Clinical analysis of denture rehabilitation after mandibular fibula free-flap recon-struction / 北京大学学报(医学版)

Objective:To evaluate the postoperative denture restoration and denture function in pa-tients with mandibular defect reconstructed with vascularized free fibula flap.Methods:In the study,154 patients who underwent mandibular segment resection and used vascularized free fibula flap to repair mandibular defects due to inflammation,trauma and tumor from January 2015 to December 2020 were collected.These patients had common inclusion criteria which were stable occlusal relationship before operation,segmental defects of mandibular bone caused by lesions of mandible and adjacent parts(such as floor of mouth,tongue,cheek),free fibula flap used for repair and surviving after operation.Relevant data were reviewed and situation of denture restoration was followed up.A questionnaire related to den-ture functional evaluation had been proposed for those who had completed the denture rehabilitation.The evaluation index of denture restoration function was assigned by expert authority to obtain the denture function score.SPSS 18.0 software was used for statistical analysis of the basic information of the patients included in the study and the denture restoration of the patients.Results:The rate of postoperative den-ture restoration in the patients with mandibular defects repaired by free fibula flap was 17.5％,and the rate of postoperative denture restoration in the patients with benign mandibular tumors was 25.0％(18/72),which was significantly greater than that in the patients with malignant tumors 11.0％(9/82,P＜0.05).There was no significant difference in denture function score between the patients with condylar defect and those without condylar defect in denture repair rate and denture function score(P＞0.05).The functional score of implant denture was significantly greater than that of removable denture(P＜0.05).According to Brown classification,the denture function score of the patients with the defect invo-lving the anterior mandibular region was significantly greater than that of the patients without the anterior mandibular region involved(P＜0.05).The poor oral conditions,such as less amount of remaining teeth,insufficient retention strength,large mobility of soft tissue in the surgical area,poor oral vestibular groove condition became the main reason of not receiving denture restoration(37.86％).Conclusion:The denture rehabilitation of mandibular defect reconstructed with vascularized free fibula flap is closely rela-ted to pathological properties and oral conditions.The clinical outcome of implant denture has been con-firmed effectively and it is a better choice for future denture restoration after mandibular reconstruction.

Biomechanics of reconstruction of total calcaneus defect using fibular flap based on finite element method / 中国组织工程研究

BACKGROUND:Calcaneal defects are common in clinical practice.It is difficult for surgeons to evaluate the effect of calcaneal reconstruction due to the complex anatomical structure and motor function of the heel.Finite element analysis has become an effective method for biomechanical behavior simulation and numerical analysis. OBJECTIVE:To compare the clinical effect and biomechanical characteristics of total calcaneal reconstruction with the Ⅱ-shaped and V-shaped fibular flap. METHODS:CT images of one left foot of a healthy 50-year-old male were acquired.Mimics software was used to obtain the preliminary three-dimensional model.Geomagic software was used to trim and curve the model.The model was imported into Solidworks software to simulate calcaneal reconstruction and complete the pre-processing of finite element calculation.Finally,Ansys software was used to solve the problem.The simulation results were compared with previous literature results to verify the effectiveness of the model.The surgical effect and biomechanical characteristics of the foot in different gait phases based on the simulated stress results were analyzed. RESULTS AND CONCLUSION:(1)Both Ⅱ-shaped and V-shaped fibular flaps could be used to reconstruct completely missing calcaneus,which could restore the length,width and height of normal calcaneus,and fill up the missing calcaneus bone.(2)Compared with the normal calcaneus,both configurations of fibular flaps showed a tendency for over-concentration of stress after loading.The normal calcaneus stress was mostly concentrated around the calcaneus nodule,the subtalar process and the calcaneus groove,while the stress of the two fibular flaps was mostly concentrated at the junction between the bone flap with the talus and cuboid bones.(3)The maximum stress of calcaneus was different between the two models and normal calcaneus under different simulation conditions,with statistically significant differences(P＜0.05).Compared with the V-shaped fibular flaps,Ⅱ-shaped fibular flaps had less force change in different gaits and were closer to the normal calcaneus.The V-shaped fibular flap bore excessive stress during the period of push-off,and the grafted bone material may yield under this condition and have the risk of fractures.

Effect of three-dimensional spatial distribution of necrotic and support areas on outcomes of fibular support for hip preservation / 中国组织工程研究

