Is immediate dental implant in fibula free flap beneficial for implant survival and osteoradionecrosis in jaw reconstruction?

OBJECTIVES: This study aimed to compare the risk of osteoradionecrosis and implant survival in oral cancer patients undergoing immediate dental implants during jaw reconstruction, termed "Jaw in a Day" (JIAD), with those receiving no implants or delayed implants (non-JIAD). PATIENTS & METHODS: Clinicopathologic data were collected from prospectively enrolled JIAD patients (n = 10, 29 implants) and retrospectively from non-JIAD patients (n = 117, 86 implants). Survival analyses were performed to assess implant survival and osteoradionecrosis-free survival. RESULTS: Osteoradionecrosis occurred in 0 % of JIAD cases compared to 19.3 % in non-JIAD cases without implants and 71.4 % in non-JIAD cases with delayed implants (p = 0.008). Osteoradionecrosis-free survival was significantly better in the JIAD group than the non-JIAD group (p = 0.0059). Implants in the JIAD group all survived regardless of radiation therapy (29/29, 100 %) and 95.1 % (58/61) of implants survived in delayed implants in non-irradiated fibula without radiotherapy. Meanwhile, only 11 of 25 implants placed in irradiated fibula flaps survived, even when the implants were placed after a median time interval of 624 days after radiotherapy, and none of them were earlier than 360 days. The survival analysis revealed a significant difference (p < 0.0001). CONCLUSION: JIAD appears to offer superior outcomes in terms of implant survival and osteoradionecrosis prevention compared to delayed implant placement. Placing implants in irradiated fibula, even after years, significantly poses high risk of implant failure and osteoradionecrosis. JIAD represents a promising approach for optimal rehabilitation, particularly in oral cancer patients requiring postoperative radiotherapy. Proper positioning and orientation of implants and flaps are crucial for implant survival.

Operative treatment of isolated epiphyseal fracture of the distal fibula: 1 case report and literature review.

Pediatric ankle injuries are common; ankle epiphyseal fractures are also common in children. But isolated distal epiphyseal fibular fractures of the distal fibula are clinically rare. We describe one unusual case of an adolescent with a completely displaced Salter-Harris type II distal fibular epiphyseal fracture. The attempt of closed reduction failed, and the patient required open reduction and internal fixation. The localized periosteum and the superior peroneal retinaculum were avulsed from the distal fibular metaphysis, with the peroneal tendons underneath exposed but no obvious subluxation. To the best of our knowledge, this combination of injuries has not been previously reported.

Intramedullary Fixation Versus Plate Fixation of Distal Fibular Fractures: A Systematic Review.

INTRODUCTION: The purpose of this systematic review and meta-analysis was to provide an update of the recent literature comparing clinical outcomes of surgically treated fibular fractures using intramedullary nailing (IMN) with open reduction and internal plate fixation (ORIF). METHODS: A literature search reporting clinical outcomes after IMN or ORIF of the distal fibula was conducted on PubMed. Inclusion criteria consisted of original studies; studies focusing on clinical outcomes after IMN or IMN and ORIF published before May 11, 2022; studies with at least 5 patients; and studies reporting union rates, complication rates, and patient-reported outcomes such as American Orthopaedic Foot and Ankle Society (AOFAS) and Olerud-Molander scores. RESULTS: Of 2,394 studies identified, a total of 29 studies (4 LOE-I, 2 LOE-II, 6 LOE-III, 17 LOE-IV) were included consisting of 1,850 IMN patients and 514 plate patients. The pooled mean age of IMN patients was 58 years (95% confidence interval [CI], 54 to 62, I2 = 42%) versus 57 years (95% CI, 53 to 62, I2 = 49%) in ORIF. Union rates for IMN patients revealed a 99% union rate (95% CI, 0.98 to 1.00, I2 = 20%) versus 97% union rate for ORIF patients (95% CI, 0.94 to 0.99, I2 = 0%). Studies that compared IMN with ORIF revealed no difference in union rates (risk ratio [RR] = 0.99, 95% CI, 0.96 to 1.02, I2 = 0%). IMN patients showed a 15% complication rate (95% CI, 0.09 to 0.23, I2 = 89%), whereas plate patients had a complication rate of 30% (95% CI, 0.18 to 0.46, I2 = 63%). When comparing studies with both treatments, IMN patients had a significantly lower risk of complications (RR = 0.49, 95% CI, 0.29 to 0.82, I2 = 50%). The IMN group trended toward a higher mean AOFAS and Olerud-Molander score than the plate group by 4.53 (95% CI, -14.58 to 23.65, I2 = 85%) and 3.54 (95% CI, -2.32 to 9.41, I2 = 76%) points, respectively. CONCLUSION: Current literature reveals near equivalence in union rates and a markedly lower risk of complications when comparing IMN with plate fixation. While IMN patients had higher AOFAS and Olerud-Molander scores, these differences were not statistically significant. Notably, subgroup analyses indicated that rates of symptomatic implant and removal of implant were comparable between IMN and ORIF, which may indicate that wound-related complications were reduced in the minimally invasive IMN technique. While the high cost of IMN implants remains a barrier to their widespread adoption, the long-term benefits of reducing complications, specifically associated with wound complications in high-risk populations, may greatly improve quality of care for patients with distal fibula fractures. Additional research and cost-effectiveness analyses are warranted to fully assess the long-term benefits and economic feasibility of using IMN fixation for distal fibula fractures. LEVEL OF EVIDENCE: Therapeutic Level IV.

