral fracture of the posterolateral tibial plateau matched the site where the bone bruise is observed.

Peroneal nerve location at the fibular head: an anatomic study using 3D imaging.

INTRODUCTION: Injuries to the peroneal nerve are a common complication in operative treatment of proximal tibial or fibular fractures. To minimize the risk of iatrogenic injury to the nerve, detailed knowledge of the anatomy of the peroneal nerve is essential. Aim of this study was to present a detailed description of the position and branching of the peroneal nerve based on 3D-images to assist preparation for surgical approaches to the fibular head and the tibial plateau. METHODS: The common peroneal nerve, the deep and the superficial peroneal nerve were marked with a radiopaque thread in 18 formalin-embalmed specimens. Three-dimensional X-ray scans were then acquired from the knee and the proximal lower leg in full extension of the knee. In 3D-reconstructions of these scans, distances of the common peroneal nerve and its branches to clearly defined osseous landmarks were measured digitally. Furthermore, the height of the branching of the common peroneal nerve was measured in relation to the landmarks. RESULTS: The mean distance of the common peroneal nerve at the level of the tibial plateau to its posterior osseous limitation was 7.92 ± 2.42 mm, and 1.31 ± 2.63 mm to the lateral osseous limitation of the tibia. In a transversal plane, distance of the common peroneal nerve branching was 27.56 ± 3.98 mm relative to the level of the most proximal osseous extension of fibula and 11.77 ± 6.1 mm relative to the proximal extension of the tibial tuberosity. The deep peroneal nerve crossed the midline of the fibular shaft at a distance of 22.14 mm ± 4.35 distally to the most proximal extension of the fibula, the superficial peroneal nerve at a distance of 33.56 mm ± 6.68. CONCLUSION: As the course of the peroneal nerve is highly variable in between individuals, surgical dissection for operative treatment of proximal posterolateral tibial or fibular fractures has to be done carefully. We defined an area were the peroneal nerve and its branches are unlikely to be found. However, specific safe zones should not be utilized due to the individual anatomic variation.

The fibular head projection is of limited use as a radiographic landmark in preoperative planning of total knee arthroplasty.

INTRODUCTION: The projection of the fibular head is recommended as a quality indicator of a correct radiographic projection. However, this landmark has yet to be sufficiently validated. METHODS: The MRIs of 334 knee joints were included. On the MRIs, the distance between the FH and lateral tibial cortical bone was simulated in projections parallel to surgically relevant axes. Then, the Pearson correlation coefficient between the distance of the FH to the lateral tibial cortical bone and the projection plane causing this was determined. RESULTS: A projection of the knee joint perpendicular to Akagi's line projected the center of the fibular head on average 4.8 ± 2.9 mm laterally of the tibial cortical bone, parallel to the maximum mediolateral axis of the tibia 7.5 ± 3.4 mm, parallel to the posterior condylar axis 5.6 ± 3.6 mm and parallel to the surgical epicondylar axis 6.1 ± 3.5 mm laterally of the tibial cortical bone. An almost linear correlation was seen, with 1.9° tilting of the projection plane per mm change in distance between the fibular head and tibial cortical bone. At the same time, the interindividual scatter was over 60°. CONCLUSIONS: The rule of thumb for a partial overlap of the fibular head by the tibia in the case of a correct antero-posterior projection plane was also confirmed. However, a considerable interindividual variability of the position of the FH was found, which limits a conclusion regarding the quality of the radiographic projection on the basis of the position of the fibular head.

Deep peroneal nerve palsy due to osteochondroma arising from fibular head and proximal lateral tibia.

Following median and ulnar nerves, peroneal nerve entrapment is the most frequent nerve involvement in the body Katirji and Wilbourn (1998) [1]. Osteochondromas are the most common benign bone tumors comprising 9% of all bone tumors and 35% of benign bone tumors Porter (2000) [2]. Hereditary exostoses (HME) is an autosomal dominant disorder with variable penetrance characterized by multiple osteochondromas near joints. It is one of the most commonskeletal dysplasias with a frequency of about 1.18%. In this study, we aimed to present a case with a drop foot resulting from osteochondromas of proximal tibia and fibula and help to guide the clinicians in differential diagnosis according to SCARE criteria Agha (2016) [3].

Surgical management of proximal fibular tumors: A report of 12 cases.