BACKGROUND:The distribution of the necrotic area plays an important role in hip preservation treatment.At present,there are few studies on whether the difference in the three-dimensional spatial distribution of osteonecrosis of the femoral head affects the clinical outcome of fibular support. OBJECTIVE:To explore the relationship between the spatial distribution and clinical outcome at the sites of osteonecrosis of the femoral head and fibular support using CT three-dimensional reconstruction so as to provide a basis for optimizing the applicable conditions of fibular support and improving the hip preservation effect of fibular support. METHODS:Eighty patients with osteonecrosis of the femoral head who were treated with fibular support for hip preservation from January 2010 to January 2021 were selected as the study subjects according to the inclusion criteria.They were followed up for at least 2 years.According to the clinical outcome,the patients were divided into the successful hip preservation group(n=55)and the failure hip preservation group(n=25).3D reconstruction was performed according to the preoperative and postoperative CT images of the patients.According to the three-column theory,the femoral head was divided into outer nine areas,middle nine areas and inner nine areas(L1-9,C1-9,and M1-9)to explore the spatial distribution of necrotic area of the femoral head and fibular support area and its relationship with clinical outcome. RESULTS AND CONCLUSION:(1)Before operation,the necrotic area of the femoral head was mainly distributed in L1,L2,L4,L5,C1,C2,C4,and C5(the upper and middle part of the anterior part of the outer ninth area and the middle part of the middle ninth area).After operation,the fibular support area was mainly distributed in L5,L6,C5,and C6(the middle and lower part of the outer ninth area and the middle and lower part of the middle ninth area).(2)There were significant differences in the distribution of osteonecrosis of the femoral head between the successful hip preservation group and the failure hip preservation group in L8(the posterior middle part of the outer ninth area),C3(the anterior lower part of the middle ninth area),C6(the lower middle part of the middle part of the inner ninth area)and M2(the anterior middle part of the inner ninth area)(P<0.05).There was a significant difference in the distribution of fibular support in L5 and L6(middle and lower part of outer nine)(P<0.05).Among them,the L8 region could be used as an independent predictor of hip preservation failure in fibular support surgery.The area under the curve of the L8 single factor prediction model was 0.698[95%CI(0.575,0.822)];the sensitivity was 76%,and the specificity was 63.6%.(3)It turns out,when the necrotic area involves L8,C3,C6,and M2,especially L8,the failure of fibular support may increase,and when the fibular support involves L5 and L6,the effect of hip preservation is often not ideal.

Reverse design of a new type of low-profile lateral malleolus steel plate assisted by computer bioengineering technology / 中国组织工程研究

BACKGROUND:Poor incision healing and infection often occur in elderly patients with lateral malleolar fractures after traditional lateral plate fixation.With the application of engineering software in medicine,a new type of plate placed posterolateral can be designed to solve the above-described problems. OBJECTIVE:To design a new type of posterior lateral low-profile steel plate with the aid of medical bioengineering software,based on the 3D CT data of the distance between the top of the lateral ankle fracture line to the anterior starting point(ACD),the distance between the top of the fracture line to the tip of the lateral ankle(CTD),the distance between the top of the fracture line to the posterior edge of the fracture line(PCD)and the angle between the anterior and posterior lateral sides of the distal fibula(CA). METHODS:Thirty cases of unstable lateral malleolar fracture and normal ankle were taken for CT scanning and three-dimensional reconstruction.The ACD,CTD,and PCD values in patients with lateral malleolar fracture were measured by 3-matic software,and the characteristics of lateral malleolar fracture line were plotted and described.The mimics software was used to measure the value of CA in the normal ankle joint.Based on the data measured above,3-matic software and solidworks software were used to design the low-profile steel plate and the thickness of the steel plate and the direction of the nail path were constructed.In Geomagic Studio software,fine surface,automatic surface,and fitting surface were used to generate the prototype of the low-profile steel plate,and then 3D printing was performed.After making a posterolateral incision of the lateral malleolus,the peroneus longus and brevis tendons were removed,and the prototype of the 3D-printed steel plate was placed behind the fibula to test its size and fit to the bone surface. RESULTS AND CONCLUSION:(1)The mean of ACD was(2.97±0.03)cm,and the variation was 5.23.The mean of PCD was(3.17±0.11)cm,and the variation was 17.60.The mean of CTD was(4.52±0.07)cm,and the variation was 8.60.(2)The fracture line of the lateral malleolus was drawn with an inverted"V"shape.The mean of CA between anterior and posterior lateral surfaces of the distal fibula was(103.20±1.94)°.At the midpoint section of the upper and lower vertices of the anterior edge of the distal fibula,the angle of the anterior and posterior lateral sides(CA)of the distal fibula was(78.50±1.78)°.(3)By using 3-matic,Solidworks,and Geomagic Studio software,a new type of posterior lateral low-profile steel could be successfully designed.Three to four holes were reserved for the screw holes at the proximal end of the plate with screw directions from back to front,and three screw holes were reserved on the inner and outer sides at the far end.The direction of the inner three holes could be from back to front,and the outer three screw holes needed to be biased towards the inner side,with an angle of 9.72°-13.28°.(4)It is indicated that the variability of the ACD position on the anterior lateral fracture line of the lateral malleolus is relatively small,while the variability of the posterior lateral PCD position is relatively large.The angle between the anterolateral and posterolateral sides of the lateral ankle fracture block shows a decreasing trend,with a smaller variation in the proximal angle and a larger variation in the distal angle.Based on three-dimensional CT reconstruction data of the external ankle,with the help of computer bioengineering software and the use of reverse design concept,a new type of low-profile lateral malleolus steel plate with a good fit can be quickly and conveniently designed to provide a valuable reference for the design of internal fixation devices.