Evaluation of the effect of vascularized fibula graft harvesting on coronal plane alignment and functional outcomes of the lower limb.

Recent studies on fibular osteotomy for varus gonarthrosis and possible subsequent biomechanical changes have attracted increasing attention to the topic. Existing studies have focused mainly on proximal fibular osteotomy with short follow-up periods. The aim of this study was to investigate changes in the alignment of the coronal plane of the ankle and knee joints in patients who underwent vascularized fibula graft harvest (VFGH). The evaluation was based on functional outcomes and radiological measurements.In the comparison between the VFGH side and the contralateral side, no significant differences in the knee inclination (KI) or talar inclination (TI) angle, knee medial clear space (K-MCS) or ankle medial clear space (A-MCS) distance were noted. However, a significant difference in the hip knee (HKA) angle was observed between the operated and nonoperated sides (0.3° ± 1.8° and 1.5° ± 1.9°, respectively [p = 0.019]). Statistically significant differences in both the knee society score (KSS) and the AOFAS scores were found between the ipsilateral donor limb and the contralateral healthy limb. Although the contralateral healthy side had better clinical scores than the VFGH side, the outcomes of the VFGH side were still satisfactory or excellent.

Full weight bearing after internal fixation of isolated distal fibular fractures with anatomically contoured locking plates: Our institutional experience.

Isolated fractures of the distal fibula mainly affect young, active people. In most cases, fixation is by open reduction with or without casting for six weeks without weight bearing. The current trend is to reduce this period of non-weight-bearing in order to promote earlier functional rehabilitation. The improved mechanical stability resulting from the use of plates with locking screws has changed the postoperative management of many fractures, but there is little evidence for the ankle. Between October 2013 and August 2015, 36 patients were enrolled in a prospective study to evaluate the performance of internal fixation of isolated distal fibular fractures using a lateral anatomically contoured titanium locking plate (InitialA® plate from Newclip Technics, Haute Goulaine, France) with immediate mobilisation and full weight bearing. No patient required further surgery due to mechanical failure or non-union. The bone healing rate was 100 % at 3 months. Two patients had septic complications requiring plate removal and antibiotic treatment and were eventually cured. The use of anatomically contoured locking plates provides strong and stable fixation, allowing immediate full weight-bearing. Such a technique has the advantage of a short recovery time and an early return to work without additional complications.

The precision of technical aspects in the minimally invasive Broström-Gould procedure: a cadaveric anatomical study.

