Reconstruction of compound loss of lateral malleolus and lateral ankle ligaments with double-bundle Achilles tendon-bone allograft

Repair of distal fibular and lateral malleolus defects with individualized 3D-printed titanium alloy prosthesis: The first case report from China

Introduction and importance

This case report describes the reconstruction of the traumatic distal fibular and lateral malleolus defects with a novel method of using individualized 3D printed titanium prosthesis for the first time.

Case presentation

A 63-year-old male farmer was hospitalized in emergency because of open injury and distal fibular and lateral malleolus defects in the left leg caused by a car accident. 3 months after debridement and latissimus dorsi muscle flap transplantation and skin graft operation, the patient re-hospitalized because of distal fibular and lateral malleolus defect and local pain. We examined the bilateral ankle joint with three-dimensional CT, obtained data about the missing left distal fibular and lateral malleolus through the mirror principle. The corresponding titanium alloy prosthesis then was designed and printed using a 3D metal printer. The patient had no obvious contraindication for surgery, so the prosthesis was surgically implanted. The patient was followed up for 2 years. There was no discomfort at the surgical site. The function of the operated ankle was satisfied by the patient, the AOFAS (American Orthopaedic Foot & Ankle Society) score was 85 (Kitaoka et al., 1994 [1]).

Clinical discussion

Individualized 3D printed titanium alloy prosthesis consistent with the anatomical structure of lost distal fibula and lateral malleolus. The proximal end of the prosthesis was designed with four nail holes to install screws to fix the fibula together with it. The lower tibiofibular and talofibular joint surfaces of the prosthesis were designed smoothly. In order to improve the stability of the lower tibiofibular joint, anchors were placed at the attachment of the anterior and posterior tibiofibular ligaments to reconstruct these ligaments.

Conclusion

The structure and function of the reconstructed distal fibular and the lateral malleous were close to normal. Individualized 3D printed prosthesis might have considerable advantages over traditional treatment methods. The individualized 3D printed titanium alloy prosthesis provides a new method for the repair and reconstruction of similar bone defects. The use of 3D printed prosthesis for surgical repair needs to be further examined in the future through long-term follow-up studies and in more cases.

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Individualized 3D printed prosthesis of traumatic distal fibular and lateral malleolus defects was initially designed.

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This individualized prosthesis is consistent with the anatomical structure of lost distal fibula and lateral malleolus.

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The structure and function of the defect site could be reconstructed after prosthesis implantation.

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Individualized 3D printed titanium alloy prosthesis provides a new method for the reconstruction of similar bone defects.

Preoperative irrigation and vacuum sealing drainage with antibiotic-containing drainage fluid of foot and ankle wounds improves outcome of reconstructive skin flap surgery

Objectives

By observing the infection and soft tissue defect on the wound surface of the foot and ankle, this paper attempts to explore the effect of preoperative irrigation and vacuum sealing drainage with antibiotic-containing drainage fluid (abPI-VSD) on the bacterial quantity and the local inflammatory response at the flap, and further to provide a basis for applying this technique before a reconstructive skin flap surgery of foot and ankle wounds.

Methods

Seventy-five patients were randomly divided into two groups, and all surgeries were done by one physician. The flap reconstructions were done to 31 cases with the abPI-VSD being used (group A); the flap reconstructions were done to the rest 44 cases after wound cleaning using antibiotic irrigation solution without the use of the abPI-VSD (group B). Quantitative bacteriology was made to group A before and after the use of abPI-VSD; quantitative bacteriology was made to group B before and after wound cleaning. Then, the reconstructive skin flap surgery was done. After the surgeries, the time of local inflammatory response at the flap in both groups were recorded. The measured bacterial quantity was evaluated in logarithm and by t test.

Results

The bacterial quantity was 3.2 ± 1.9 × 10⁷ cfu/g in group A before the use of abPI-VSD and 2.3 ± 2.0 × 10⁷ in group B (P > 0.05) before debridement. The bacterial quantity was 1.2 ± 2.0 × 10⁴ cfu/g in group A after abPI-VSD and was 2.9 ± 4.0 × 10⁶ in group B after wound cleaning (P < 0.05). The time of postoperative inflammatory response in the flap was 8 ± 2.5 days in group A and 13 ± 3.4 days in group B (P < 0.05).