Meta-analysis of the role of fibular fixation in tibiofibular fractures / 中国骨伤

OBJECTIVE@#To compare the role and importance of fibular fixation in tibiofibular fractures by Meta-analysis.@*METHODS@#The literature related to the comparison of the efficacy of fixation of the fibula with or without fixation on the treatment of tibiofibular fractures was searched through the databases of China Knowledge Network, Wipu, Wanfang, The Cochrane Library, Web of science and Pubmed, and statistical analysis was performed using RevMan 5.3 software. The rates of malrotation, rotational deformity, internal/external deformity, anterior/posterior deformity, non-union, infection, secondary surgery and operative time were compared between the fibula fixation and non-fixation groups.@*RESULTS@#A total of 11 publications were included, six randomised controlled trials and five case-control trials, eight of which were of high quality. A total of 813 cases were included, of which 383 were treated with fibula fixation and 430 with unfixed fibulae.Meta-analysis results showed that fixation of the fibulae in the treatment of tibiofibular fractures reduced the rates of postoperative rotational deformity[RR=0.22, 95%CI(0.10, 0.45), P<0.000 1] and internal/external deformity[RR=0.34, 95%CI(0.14, 0.84), P=0.02] and promoted fracture healing [RR=0.76, 95%CI(0.58, 0.99), P=0.04]. In contrast, the rates of poor reduction [RR=0.48, 95% CI(0.10, 2.33), P=0.36], anterior/posterior deformity[RR=1.50, 95%CI(0.76, 2.96), P=0.24], infection[RR=1.43, 95%CI(0.76, 2.72), P=0.27], secondary surgery[RR=1.32, 95%CI(0.82, 2.11), P=0.25], and operative time[MD=10.21, 95%CI(-17.79, 38.21), P=0.47] were not statistically significant (P>0.05) for comparison.@*CONCLUSION@#Simultaneous fixation of the tibia and fibula is clinically more effective in the treatment of tibiofibular fractures.

Enfermedad ultrarara frecuente en Perú: Reporte de casos del síndrome FATCO

El síndrome FATCO (fibular aplasia, tibial camptomelia, oligosyndactyly) está caracterizado por la presencia de anomalías en miembros inferiores. Es una enfermedad, de la cual no se ha precisado la etiología genética hasta la actualidad; sin embargo, se ha planteado que el tipo de herencia es dominante autosómica. La frecuencia de presentación a nivel global es muy rara y esta es la razón principal de los pocos pacientes publicados hasta la fecha. Existe un reporte de la presentación inusual de catorce pacientes peruanos, diagnosticados en un solo centro, con las características clínicas del síndrome FATCO en un período de 13 años. A la fecha, se han publicado catorce pacientes a nivel mundial, con los cuales se comparó y discutió los datos clínicos y radiológicos. Además, se analizaron las características demográficas, antecedentes familiares, sexo, edad y anomalías concomitantes.

The fibular aplasia, tibial campomelia, oligosyndactyly (FATCO) syndrome is characterized by the variable leg anomalies. The genetic etiology of this disease has not been determined to date; however, it has been suggested that the genetic inheritance is autosomal dominant. The frequency of presentation globally is infrequent and this is the main reason for the low number of patient reports. There's a report of the unusually high presentation of 14 peruvian patients diagnosed at a single center with the clinical features of FATCO syndrome over a 13-year period. We compare and discuss the clinical and radiological data of our patients with those of the 14 cases described worldwide. In addition, the demographic characteristics, family history, sex, age, and concomitant anomalies are analyzed.

Dental implant treatment in vascularized bone flaps after jaw reconstruction / 华西口腔医学杂志

Jaw defects caused by various reasons often seriously affect appearance and function. The goal of the treatment of oral and maxillofacial tumors should include the cure of the tumor and the restoration of premorbid function. The development of microsurgery and digital surgery technology has promoted the development of jaw reconstruction with vascularized free bone flap. Good appearance and improved predictability could be obtained with the help of preope-rative visual design. How to rehabilitate occlusal function on the reconstructed jaw and improve the quality of life of patients has become an important research direction. This article discusses the challenge of jaw reconstruction, the selection of vascularized bone flap, the choice of implant timing, the treatment of peri-implant soft tissue, and the influence of radiotherapy on implants after jaw reconstruction.

Biomechanical stability of endosteal augmentation for osteoporotic proximal humerus fracture: a finite element analysis / 中华创伤骨科杂志