BACKGROUND: A comprehensive understanding of the anatomy of the anterolateral ankle joint and its interrelationships is essential for advancing the development of minimally invasive Broström-Gould procedure, thereby enhancing surgical efficacy and minimizing postoperative complications. METHODS: Ten fresh human ankle specimens were dissected to observe the shape and trajectory of the lateral bundle of the inferior extensor retinaculum (IER) and its relationship with the deep fascia. To observe the relationship between the ankle capsule and the anterior talofibular ligament (ATFL). The center of the insertion point of ATFL at the lateral malleolus was used as the reference point. The vertical distance from the reference point to the fibula tip, the horizontal distance from the reference point to the lateral branch of the superficial peroneal nerve, the shortest distance from the reference point to IER, the narrowest width of the IER, the angle between the line connecting the shortest distance from the reference point to the IER and the longitudinal axis of the fibula were measured. The tension and elasticity of ATFL was understood. To describe the minimally invasive Broström-Gould procedure according to the anatomical characteristics of the anterolateral ankle joint. RESULTS: Among the 10 cases, 8 cases (80%) had double bundles of ATFL, 2 cases (20%) had single bundle of ATFL, and no outer superior oblique bundle was observed in IER. The vertical distance from the reference point to the fibula tip was 1.2 ± 0.3 (range 1.1-1.3) mm. The shortest distance from the reference point to the level of the superficial peroneal branch was 28.2 ± 4.3 (range 24.5-32.4) mm. The shortest distance from the reference point to IER was 12.5 ± 0.6 (range 12.1-12.9) mm, and the width of IER at this point was 7.2 ± 0.3 (range 7.0-7.6) mm. The angle between the line connecting the shortest distance from the reference point to the IER and the longitudinal axis of the fibula was about 60° ± 2.8° (range 58.1°-62.1°) mm. The space between the anterolateral deep fascia of the ankle joint and the ankle capsule is very small, and only a few fat granules are separated between them. The ATFL is largely fused to the ankle capsule. The ATFL exhibited high tension and poor elasticity after traction with the probe hook. CONCLUSIONS: The results showed that in the minimally invasive Broström-Gould technique for lateral ankle stabilization, the Broström procedure actually sutured the insertion of the ATFL together with the ankle capsule to the anterior edge of the lateral malleolus. In the Gould procedure, the deep fascia was mostly reinforced with the ankle capsule. The minimum suture span was obtained when the Gould suture needle direction was at an Angle of 60° to the longitudinal axis of the fibula.

Repair of distal finger soft-tissue defects with free fibular great toe neurovascular flaps.

BACKGROUND: This work aimed to investigate the change in fingerprint depth and the recovery rule of fingerprint biological recognition function after repairing finger abdominal defects and rebuilding fingerprint with a free flap. METHOD: From April 2018 to March 2023, we collected a total of 43 cases of repairing finger pulp defects using the free flap of the fibular side of the great toe with the digital nerve. After surgery, irregular follow-up visits were conducted to observe fingerprint clarity, perform the ninhydrin test or detect visible sweating with the naked eye. We recorded fingerprint clarity, nail shape, two-point discrimination, cold perception, warm perception and fingerprint recognition using smartphones. The reconstruction process of the repaired finger was recorded to understand the changes in various observation indicators and their relationship with the depth of the fingerprint. The correlation between fingerprint depth and neural repair was determined, and the process of fingerprint biological recognition function repair was elucidated. RESULT: All flaps survived, and we observed various manifestations in different stages of nerve recovery. The reconstructed fingerprint had a clear fuzzy process, and the depth changes of the fingerprint were consistent with the changes in the biological recognition function curve. CONCLUSION: The free flap with the digital nerve is used to repair finger pulp defects. The reconstructed fingerprint has a biological recognition function, and the depth of the fingerprint is correlated with the process of nerve repair. The fingerprint morphology has a dynamic recovery process, and it can reach a stable state after 6-8 months.

Joint preserving procedures for Takakura stage IIIB varus ankle osteoarthritis.

A man in his early 70s with right Takakura stage IIIB varus ankle osteoarthritis underwent medial opening wedge supramalleolar osteotomy with inframalleolar correction as joint preserving procedure. We also performed anteroinferior tibiofibular ligament (AITFL) resection with fibular shortening valgisation osteotomy to enhance the talar tilt correction. Postoperative decrease in talar tilt with dramatic symptom improvement was achieved. Performing the AITFL resection with fibular shortening valgisation osteotomy plus concomitant supramalleolar osteotomy and inframalleolar correction for Takakura stage IIIB varus ankle osteoarthritis resulted in successful improvement in talar tilt by making room for the valgus deviation of the talus.

