Accuracy of fibula reconstruction using patient-specific CAD/CAM reconstruction plates and dental implants: A new modality for functional reconstruction of mandibular defects

BACKGROUND

The purpose of this study was to analyze the accuracy of mandibular reconstruction using patient-specific computer-aided designed and computer-aided manufactured (CAD/CAM) reconstruction plates as a guide to place fibula grafts and dental implants in a one-stage procedure using pre-operative 3D virtual planning.

METHODS

Seven consecutive patients were analyzed retrospectively, the 3D accuracy of placement of the fibula grafts and dental implants was compared to the virtual plan.

RESULTS

Six out of seven flaps survived for an average follow-up time of 9.4 months. The outcome was compared to the virtual plan, superimposed on the mandible. For the fibula segments, the mean deviation (SD) was 3.0 (1.8) mm and the mean angulation (SD) was 4.2° (3.2°). For the implants, the mean deviation (SD) was 3.3 (1.3) mm and the mean angulation (SD) was 13.0° (6.7°). The mean (SD) mandibular resection plane deviation was 1.8 (0.9) mm.

CONCLUSIONS

A patient-specific reconstruction plate is a valuable tool in the reconstruction of mandibular defects with fibula grafts and dental implants. Implant angulation showed a greater deviation from the virtual plans in patients with a sharp ventral fibula rim, where the guide is removed after pilot drilling of the implants.

Mandibular Reconstruction Using the Free Vascularized Fibula Graft: An Overview of Different Modifications

The reconstruction of the mandible is a complex procedure because various cosmetic as well as functional challenges must be addressed, including mastication and oral competence. Many surgical techniques have been described to address these challenges, including non-vascularized bone grafts, vascularized bone grafts, and approaches related to tissue engineering. This review summarizes different modifications of the free vascularized fibula graft, which, since its introduction by Hidalgo in 1989, has become the first option for mandibular reconstruction. The fibula free flap can undergo various modifications according to the individual requirements of a particular reconstruction. Osteocutaneous flaps can be harvested for reconstruction of composite defects. 'Double-barreling' of the fibula can, for instance, enable enhanced aesthetic and functional results, as well as immediate one-stage osseointegrated dental implantation. Recently described preoperative virtual surgery planning to facilitate neomandible remodeling could guarantee good results. To conclude, the free fibula bone graft can currently be regarded as the "gold standard" for mandibular reconstruction in case of composite (inside and outside) oral cavity defects as well as a way of enabling the performance of one-stage dental implantation.

Stress fractures of the foot and ankle, part 2: site-specific etiology, imaging, and treatment, and differential diagnosis

Stress fractures of the foot and ankle are a commonly encountered problem among athletes and individuals participating in a wide range of activities. This illustrated review, the second of two parts, discusses site-specific etiological factors, imaging appearances, treatment options, and differential considerations of stress fractures of the foot and ankle. The imaging and clinical management of stress fractures of the foot and ankle are highly dependent on the specific location of the fracture, mechanical forces acting upon the injured site, vascular supply of the injured bone, and the proportion of trabecular to cortical bone at the site of injury. The most common stress fractures of the foot and ankle are low risk and include the posteromedial tibia, the calcaneus, and the second and third metatarsals. The distal fibula is a less common location, and stress fractures of the cuboid and cuneiforms are very rare, but are also considered low risk. In contrast, high-risk stress fractures are more prone to delayed union or nonunion and include the anterior tibial cortex, medial malleolus, navicular, base of the second metatarsal, proximal fifth metatarsal, hallux sesamoids, and the talus. Of these high-risk types, stress fractures of the anterior tibial cortex, the navicular, and the proximal tibial cortex may be predisposed to poor healing because of the watershed blood supply in these locations. The radiographic differential diagnosis of stress fracture includes osteoid osteoma, malignancy, and chronic osteomyelitis.

Implant rehabilitation in fibula-free flap reconstruction: A retrospective study of cases at 1-18 years following surgery

PURPOSE

To determine the dental implant and prostheses success rate in a cohort of patients who underwent a vascularized fibula-free flap (FFF) for maxillary or mandibular reconstruction.