Objective:To explore which configuration schemes of proximal humerus internal locking system (PHILOS) fixation with endosteal augmentation can provide the optimal biomechanical stability for treatment of osteoporotic proximal humeral fractures by means of finite element analysis.Methods:Based on the CT data of the humerus of an old female volunteer (78 years old, with a bone density T-value of -3.0), a three-dimensional finite element model of the humerus was established by digital medical software such as Mimics 19.0, Geomagic Studio 12, and Creo 2.0 ANSYS Workbench2019. Next, a model of unstable proximal humerus fracture was established and subjected respectively to 5 different fixations: simple PHILOS fixation (PHILOS group), PHILOS plus 6-cm fibula fixation with calcar screws (PHILOS-F-C-6 group), PHILOS plus 6-cm fibula fixation without calcar screws (PHILOS-F-6 group), PHILOS plus 9-cm fibula fixation with calcar screws (PHILOS-F-C-9), and PHILOS plus 9-cm fibula fixation without calcar screws (PHILOS-F-9 group). After a stress mode of shoulder joint abduction at 25° was simulated, a compressive load of 200N was applied to the 5 fixation models. The stress distribution and displacement of fracture ends in different fixation models were tested, and the biomechanical stability was compared among the 5 different internal fixations.Results:Under a shoulder joint abduction at 25° and a load of 200 N, the maximum stress and the displacement of the fracture ends in PHILOS-F-C-9 group (38.678 Mpa and 0.012 mm) decreased by 30.08% and 45.45%, respectively, compared with PHILOS-F-C-6 group (55.321 Mpa and 0.022 mm), and decreased by 12.48% and 15.38%, respectively, in PHILOS-F-9 group (77.012 Mpa and 0.033 mm) compared with PHILOS-F-6 group (88.106 Mpa and 0.039 mm). The maximum stress and the displacement of the fracture ends in PHILOS-F-C-6 group decreased by 37.21% and 43.59%, respectively, compared with PHILOS-F-6 group while decreased by 49.83% and 63.63% in PHILOS-F-C-9 group compared with PHILOS-F-9 group, respectively.Conclusion:For treatment of osteoporotic proximal humeral fractures with medial instability, PHILOS fixation with longer fibula endosteal augmentation plus insertion of calcar screws is a more appropriate choice which can reduce the stress of internal fixation and reduce the displacement of the fracture ends.

Application of vascularized iliac flap and fibular flap in mandibular defect repair: a comparative study / 中华医学美学美容杂志

Objective:To provide theoretical guidance for the treatment of mandibular ameloblastoma by comparing the differences in the quality of life (QOL) of patients with mandibular ameloblastoma repaired by vascularized iliac bone flap and fibular flap.Methods:Seventy-two patients with mandibular ameloblastoma were admitted to the Department of Oral and Maxillofacial Surgery, the First Affiliated Hospital of Zhengzhou University from August 2016 to April 2019. There were 38 males and 34 females, aged 18-45 years, with an average of 33 years. The patients were divided into group A (iliac bone flap) with 28 cases and group B (fibula skin flap) with 44 cases. The 14-item Oral Health Impact Profile questionnaires (OHIP-14) was used to investigate and compare the differences in the QOL of patients 6 and 24 months after surgery.Results:All the 72 cases of free flaps survived. The OHIP-14 showed that there was no difference in physiological pain between the preoperative and postoperative levels ( P>0.05). There was no difference between the two groups. The scores of psychological discomfort and psychological disorder decreased at 24 months after surgery, without significantly statistical difference compared with that at 6 months after surgery ( P>0.05). The scores of physical impairment, disability and social impairment significantly reduced at 24 months after surgery, with significantly statistical difference compared with that at 6 months after surgery (iliac bone group t=8.07, 6.01 and 23.19; fibula group t=6.56, 4.27 and 13.01, P<0.05). The scores of functional limitations significantly reduced in both groups at 24 months after surgery, but the difference was still statistically significant ( t=2.30, P<0.05) between the iliac bone group (17.68±3.44) and the fibula group (22.70±11.19). Conclusions:There is no significant difference in the QOL between the two groups of patients with mandibular defects at 24 months after surgery. The application of iliac bone flapis is recommended for patients with mandibular body defects and fibular flap for large defects or lesions involving the condyles and chin.

Effect of proximal fibula osteotomy on tension of lateral knee soft tissue in patients with knee osteoarthritis / 中国骨伤

OBJECTIVE@#To evaluate the short-term efficacy of proximal fibula osteotomy in the treatment of knee osteoarthritis, and to analyze the effect of osteotomy on the tension of the lateral knee soft tissue of patients and verify the reliability of the Arch string theory.@*METHODS@#A total of 71 patients with varus knee osteoarthritis from December 2019 to March 2022 were included, 3 patients dropped out, and 68 patients completed all trials, collected 27 males and 41 females, aged from 51 to 79 years old, with an average of (68.0±7.0 ) years old. The follow-up time ranged from 4 to 12 weeks, with an average of (3.76±1.94) weeks. After admission, the patient underwent Proximal fibula osteotomy, and the tension of lateral knee soft tissue, visual analogue scale (VAS) of pain, the western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and other indicators were recorded before surgery and 1 month after surgery in the weight-bearing state.@*RESULTS@#According to the VAS, the curative effect of a single index was evaluated by referring to the score before and after treatment by Bao Zongzhao. Thirty seven cases were markedly effective, 27 cases were effective, and 4 cases were ineffective. After surgery, 3 patients presented with weakness of dorsalis pedis extension and 1 presented with paresthesia of dorsalis pedis, which disappeared after symptomatic treatment . The VAS and WOMAC score at 1 month after operation were lower than those before operation, and the differences were statistically significant(P<0.001). The tension of lateral knee soft tissue 1 month after operation was lower than that before operation, and the difference had statistical significance(P<0.001).@*CONCLUSION@#Proximal fibula osteotomy is safe and effective in the treatment of varus knee osteoarthritis in the short term. One month after osteotomy, the tension of lateral knee soft tissue increases under weight-bearing state, but the long-term changes still need further observation and follow-up.