How effective is proximal fibular osteotomy in redistributing joint pressures? Insights from an HTO comparative in-silico study.

BACKGROUND: Knee osteoarthritis (KOA) represents a widespread degenerative condition among adults that significantly affects quality of life. This study aims to elucidate the biomechanical implications of proximal fibular osteotomy (PFO), a proposed cost-effective and straightforward intervention for KOA, comparing its effects against traditional high tibial osteotomy (HTO) through in-silico analysis. METHODS: Using medical imaging and finite element analysis (FEA), this research quantitatively evaluates the biomechanical outcomes of a simulated PFO procedure in patients with severe medial compartment genu-varum, who have undergone surgical correction with HTO. The study focused on evaluating changes in knee joint contact pressures, stress distribution, and anatomical positioning of the center of pressure (CoP). Three models are generated for each of the five patients investigated in this study, a preoperative original condition model, an in-silico PFO based on the same original condition data, and a reversed-engineered HTO in-silico model. RESULTS: The novel contribution of this investigation is the quantitative analysis of the impact of PFO on the biomechanics of the knee joint. The results provide mechanical evidence that PFO can effectively redistribute and homogenize joint stresses, while also repositioning the CoP towards the center of the knee, similar to what is observed post HTO. The findings propose PFO as a potentially viable and simpler alternative to conventional surgical methods for managing severe KOA, specifically in patients with medial compartment genu-varum. CONCLUSION: This research also marks the first application of FEA that may support one of the underlying biomechanical theories of PFO, providing a foundation for future clinical and in-silico studies.

Aggressive Late Recurrence of a Calcifying Epithelial Odontogenic Tumor: Surgical Refinements Based on New Technologies.

A calcifying epithelial odontogenic tumor is a rare, benign odontogenic neoplasm. Surgical treatment is the option, and late recurrence is very rare. Radiologically, the lesions are commonly present scattered calcifications. This case report details a 64-year-old female patient with a recurrence of a right mandibular calcifying epithelial odontogenic tumor 2 decades after successful initial surgical removal. A segmental mandibulectomy and immediate reconstruction were performed using a planned vascularized free fibula flap with virtual surgery, custom reconstruction plate, and intraoperative computed tomography. Modifications were made to the design of the reconstruction plate to improve the cervicofacial profile and subsequent rehabilitation with dental implants. Fully guided implant surgery with point-of-care manufacturing protocol was done to improve prosthetically driven implant planning. The case presented highlights the usefulness of new technologies for mandibular reconstruction with the free fibula flap and the concept of point-of-care with technical notes that increase precision and reduce morbidity in implant-supported rehabilitation.

In-silico study of the biomechanical effects of proximal-fibular osteotomy on knee joint contact pressure in varus-valgus misalignment.

The aim of this work is to investigate in-silico the biomechanical effects of a proximal fibular osteotomy (PFO) on a knee joint with different varus/valgus deformities on the progression of knee osteoarthritis (KOA). A finite element analysis (FEA) of a human lower extremity consisting of the femoral, tibial and fibular bones and the cartilage connecting them was designed. The FEA was performed in a static standing primitive position to determine the contact pressure (CP) distribution and the location of the center of pressure (CoP). The analysis examined the relationship between these factors and the degree of deformation of the hip-knee angle in the baseline condition. The results suggested that PFO could be a simple and effective surgical treatment for patients with associated genu varum. This work also reported that a possible CP homogenization and a CoP correction can be achieved for medial varus deformities after PFO. However, it reduced its effectiveness for tibial origin valgus misalignment and worsened in cases of femoral valgus misalignment.

Novel Dual Bicolumnar Fibula Graft Reconstruction of Distal Humerus in Pediatric Patients After Massive Bone Resection: A Report of Two Cases.

CASE: We describe 2 case studies, involving a 10-year-old girl with an aneurysmal bone cyst and a 12-year-old adolescent boy with Ewing sarcoma. The patient with Ewing sarcoma was previously managed with wide surgical excision and fibular graft reconstruction and subsequently experienced significant graft resorption, hardware failure, and fracture 24 months after operation. A revision limb salvage attempt was undertaken. In both cases, fibular strut grafts were harvested and fixed with intramedullary k-wires to recreate the medial and lateral columns of the distal humeral triangle. CONCLUSION: The technique achieved complete osseous integration, structural support, and functional restoration of the elbow in both cases, with good functional outcomes.