METHODS

The investigators implemented a retrospective cohort study composed of patients who had undergone primary or secondary FFF reconstruction jaw surgery plus placement of 2-6 implants in the reconstructed arch, which were restored with an implant-supported prosthesis. The sample was composed of all patients who underwent FFF surgery between 1998 and 2012 and had either simultaneous or secondary dental implant placement. A total of 28 patients met inclusion criteria. Of these, 22 patients participated in the retrospective review. Patients were examined by an independent observer between January-December 2015. In addition, all patients completed a questionnaire to access satisfaction with the implant-supported prosthesis.

RESULTS

The patient cohort consisted of 12 males and 10 females, age 12-70 years. A total of 100 implants were placed, 92 implants in fibular bone and 8 implants in native bone. In the maxilla, 35 implants were placed into fibular bone and 4 into native bone (11 in irradiated patients and 28 in non-irradiated patients). In the mandible, 57 implants were placed into fibular bone and 4 into native bone (15 in irradiated patients and 46 in non-irradiated patients). The mean follow-up after implant loading was 7.8 years (range 1.3-17.5 years). The implant survival rate was 98% (95% CI: 92.2%-99.5%). No statistically significant difference was found in implant success between maxillary and mandibular implants, or between radiated and non-radiated bone. The prostheses success rate, determined by clinical exam and patient satisfaction, was 100%.

CONCLUSION

The results of this study suggest that implant survival is high and implant-supported prostheses are a reliable rehabilitation option in patients whose jaws have been reconstruction with a FFF.

A biomechanical comparison study of a modern fibular nail and distal fibular locking plate in AO/OTA 44C2 ankle fractures

Background

A lateral approach with open reduction and internal fixation with a plate is a very effective technique for the majority of distal fibular fractures. However, this open approach for ankle fixation may be complicated by wound dehiscence and infection, especially in high-risk patients. An alternative to plating is an intramedullary implant, which allows maintenance of length, alignment, and rotation and which allows for decreased soft tissue dissection. While there has been clinical data suggesting favorable short-term outcomes with these implants, there is no current biomechanical literature investigating this technology in this particular fracture pattern. This study sought to biomechanically compare an emerging technology with an established method of fixation for distal fibular fractures that traditionally require an extensive exposure.

Methods

Ten matched cadaveric pairs from the proximal tibia to the foot were prepared to simulate an Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 44C2 ankle fracture and randomized to fixation with a distal fibular locking plate or intramedullary fibular rod. A constant 700-N axial load was applied, and all specimens underwent testing for external rotation stiffness, external rotation cyclic loading, and torque to failure. The syndesmotic diastasis, stiffness, torque to failure, angle at failure, and mode of failure were obtained from each specimen.

Results

There was no significant difference in syndesmotic diastasis during cyclic loading or at maximal external rotation between the rod and plate groups. Post-cycle external rotation stiffness across the syndesmosis was significantly higher for the locking plate than the fibular rod. There was no significant difference between the rod and plate in torque at failure or external rotation angle. The majority of specimens had failure at the syndesmotic screw.

Conclusions

In the present cadaveric study of an AO/OTA 44C2 ankle fracture, a modern fibular rod demonstrated less external rotation stiffness while maintaining the syndesmotic diastasis to within acceptable tolerances and having similar failure characteristics.

External fixator combined with three different fixation methods of fibula for treatment of extra-articular open fractures of distal tibia and fibula: a retrospective study

Background

To compare the efficacy of three different fixation methods of fibula combined with external fixation of tibia for the treatment of extra-articular open fractures of distal tibia and fibula.

Methods

From January 2017 to July 2019, 91 cases of open fractures of distal tibia and fibula were treated with external fixator, and the fibula was fixed with non-fixation (group A, n = 35), plate-screw (group B, n = 30) and Kirschner wire (group C, n = 26). The operation time, intraoperative blood loss, surgical and implants costs, fracture healing time, postoperative complications, and American Orthopaedic Foot and Ankle surgery (AOFAS) scores were compared among the groups.