Comparative study of the effects of intramedullary nail fixation and minimally invasive percutaneous plate internal fixation technique on platelet activation and serum transforming growth factor-β1(TGF-β) 1 and bone morphogenetic protein-2 (BMP-2) in patients with tibial and fibular fracture / 中国骨伤

OBJECTIVE@#To investigate the effect of intramedullary nail fixation (IMN) and minimally invasive percutaneous plate internal fixation (MIPPO) techniques on tibiofibular fractures and their effect on platelet activation and serum transforming growth factor-β1 (TGF-β1) and bone morphogenetic protein-2 (BMP-2).@*METHODS@#Total of 105 patients with tibiofibular fractures from February 2019 to February 2020 were selected and divided into 53 cases in the MIPPO group and 52 cases in the IMN group. There were 29 males and 24 females with an average age of (41.74±6.05) years old in MIPPO group;in IMN group, 31 males and 21 females with an average age of (40.59±5.26) years old. The perioperative surgical indexes, postoperative complications, ankle function recovery at 12 months postoperatively, platelet activation indexes at 3 and 7 days preoperatively and postoperatively, and serum TGF-β1 and BMP-2 levels at 4 and 8 weeks preoperatively and postoperatively were compared between the two groups.@*RESULTS@#The operating time and fracture healing time in the MIPPO group were shorter than those in the IMN group(P<0.05); Compared with the preoperative period, the levels of GMP-140, PAC-1, CD63, and CD61 increased in both groups at 3 and 7 days after surgery, but were lower in the MIPPO group than in the IMN group(P<0.05);the levels of serum TGF-β1 and BMP-2 increased in both groups at 4 and 8 weeks after surgery compared with the preoperative period, and the postoperative complication rate in the MIPPO group was lower than that in the IMN group(P<0.05);the difference was not statistically significant in the excellent rate of ankle function recovery at 12 months follow-up after surgery between two groups(P>0.05).@*CONCLUSION@#Both intramedullary nail fixation and MIPO technique for treatment of tibia and fibula fractures can improve ankle joint function, but the latter has the advantages of short operation time, fast fracture healing, fewer complications, and light platelet activation. Serum TGF-β1, BMP-2 level improves quickly.

Donor Site Morbidity of Nonvascularized Bone Graft: A Systematic Review

ABSTRACT Objective: To evaluate the donor site morbidity of iliac and fibular nonvascularized bone graft after mandibular resection. Material and Methods: This study was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) in PubMed, Proquest, Science Direct, and Ebsco. A total of 12 studies met the criteria of studies in humans using iliac and fibular nonvascularized bone grafts in mandibular reconstruction after mandibular resection. Results: A greater proportion of patients received iliac nonvascularized bone graft (88.9%) than fibular nonvascularized bone graft (11.1%). Of the 385 cases of iliac bone graft, 153 cases (40%) experienced complications at the iliac donor site, whereas in 48 cases of fibular bone graft, two (4%) experienced complications at the donor site. Hemorrhage, bone fracture, infection requiring debridement, and hematoma were the major complications. Conclusion: The morbidity rate of the nonvascularized bone graft donor site of the fibula (4%) tended to be lower than that of the ilium (40%). Patient age and defect size were not significantly correlated with the occurrence of morbidity donor sites in either the ilium or fibula.

A Case of Paediatric Non-union of Tibia Treated With Tibialization of Fibula

Management of non-union with bone gap in tibia is difficult, especially if superimposed by infection of bone. Various modalities have been described for the treatment of gap non-union, with their own advantages and disadvantages. A case of a paediatric patient with traumatic left tibia fracture which was complicated by subsequent osteomyelitis and non-union presented to tertiary care hospital. After failure of different modalities of treatment, to provide union, the patient was managed with tibialization of fibula with fibula strut graft supported by a rush nail

El peroné flotante: resultado de una luxación tibioastragalina pura con lesión de la articulación tibioperonea proximal: reporte de caso / The floating fibula: outcome of pure tibiotalar dislocation with lesion to the proximal tibiofibular joint: case report

ANTECEDENTES El peroné flotante tras un traumatismo de alta energía es una entidad muy poco frecuente. Este es el primer reporte de caso asociado a luxación del tendón bicipital. OBJETIVO Presentar un caso de peroné flotante tras luxación divergente de tobillo asociado a luxación peronea proximal. MATERIALES Y MÉTODOS Mujer de 17 añ que, tras accidente de tráfico, sufrió caída y presentó dolor y deformidad del tobillo izquierdo, junto con dolor e impotencia funcional de la rodilla ipsilateral. En las radiografías, se apreció una luxación pura divergente del tobillo izquierdo de tipo IV. Se realizó reducción cerrada en urgencias. El estudio se complementó con una resonancia magnética que mostró una rotura completa de la sindesmosis y del ligamento deltoideo, así como una fractura no desplazada de la meseta tibial externa, junto con un desgarro de la cápsula tibioperonea proximal y desprendimiento completo del ligamento lateral externo y del tendón bicipital desde su inserción en la cabeza del peroné. Se realizó reanclaje de la sindesmosis y del ligamento deltoideo, así como del ligamento lateral externo y del tendón bicipital mediante anclajes óseos metálicos y reducción de peroné tanto proximal como distalmente, mediante sistema de sutura tipo botón. Se inmovilizó con férula cruropédica por cuatro semanas. RESULTADOS La paciente presentó recuperación completa de la fuerza a los cinco meses de seguimiento, con movilidad completa del tobillo y de la rodilla. CONCLUSIÓN El peroné flotante es muy poco frecuente; sólo se ha descrito un caso en la literatura. Implica la disrupción de la articulación tibioperonea proximal y distal, lo que puede provocar inestabilidad en la rodilla y en el tobillo. Por tanto, ante un traumatismo de alta energía en el tobillo, es necesaria la exploración minuciosa de la rodilla ipsilateral.