BACKGROUND/AIM: Aggressive benign or malignant tumors in the proximal fibula may require en bloc resection of the fibular head, including the peroneal nerve and lateral collateral ligament. Here, we report the treatment outcomes of 12 patients with aggressive benign or malignant proximal fibula tumors. PATIENTS AND METHODS: Four patients with osteosarcoma and 1 patient with Ewing's sarcoma were treated with intentional marginal resections after effective chemotherapy, and 4 patients underwent fibular head resections without ligamentous reconstruction. Clinical outcomes were investigated. RESULTS: The mean Musculoskeletal Tumor Society scores were 96% and 65% in patients without peroneal nerve resection and those with nerve resection, respectively. No patients complained of knee instability. CONCLUSION: Functional outcomes after resection of the fibular head were primarily influenced by peroneal nerve preservation. If patients are good responders to preoperative chemotherapy, malignant tumors may be treated with marginal excision, resulting in peroneal nerve preservation and good function.

The anterolateral supra-fibular-head approach for plating posterolateral tibial plateau fractures: A novel surgical technique.

OBJECTIVE: The posterolateral (PL) tibial plateau quadrant is laterally covered by the fibular head and posteriorly covered by a mass of muscle ligament and important neurovascular structures. There are several limitations in exposing and fixing the PL tibial plateau fractures using a posterior approach. The aim of this study is to present a novel anterolateral supra-fibular-head approach for plating PL tibial plateau fractures. METHODS: Five fresh and ten preserved knee specimens were dissected to measure the following parameters:1) the vertical distance from the apex of the fibular head to the lateral plateau surface, 2) the transverse distance between the PL platform and fibula collateral ligament (FCL), and 3) the tension of the FCL in different knee flexion positions. Clinically, isolated PL quadrant tibial plateau fractures were treated via an anterolateral supra-fibular-head approach and lateral rafting plate fixation. The outcome of the patients was assessed after a short to medium follow-up period. RESULTS: The distance from the apex of the fibular head to the lateral condylar surface was 12.2 ± 1.6 mm on average. With the knee extended and the FCL tensioned, the transverse distance between the PL platform and the FCL was 6.7 ± 1.1 mm. With the knee flexed to 60° and the FCL was in the most relaxed position, the distance increased to 21.1 ± 3.0 mm. Clinically, a series of 7 cases of PL tibial plateau fractures were treated via this anterolateral supra-fibular-head approach. The patient was placed in a lateral decubitus position with the knee flexed to approximately 60 degrees. After the posterior retraction of the FCL, the plate was placed more posteriorly to provide a raft or horizontal belt fixation of the PL tibial plateau fragment. After an average of 14.3 months of follow up, the knee range of motion(ROM) was 121.4° ± 8.8° (range: 105°-135°), the HSS score was 96.7 ± 2.6 (range: 90-100), and the SMFA dysfunction score was 22.4 ± 3.8 (range: 16-28) points. CONCLUSION: The anterolateral supra-fibular-head approach can provide direct visualization of the posterolateral tibial plateau quadrant and put the plate more posteriorly to provide a raft for the fragments such that good clinical outcomes can be anticipated.

Factors that increase external pressure to the fibular head region, but not medial region, during use of a knee-crutch/leg-holder system in the lithotomy position.

BACKGROUND: Paralysis of the common peroneal nerve is one of the relatively common nerve injuries related to the lithotomy position with the use of a knee-crutch/leg-holder system. Several risk factors have been implicated in lithotomy position-related common peroneal nerve paralysis during operation. MATERIALS AND METHODS: In the present study, 21 young healthy volunteers participated in the investigation of the causes of the paralysis of the common peroneal nerve in the lithotomy position using a knee-crutch/leg-holder; Knee Crutch. We assessed the external pressure applied to the fibular head and medial regions using the Big-Mat pressure-distribution measurement system. Relationships between the peak contact pressure and physical characteristics, such as sex, height, weight, body mass index (BMI), and fibular head circumference, were analyzed. RESULTS: The peak contact pressure to the fibular head region was greater for males than for females. For all subjects, significant positive correlations were observed between the peak contact pressure to the fibular head region and weight, BMI, or fibular head circumference. However, there was no significant difference between the peak contact pressure to the fibular head region and height for any subjects. Moreover, there was no sex-related difference in the peak contact pressure to the fibular medial region, and no significant differences between the peak contact pressure to the fibular medial region and height, weight, BMI, or fibular head circumference. CONCLUSION: External pressure to the fibular head region is greater for males than for females using a knee-crutch/leg-holder system in the lithotomy position. In addition, the external pressure to the fibular head region, but not the fibular medial region, increases with increasing weight, BMI, and fibular head circumference. Therefore, these patient-related characteristics may contribute to the risk of developing lower-extremity neuropathy, leading to injury or ischemia of the common peroneal nerve.