Results

Four patients were lost to follow-up, and 87 patients were followed up for 5–35 months (average, 14.2 months). The operation time of group C (114.92 ± 36.09 min) was shorter than that of group A (142.27 ± 47.05 min) and group B (184.00 ± 48.56 min) (P < 0.05). There was no difference in intraoperative blood loss among the three groups (P > 0.05). The surgical and implants costs in group C (5.24 ± 1.21, thousand dollars) is lower than that in group A (6.48 ± 1.11, thousand dollars) and group B (9.37 ± 2.16, thousand dollars) (P < 0.05). The fracture healing time of group C (5.67 ± 1.42 months) was significantly less than that of group A (6.90 ± 1.33 months) and group B (6.70 ± 1.12 months) (P < 0.05). The postoperative complications such as fractures delayed union and nonunion in group C (2 cases, 8.00%) is less than that in group A (13 cases, 39.39%) and group B (11cases, 37.93%) (P < 0.05). The wound infection and needle-tract infection did not differ among the three groups (P > 0.05). The excellent or good rate of ankle function was 69.70% in group A, 72.41% in group B and 84.00% in group C, with no statistical difference among the three groups (P > 0.05).

Conclusion

Compared with simple external fixator fixation and external fixator combined with plate-screw osteosynthesis, external fixator combined with K-wire intramedullary fixation shortens the operative time and fracture healing time, reduced costs and complications of fracture healing, while the blood loss, infection complications and ankle function recovery showed no difference with the other two groups. External fixator combined with plate-screw osteosynthesis had no advantage in treating extra-articular open fractures of distal tibia and fibula when compared with simple external fixation.

Comparison of modern locked plating and antiglide plating for fixation of osteoporotic distal fibular fractures

BACKGROUND

Fractures in osteoporotic patients can be difficult to treat because of poor bone quality and inability to gain screw purchase. The purpose of this study is to compare modern lateral periarticular distal fibula locked plating to antiglide plating in the setting of an osteoporotic, unstable distal fibula fracture.

METHODS

AO/OTA 44-B2 distal fibula fractures were created in sixteen paired fresh frozen cadaveric ankles and fixed with a lateral locking plate and an independent lag screw or an antiglide plate with a lag screw through the plate. The specimens underwent stiffness, cyclic loading, and load to failure testing. The energy absorbed until failure, torque to failure, construct stiffness, angle at failure, and energy at failure was recorded.

RESULTS

The lateral locking construct had a higher torque to failure (p=0.02) and construct stiffness (p=0.04). The locking construct showed a trend toward increased angle at failure, but did not reach statistical significance (p=0.07). Seven of the eight lateral locking plate specimens failed through the distal locking screws, while the antiglide plating construct failed with pullout of the distal screws and displacement of the fracture in six of the eight specimens.

CONCLUSION

In our study, the newly designed distal fibula periarticular locking plate with increased distal fixation is biomechanically stronger than a non-locking one third tubular plate applied in antiglide fashion for the treatment of AO/OTA 44-B2 osteoporotic distal fibula fractures.

LEVEL OF EVIDENCE

V: This is an ex-vivo study performed on cadavers and is not a study performed on live patients. Therefore, this is considered Level V evidence.

Combined use of the Ilizarov method, concentrated bone marrow aspirate (cBMA), and platelet-rich plasma (PRP) to expedite healing of bimalleolar fractures

Distal tibial and fibular fractures, particularly in patients with comorbidities, heal slowly and have a high incidence of postoperative nonunion and infection. Autologous concentrated bone marrow aspirate (cBMA) and platelet-rich plasma (PRP) increase osteogenic potential of demineralized bone matrix (DBM). The purpose of this case series was to evaluate the efficacy of cBMA, PRP, DBM in conjunction with the Ilizarov fixator as compared to DBM and the Ilizarov fixator alone in expediting fracture healing. Ten patients (mean age 52.9 years) were in the cBMA Group, and 10 patients (mean age 54 years) were in the Control Group. Comorbidities included diabetes, obesity, smoking, and renal disease. Radiographs showed a significant difference in the rate of complete healing in the cBMA Group at 16 ± 1.6 weeks post-surgery as compared to 24 ± 1.3 weeks in the Control Group (P < 0.001). No differences were observed between groups in infection rate or nonunions. We conclude that the Ilizarov fixator combined with DBM, cBMA, and PRP expedites fracture healing of the distal tibia and fibula in patients with significant comorbidities.

The comparison of point-of-care ultrasonography and radiography in the diagnosis of tibia and fibula fractures

OBJECTIVE

We aimed to compare the efficacy of Point-of-care ultrasonography (POCUS) with radiography in the diagnosis of tibia fracture (TF) and fibula fracture (FF), and determation of fracture characteristics.