BACKGROUND Floating fibula after high-energy trauma is a very uncommon entity. The present is the first report of a case associated with avulsion of the bicipital tendon. PURPOSE To present a case of floating fibula after divergent ankle dislocation associated with proximal peroneal dislocation. MATERIALS AND METHODOS A 17-year-old woman who fell after a traffic accident and presented pain and deformity of the left ankle with pain and functional impotence in the ipsilateral knee. The radiographs showed a pure divergent type-IV left-ankle dislocation. Closed reduction was performed in the emergency room. The study was complemented with a magnetic resonance imaging scan which showed complete rupture of the syndesmosis and the deltoid ligament, as well as a non-displaced fracture of the external tibial plateau together with a tear of the proximal tibiofibular capsule and complete detachment of the external lateral ligament and bicipital tendon from its insertion in the peroneal head. The syndesmosis and deltoid ligament were reanchored, as well as the external lateral ligament and the bicipital tendon, using metallic bone anchors and fibula reduction both proximally and distally, using a suture-button system. The patient was immobilized with a long-leg splint for four weeks. RESULTS The patient presented complete recovery of strength at five months of follow-up. CONCLUSSION Floating fibula is a rare entity, with only one case described in the literature. It involves a disruption of the proximal and distal tibiofibular joint, which can lead to knee and ankle instability. Therefore, in cases of high-energy trauma to the ankle, a careful examination of the ipsilateral knee is necessary.

Variations in Innervation Pattern to Dorsum of Foot by Medial Dorsal Cutaneous Nerve, Intermediate Dorsal Cutaneous Nerve, Lateral Dorsal Cutaneous Nerve with Surgical and Clinical Correlations: A Cadaveric Dissection Based Study

The complete reconstruction of any soft tissue defect includes even the sensory recovery which is very significant aspect pertaining to prognosis. Superficial nerves in the vicinity of the vascular axis can be considered as vascular relays and neuroskin grafts can be constructed on them. Variations in innervation to various part of the dorsum of the foot by this nerve should be kept in mind while making these grafts. Authors dissected 50 formalinized cadaveric feet and studied normal anatomy and variations in origin, course, branching pattern, communications, and any other variations in medial, intermediate and lateral dorsal cutaneous nerve. The intermediate dorsal cutaneous nerve was innervating larger area of the skin around 3rd and 4th web spaces in 60% of cadaveric feet. The 2nd web space was innervated by medial dorsal cutaneous nerve in 92% of cadaveric feet. In 52% of cadaveric feet communicating branches were found between intermediate dorsal cutaneous nerve and lateral dorsal cutaneous nerve. In 63% cadaveric feet communicating branches were found between medial dorsal cutaneous nerve and branch of deep peroneal nerve to 2nd web space. The mean distance between lateral malleolus and intermediate dorsal cutaneous nerve was 4.05cm. These all observations can provide anatomical basis at the time of preparing medial dorsal cutaneous nerve flaps and intermediate dorsal cutaneous nerve flaps and also can minimize morbidity at donor site.

No unión infectada de fractura subtrocantérica de fémur, tratada con autoinjerto y placa / No infected union of subtrochanteric fracture of femur, treated with autograft and plate

Resumen: Las fracturas de cadera se consideran un problema de salud pública en el mundo, entre las fracturas de cadera encontramos las subtrocantéricas, que se definen como fracturas proximales de fémur situadas en la región trocantérea dentro de los 5 cm debajo del trocánter menor; tienen una incidencia aproximada de 15 a 20 por cada 100,000 personas. El objetivo de este de caso es reportar el éxito de la reconstrucción de una fractura subtrocantérica infectada, con un segmento del peroné no vascularizado y una placa de soporte condíleo de fémur distal. Caso clínico: masculino de 41 años de edad que sufre fractura subtrocantérica derecha producto de un accidente de tránsito que requirió manejo de osteosíntesis. Con posterior ruptura del clavo cefalomedular en su tercio proximal, no unión de la fractura e infecciones en sitio de la fractura. Fue tratado con múltiples lavados quirúrgicos, antibioticoterapia y un procedimiento ortopédico y quirúrgico poco convencional como el uso de una placa de soporte condíleo de fémur distal y un injerto óseo endomedular con un segmento de 10 cm de peroné no vascularizado. Paciente con evolución satisfactoria y favorable.