Conclusions

abPI-VSD can distinctly reduce the bacterial quantity on the surface of the wound, provide a good condition of tissue bed for the flap reconstruction, and effectively control the local inflammatory response at the flap and hence improve the survival quality of the flap.

Arthroscopic ankle fusion to manage sequel of loss of lateral malleoli in compound crushed ankle injury

Defect in the lateral malleolus along with lateral ligamentous injury of ankle is rare. It occurs mainly due to resection of distal fibula tumors and severe trauma leading to loss of lateral malleolus. Lateral malleoli has the major contribution in weight transmission to foot and ankle stability. To avoid persistent pain and gait abnormality due to ankle instability, reconstruction of bony defect is inevitable. Methods to address these defects are iliac crest bone grafting, vascular and nonvascular proximal fibula transfer, patella tendon bone graft and allograft. Donor site morbidity, allograft related problems are not rare. Arthrodesis of ankle gives painless stable joint. Arthrodesis can be performed by open and arthroscopic methods. Open method has more soft tissue dissection and too difficult in scenario with previous skin grafting with adherent skin to bone. We managed a case of compound ankle injury with loss of lateral malleolus with loss of lateral ligament in stages, first management of compound crushed ankle followed by arthroscopic ankle arthrodesis. Even after 6 year of follow patient has stable pain less ankle with satisfactory gait.

[Research progress of surgical treatment for lateral malleolus defect]

OBJECTIVE

To review the research progress of the surgical treatment for lateral malleolus defect.

METHODS

The related literature about surgical treatment and effectiveness of lateral malleolus defect at home and abroad was reviewed, summarized, and analysed.

RESULTS

Lateral malleolus defects are often caused by severe trauma or wide resection of fibular neoplasms. Although the incidence is not high, the defects are difficult to handle. These bony defects should be reconstructed to prevent an abnormal gait induced by ankle instability and avoid the occurrence of traumatic arthritis. Various repair methods have been developed, including bone transplantation, fibula lengthening, and ankle arthrodesis.

CONCLUSION

There are various surgical methods to repair the defect of lateral malleolus, but each has its own advantages and disadvantages. In order to achieve the best results, the surgeon should choose the appropriate operation according to his own level, the patient's specific injury, and age.

Clinical applications of allografts in foot and ankle surgery

PURPOSE

The purpose of this review is to systematically analyse current literature on the use of allografts in the surgical treatment of foot and ankle disorders in adult patients. Based on this study, we propose evidence-based recommendations.

METHODS

The database for PubMed was searched for all published articles. No timeframe restrictions were applied. Clinical studies eligible for inclusion met the following criteria: performed on patients over 18 years old; subject to surgical treatment of foot and ankle disorders; with report on the outcome of the use of allografts; with a report and assessment of pain and function, or equivalent; minimum follow-up of 1 year was required. Two reviewers independently screened and selected studies for full-text analysis from title and abstract. 107 studies were included from 1113 records. Studies were grouped according to surgical indications into ten categories: musculoskeletal tumours (n = 16), chronic ankle instability (n = 15), ankle arthritis (n = 14), osteochondral lesions of the talus (n = 12), Achilles tendon defects (n = 11), other tendon defects (n = 9), fusions (n = 9), fractures (n = 8), hallux rigidus (n = 3) and other indications (n = 10).

RESULTS

Most studies displayed evidence level of IV (n = 57) and V (n = 39). There was one level I, one level II and nine level III studies. Most studies reported allografting as a good option (n = 99; 92.5%). Overall complication rate was 17% (n = 202).

CONCLUSIONS

Fair evidence (Grade B) was found in favour of the use of allografts in lateral ankle ligament reconstruction or treatment of intra-articular calcaneal fracture. Fair evidence (Grade B) was found against the use of allogeneic MSCs in tibiotalar fusions.

LEVEL OF EVIDENCE

V.