METHODS

Patients aged 5-55 years who were admitted to ED due to low-energy, simple extremity trauma, who had a suspected TF and FF on physical examination were included in this prospective study. One physician performed POCUS examination. Other physician evaluated the radiography images. The obtained results were compared.

RESULTS

A total of 62 patients were included in the study. TF was detected in 21 patients by radiography and in 24 patients by POCUS. FF was detected in 24 patients by radiography and in 25 patients by POCUS. Ten of the patients had both TF and FF. Compared with radiography, sensitivity, specificity, PPV and NPV of POCUS in the detection of TF were 100%, 93%, 88% and 100% (95% CI, 91-100%), respectively. Compared with direct X-ray imaging, sensitivity, specificity, PPV and NPV of POCUS in the detection of FF were 100%, 97%, 96% and 100% (95% CI, 96-100%), respectively. We determined that POCUS is also successful in detection of fracture features such as angulation, step-off, extension into the joint space that can determine the treatment decision.

CONCLUSION

This study demonstrated that POCUS was found to be as successful as direct X-ray imaging in the diagnosis of TF and FF.

Reconstruction of isolated mandibular bone defects with non-vascularized corticocancellous bone autograft and graft viability

OBJECTIVE

The aim of this study is to discuss the use of non-vascularized bone grafts in mandibular reconstruction and their viability.

METHODS

In this study, 11 patients with mandibular defect treated by surgery using non-vascularized bone grafts between 2011 and 2012 were reviewed. All patients underwent preoperative and postoperative 3-dimensional computerized tomography scan for surgical planning and evaluation of success after surgery. Grafts were used for defects caused by mandible tumors in 2 patients and firearm injuries in 9 patients. Reconstruction was achieved by using various non-vascularized bones, including iliac crest, fibula and scapula. To improve graft supply, periosteum of the grafts was spared and multiple bores were created on the graft during surgery by drilling. At the postoperative period, Dextran 70 and Bencyclane Hydrogen Fumarate was given in order to enhance micro-circulation. On the postoperative day 5, 15 and 30, Tc-99m methylenediphosphonate scintigraph, blood-pool single photon emission computed tomography and it's bone phase were performed in order to assess viability of bone grafts greater than 3cm.

RESULTS

Mean age was 32. 27±13.33 (min=10-max=56). Of the 11 patients, 10 (90. 9%) were men and 1 (9. 1%) was woman. Mandibular defects were at right corpus in 3 patients; at right ramus and angulus in 1 patient; at left corpus in 1 patient; at left ramus and angulus in 1 patient; at left ramus, angulus and corpus in 1 patient; left parasymphysis in 1 patient; at bilateral corpus in 1 patient; at symphysis in 1 patient and at whole segment from right corpus to left one in 1 patient. The following grafts were used: iliac crest grafts in 9 cases, scapula graft in 1 case and fibula graft in 1 case. The smallest graft used was 1×2cm in size, while the greatest, single piece graft was 7cm in size. The greatest multi-piece graft was a fibula graft of 14cm in length. All grafts with a size of 3 and 7cm had been supplied at the end of first month. No bone resorption or donor site morbidity was observed in any patient.

CONCLUSION

Non-vascular bone grafts can be successfully used in isolated bone defects of mandible in case of appropriate graft selection for fitting anatomical region. A single piece iliac crest grafts up to 7cm can be revascularized in long-term.

Vascularized bone grafts for post-traumatic defects in the upper extremity

Vascularized bone grafts (VBGs) are widely employed to reconstruct upper extremity bone defects. Conventional bone grafting is generally used to treat defects smaller than 5–6 cm, when tissue vascularization is adequate and there is no infection risk. Vascularized fibular grafts (VFGs) are mainly used in the humerus, radius or ulna in cases of persistent non-union where traditional bone grafting has failed or for bone defects larger than 6 cm. Furthermore, VFGs are considered to be the standard treatment for large bone defects located in the radius, ulna and humerus and enable the reconstruction of soft-tissue loss, as VFGs can be harvested as osteocutaneous flaps. VBGs enable one-stage surgical reconstruction and are highly infection-resistant because of their autonomous vascularization. A vascularized medial femoral condyle (VFMC) free flap can be used to treat small defects and non-unions in the upper extremity. Relative contraindications to these procedures are diabetes, immunosuppression, chronic infections, alcohol, tobacco, drug abuse and obesity. The aim of our study was to illustrate the use of VFGs to treat large post-traumatic bone defects and osteomyelitis located in the upper extremity. Moreover, the use of VFMC autografts is presented.