Abstract: Hip fractures are considered a public health problem in the world. Among hip fractures we find subtrochanteric fractures that are defined as proximal femur fractures located in the trochanteric region within 5 cm below the lesser trochanter; and they have an approximate incidence of 15 to 20 per 100,000 people. The objective of this case is to report the success of the reconstruction of an infected subtrochanteric fracture, with a non-vascularized fibular segment and a distal femur condylar support plate. Clinical case: 41-year-old male patient suffering from a right subtrochanteric fracture as a result of a traffic accident that required the use of osteosynthesis material. With subsequent rupture of the cephalomedullary nail in its proximal third, non-union of the fracture and infections at the fracture site. He was treated with multiple surgical lavages, antibiotic therapy, and an unconventional orthopedic and surgical procedure, such as the use of a distal femur condylar support plate and an endomedullary bone graft with a 10-cm segment of non-vascularized fibula. Patient with satisfactory and favorable evolution.

COMPARATIVE STUDY BETWEEN FIBULA PLATING VERSUS INTRAMEDULLARY K-WIRE WITH MEDIAL MALLEOLAR SCREW IN FIXATION IN BIMALLEOLAR FRACTURES OF ANKLE

Background: Pott's fracture is eponym of bimalleolar fracture, which account for one fourth of patients of ankle injury, it is more common in women, people over 60 years of age. There has been an increase in the prevalence of one such fracture over the last two decades both in the young, active patients and in the elderly. Objectives: The aim of this study was to compare the clinical and functional results of patients with bimalleolar fractures treated with semi tubular / reconstruction plating or intra medullary k-wire in fibula along with medial malleolar screw. Material And Method: This was a prospective randomized comparative study carried out using fibula plating and intramedullary k wire for fixation of lateral malleolus fracture and malleolar screw fixation for fracture medial malleolus among 60 patients admitted in S.M.S Hospital, Jaipur during the study period of April 2018 to December 2019. Informed consent was taken and functional assessment of patient was done at 1, 3 and 6 months after discharge according to the Modified ankle score of Olerud Molander. Results: The quantitative data was presented as mean and standard deviation and were compared by student's t-test. Probability was considered to be significant if less than 0.05. There was a significant differences (P=0.008 & P=0.001) in both the groups on the basis of mean duration of partial weight bearing (weeks) and initiation of full weight bearing (weeks). There was a significant difference in both the groups on the basis OMAscore at 1, 3 and 6 months. Conclusion: The final functional outcome was compared by Modified Olerud & Molander Score. 24 (80%) cases in fibula plating group had excellent to good results whereas, 15 (50%) cases in intramedullary k wire group had excellent to good results (P=0.010). In conclusion, cases managed by Fibula Platting had better functional outcome as compared to those treated by Intramedullary K Wire group.

Fibula-preserving anterolateral approach for tibiotalocalcaneal arthrodesis: clinical and radiographic outcomes / 中华创伤骨科杂志

Objective:To evaluate the clinical and radiographic outcomes of tibiotalocalcaneal arthrodesis via the fibula-preserving anterolateral approach.Methods:From March 2018 to February 2021, 23 patients underwent tibiotalocalcaneal arthrodesis via the fibula-preserving anterolateral approach at the Department of Foot and Ankle Surgery, Beijing Jishuitan Hospital.Of them, 15 were males and 8 females. Their average age at surgery was 54.4 years (range, from 28 to 72 years). There were 11 cases of traumatic arthritis, 2 cases of Charcot arthropathy, 6 cases of neurogenic equinovarus, 2 cases of traumatic equinovarus, and 2 cases of Kashin-Beck disease. Comparisons were made between preoperation and the last follow-up in ankle-hindfoot score of American Orthopedic Foot and Ankle Society (AOFAS), visual analogue scale (VAS), foot function index (FFI), hindfoot alignment angle (HA), hindfoot alignment distance (HD), and hindfoot alignment ratio (HR). The tibia-foot angle on lateral weight-bearing and patient satisfaction at the last follow-up and postoperative complications were documented.Results:This cohort were followed up for an average of 24.7 months (from 12 to 48 months). The AOFAS ankle-hindfoot score (78.2 ± 9.2), VAS [2.0 (0.5, 2.0)], FFI [19.0 (10.5, 35.0)], HA (2.7° ± 5.8°), HD [(0.1 ± 0.8) cm] and HR [44.2 (36.4, 59.2)%] at the last follow-up were significantly improved than the preoperative values [43.4 ± 12.7, 4.0 (4.0, 6.0), 98.0 (60.0, 127.0), 22.0° ± 14.3°, (2.2 ± 1.6) cm and 86.0 (66.3, 100.0)%] (all P<0.05). The tibia-foot angle on lateral weight-bearing was 89.0° (87.1°, 90.4°) at the last follow-up. By the Likert scale, 17 cases were very satisfied with the surgery, 4 cases satisfied and 2 cases tolerate, giving a satisfaction rate of 91.3%(21/23). Infection occurred in one case and nonunion in one. Conclusion:Tibiotalocalcaneal arthrodesis via the fibula-preserving anterolateral approach yields good mid- to short-term clinical and radiographic outcomes, showing a strong capability to correct ankle and hindfoot varus and equinus.