Comparison of tibial fracture plate length, placement, and fibular integrity effects on plate integrity through finite element analysis.

Minimally invasive plate osteosynthesis is the most commonly used minimally invasive surgery technique for tibial fractures, possibly involving single or dual plate methods. Herein, we performed a finite element analysis to investigate plate strength according to the plate type, length, and presence of a fibula by constructing a three-dimensional tibia model. A thickness of 20 mm was cut 50 mm distal from the lateral plateau, and the ligaments were created. Plates were modeled with lengths of 150, 200, and 250 mm and mounted to the tibia. Screws were arranged to avoid overlapping in the dual plating. The von-Mises stress applied to the plates was measured by applying a load of 1 body weight. Dual plates showed the least stress with low displacement, followed by medial and lateral plates. As the plate length increased, the average stress gradually decreased, increasing plate safety. The difference in the influence of the fibula depending on the presence of proximal fibula osteotomy showed that the average stress increased by 35% following proximal fibula osteotomy in the D1(Plate type: Dual plate, Medial plate length: 150 mm, Lateral plate length: 200 mm, Non Proximal fibula osteotomy) and D1P(Plate type: Dual plate, Medial plate length: 150 mm, Lateral plate length: 200 mm, Proximal fibula osteotomy) models, confirming the necessity of the fibula model. There is no consensus guideline for treatment of this kind of fracture case. A single fracture plate can decrease the risk of skin damage, ligament damage, and wound infection, but because of its design, it cannot provide sufficient stability and satisfactory reduction of the condylar fragment, especially in cases of comminution or coronal fracture. So, these results will help clinicians make an informed choice on which plate to use in patients with tibial fractures.

Outcomes of Simultaneous Lengthening and ACL Reconstruction in Fibular Hemimelia: A Retrospective Case Series.

Background: Fibular hemimelia is the most common congenital long bone deficiency. It is often associated with femoral and tibial deficiencies which result in a clinically evident leg length discrepancy. The primary soft tissue concern is ACL/PCL deficiency. If treatment includes bony lengthening, joint stability is imperative to avoid complications. In this study, we detail a novel technique for long bone lengthening and ACL reconstruction in a single, cohesive surgery. This consolidates the need for multiple procedures and offers improved limb length symmetry and knee stability for this patient population. Clinical outcomes of pediatric patients with hemimelia who underwent either femoral or tibial lengthening with PRECICE® nail and concomitant ACL reconstruction are presented. Methods: After IRB approval, we identified five patients with complex fibular hemimelia who underwent ACL reconstruction and concomitant lengthening with at least two years of follow-up. Two patients (40%) presented with congenital short femur, and three (60%) with congenital short tibia. In each case, ACL reconstruction and either femoral or tibial guided growth via PRECICE® nail were performed. Operative techniques involving both soft tissue and bony methodology are described in detail. Results: All patients had objective improvement in knee stability as assessed both intra and post operatively, as well as successful intermedullary lengthening without complications related to joint stability. Three patients had minor complications unrelated to joint stability that did not interfere with overall result. Conclusion: Fibular hemimelia associated with hypoplasia of bony and soft tissue structures can be successfully addressed with concomitant ligamentous reconstruction at the time of implantation of lengthening devices. This addresses knee instability and reduces both number of operative procedures and potential complications related to joint instability while pursuing bony lengthening. Level of Evidence: V.

Risk factors associated with breakage of tibio-fibular syndesmotic screws.