Vascularized fibula autograft combined bone graft for reconstruction of femoral shaft continuity after resection of malignant tumor / 中华骨科杂志

Objective:To investigate the effects of parallel reconstruction with titanium cable fixation and concentric reconstruction with plate fixation in the reconstruction of femoral shaft continuity after resection of malignant tumor.Methods:From September 2013 to December 2017, the data of 11 consecutive patients with thigh malignancies and related complications were retrospectively analyzed, including 10 males and 1 female. The mean age of the 11 patients was 27.1±15.6 years (range, 7-49 years). These case series included 6 cases of primary bone defect reconstruction after resection of femoral shaft malignant tumor, 4 cases of nonunion or allogeneic bone fracture after massive bone allograft for femoral malignant tumor, and 1 case of femoral fracture caused by radiotherapy after resection of thigh soft tissue sarcoma. Vascularized fibular autograft combined with massive bone allograft or devitalized bone graft was used for reconstruction. The patients were divided into two groups according to reconstruction method, namely parallel reconstruction group and concentric reconstruction group. In the parallel reconstruction group, the vascularized fibula was placed on the medial side of the femur and the allograft and fixed with titanium cable. In the concentric reconstruction group, the vascularized fibula was placed in the medullary cavity of the allogeneic bone or devitalized bone and further fixed with the plate and screws.Results:There were 5 patients with 7 allograft-host junctions or fracture were treated with parallel reconstruction. The grafted length of fibula was 15.0±4.3 cm (range, 10-20 cm). The follow-up duration was 33.2±15.6 months (range, 20-53 months). Six patients with 10 allograft-host junctions were treated by concentric reconstruction. The grafted length of fibula was 15.5±2.3 cm (range, 12-18 cm). The follow-up duration was 45.8±15.3 months (range, 22-62 months). There was no significant difference during follow-up between the two groups ( t=1.36, P=0.208). The union rate in parallel reconstruction group was 100% (7/7), and the union duration was 15.9±6.8 months (range, 3-22 months). The union rate in the concentric reconstruction group was 70% (7/10), and the union duration was 18.9±6.4 months (range, 11-30 months). There was no significant difference in the union rate ( P=0.228) or the union duration ( t=0.846, P=0.414) between the two groups. Conclusion:Both parallel reconstruction and concentric reconstruction of vascularized fibular autograft are important methods for reconstruction of femoral shaft continuity after resection of malignant tumor. There might be no significant difference in union rate or union duration between the two methods.

Osteotomías de alargamiento para realineación en maluniones postraumáticas de peroné / Lengthening osteotomy for realignment in posttraumatic fibular malunions

El acortamiento y la rotación del peroné son las deformidades más frecuentemente encontradas cuando se presentan maluniones postraumáticas del tobillo resultando en ensanchamiento de la mortaja e inestabilidad astragalina, con consecuentes cambios artrósicos. Los pacientes acuden por presentar dolor y limitación en sus actividades diarias y deportivas. En el presente estudio retrospectivo se hace una evaluación de los resultados clínicos y radiológicos de 9 pacientes que se sometieron a tratamiento quirúrgico posterior a maluniones de fracturas de peroné, en los cuales se realizaron osteotomías de alargamiento y desrotación para reconstrucción del tobillo, en la Unidad de Cirugía de Pie y Tobillo del Hospital Universitario de Caracas, entre junio de 2014 y agosto del 2019. Se realizaron mediciones radiológicas pre y postoperatorias de los ángulos de inclinación astragalina, talocrural y bimaleolar, y se reportaron los cambios degenerativos articulares. Para la evaluación clínica y funcional se aplicó la Escala Análoga Visual (VAS) para el dolor, y la Escala AOFAS de retropié, evidenciándose mejoría en cuanto a dolor, función y alineación. El objetivo del tratamiento fue restituir la longitud inicial del peroné, mediante osteototomías oblicuas en el sitio de la fractura anterior, o transversas suprasindesmales, con lo cual también se corrige la alineación del astrágalo, y de esta manera prevenir o disminuir los síntomas y signos inherentes a degeneración articular progresiva(AU)

The shortening and rotation of the fibula are the most frequent deformities found when post-traumatic ankle malunions occur, resulting in widening of the mortise and talus instability, with consequent arthritic changes. Patients have pain and limitation in their daily activities and sports. In the present retrospective study, an evaluation of the clinical and radiological results of 9 patients who underwent surgical treatment after fibular fracture malunions was performed, in which osteotomies of lengthening and de-rotation were performed for reconstruction of the ankle, in the Unit of Foot and Ankle Surgery at the University Hospital of Caracas, between June 2014 and August 2019. Pre and postoperative radiological measurements of the astragaline, talocrural and bimaleolar inclination angles were performed, and degenerative joint changes were reported. For the clinical and functional evaluation, the Visual Analog Scale (VAS) was applied for pain, and the AOFAS Hindfoot Scale, evidencing improvement in pain, function, and alignment. The objective of the treatment was to restore the initial length of the fibula by means of oblique osteotomies at the site of the previous fracture or suprasindesmal transverse osteotomy, which also corrects the alignment of the talus and thus prevents or decreases the symptoms and signs inherent to joint progressive degeneration(AU)