PURPOSE: This retrospective study aimed to investigate the factors associated with the breakage of tibio-fibular syndesmotic screws (SS). METHODS: 69 patients with unstable AO-Weber Type 44-B ankle fractures who underwent three cortex SS (3.5 mm ø) fixation were included. Patients were followed for at least one year (mean, 18.3 ± 7.6 months). At the final follow-up, patients with broken (Group I) and intact (Group II) SS were compared regarding age, gender, height, weight, body mass index, fracture type, SS length, location, and orientation. Multivariate logistic regression was used to identify the independent risk factors associated with SS breakage. The sensitivity, specificity, cut-off value, and area under the ROC curve were analyzed. RESULTS: A stepwise backward logistic regression analysis revealed that age was the only independent predictor for SS breakage (OR = 0.938, 95% CI = 0.904-0.973, R2 = 0.270). ROC curve analysis demonstrated that patients younger than 36 years were associated with seven times increased risk of SS breakage [Odds ratio (95% CI), 7.042 (2.251-22.031)]. CONCLUSION: Age under 36 years was the only significant risk factor for SS breakage. The higher incidence of breakage of the syndesmotic screw can be informed to patients younger than 36.

Gait asymmetries after fibular free flap harvest: A cross-sectional observational study.

BACKGROUND: The ability to walk safely after head and neck reconstruction with fibular free flaps in tumor surgery is a high priority for patients. In addition, surgeons and patients require objective knowledge of the functional donor-site morbidity. However, the effects of fibular free flap surgery on gait asymmetries have only been studied for step length and stance duration. This study analyses whether patients who have undergone fibular free flap reconstruction have enduring gait asymmetries compared to age-matched controls. METHODS: Patients who underwent head and neck reconstruction with fibular free flaps between 2019 and 2023 were recruited, as well as age-matched controls. Participants walked on an instrumented treadmill at 3 km/h. The primary outcome measures were 22 gait asymmetry metrics. Secondary outcome measures were the associations of gait asymmetry with the length of the harvested fibula, and with the time after surgery. FINDINGS: Nine out of 13 recruited patients completed the full assessment without holding on to the handrail on the treadmill. In addition, nine age-matched controls were enrolled. Twenty out of the 22 gait asymmetry parameters of patients were similar to healthy controls, while push-off peak force (p = 0.008) and medial impulse differed (p = 0.003). Gait asymmetry did not correlate with the length of the fibula harvested. Seven gait asymmetry parameters had a strong correlation with the time after surgery. INTERPRETATION: On the long-term, fibular free flap reconstruction has only a limited effect on the asymmetry of force-related and temporal gait parameters while walking on a treadmill.

Fibular hemimelia: reconstruction of difficult cases with tibial lengthening and ankle arthrodesis.

PURPOSE: Management of fibular hemimelia includes either prosthetic care with or without a suitable amputation or tibial lengthening. Many studies have documented the success of both procedures. Most parents of these children refuse an amputation or have no access to good prosthetic care. The author presents a limb-salvage procedure with tibial lengthening and ankle stabilization. METHODS: Twelve children of fibular hemimelia with 14 extremities had been subjected to limb lengthening after lateral leg release. To correct the valgus procurvatum, double oblique diaphyseal osteotomy (DODO) of the tibia was performed in 11 extremities. The age of the patients ranged from two to 15 years with the median of five years. All were male. The proposed procedure included three stages of loosening, lengthening, and stabilization with ankle arthrodesis at a later stage. RESULTS: All patients returned for follow-up for the first four years and had been walking on their sensate feet. With DODO followed by fixator/traction could straighten and lengthen the tibia simultaneously and correct the valgus procurvatum. Ankle stabilization provided stability and a plantigrade foot. A follow-up of six to 30 years with a median of ten years has been reported. CONCLUSION: A new procedure of loosening, lengthening, and stabilization of the leg with ankle arthrodesis has been proposed. A follow-up of 30 years with a median of ten years of the said procedure has been reported. The procedure provides a long-lasting plantigrade and painless foot that has sensation and proprioception. An amputation at any level has not been recommended.

Diaphyseal giant cell tumour of mid-shaft tibia.

SummaryGiant cell tumours of bone are benign and locally aggressive tumours that usually occur in young adults and at the epiphysial locations after physeal closure. Occurrence outside of epiphysial locations and appearance in geriatric patients is rare. We report a case of a woman in her late 60s with a giant cell tumour of the mid-shaft of the right tibia. Extended curettage and biological reconstruction were performed with autologous double-barrel fibular struts and tri-cortical iliac crest bone grafting. At the 28-month follow-up examination, we noted full bony union at both ends with successful consolidation of the fibular struts, and importantly, no evidence of recurrence or other complications was observed.