Fibula Fracture: Plate versus Nail Fixation

Backgroud

Intramedullary fixation has only uncommonly been used in the fibula although it may confer some advantages. Our goal was to investigate a single surgeon's learning curve with initial usage of an intramedullary device for fibular fixation based on surgical time and quality of reduction.

Methods

Prior to initiation of this study, an experienced ankle fracture surgeon performed fibular nail fixation in a sawbones and a cadaver setting. Between February and August 2018, all patients who suffered from a distal fibula fracture underwent fibula fixation (n = 20) using the Fibulock (Arthrex). Patients were retrospectively investigated and compared with a control of fibular plate fixation. The tourniquet time, time of anesthesia, and surgery time were recorded as well as the quality of reduction.

Results

In the 20 cases, the mean tourniquet time was 68.9 ± 23.2 minutes for nail fixation, while in the fibular plate fixation group, the mean time was 75.8 ± 23.9 minutes (p = 0.37). Two patients had slight malreductions (first and third cases): one was corrected with a lag screw outside the nail, the other was an elderly patient with significant blistering in whom an entirely percutaneous reduction was performed.

Conclusions

Intramedullary fixation for fibular fractures does not appear to have a significant learning curve for an experienced ankle fracture surgeon.

Structural differences in cortical shell properties between upper and lower human fibula as described by pQCT serial scans. A biomechanical interpretation

This study describes the structural features of fibula cortical shell as allowed by serial pQCT scans in 10/10 healthy men and women aged 20-40years. Indicators of cortical mass (mineral content -BMC-, cross-sectional area -CSA-), mineralization (volumetric BMD, vBMD), design (perimeters, thickness, moments of inertia -MIs-) and strength (Bone Strength Indices, BSIs; polar Strength-Strain Index, pSSI) were determined. All cross-sectional shapes and geometrical or strength indicators suggested a sequence of five different regions along the bone, which would be successively adapted to 1. transmit loads from the articular surface to the cortical shell (near the proximal tibia-fibular joint), 2. favor lateral bending (central part of upper half), 3. resist lateral bending (mid-diaphysis), 4. favor lateral bending again (central part of the lower half), and 5. resist bending/torsion (distal end). Cortical BMC and the cortical/total CSA ratio were higher at the midshaft than at both bone ends (p<0.001). However, all MIs, BSIs and pSSI values and the endocortical perimeter/cortical CSA ratio (indicator of the mechanostat's ability to re-distribute the available cortical mass) showed a "W-shaped" distribution along the bone, with maximums at the mid-shaft and at both bone's ends (site effect, p<0.001). The correlation coefficient (r) of the relationship between MIs (y) and cortical vBMD (x) at each bone site ("distribution/quality" curve that describes the efficiency of distribution of the cortical tissue as a function of the local tissue stiffness) was higher at proximal than distal bone regions (p<0.001). The results from the study suggest that human fibula is primarily adapted to resist bending and torsion rather than compression stresses, and that fibula's bending strength is lower at the center of its proximal and distal halves and higher at the mid-shaft and at both bone's ends. This would favor, proximally, the elastic absorption of energy by the attached muscles that rotate or evert the foot, and distally, the widening of the heel joint and the resistance to excessive lateral bending. Results also suggest that biomechanical control of structural stiffness differs between proximal and distal fibula.

Fibula regeneration following non-vascularized graft harvest in children

BACKGROUND

A peculiarity of non-vascularized fibular harvest is that the donor site regenerates new bone provided periosteum is preserved. We prospectively investigated the regenerated fibula quantitatively and studied clinical implications of non-regeneration.

MATERIAL AND METHODS

The fibula was harvested using a periosteum preserving technique. Only fibulae from healthy legs were harvested. X-rays were done pre- and post-operatively at three and six months. Clinical assessment of donor limb included pain, gait, motor and sensory examination. Fibular regeneration was quantified using defined length and width criteria.

RESULTS

There were 16 children with 21 harvested fibula. About 65 % of total fibular length was available for use as graft. There was regeneration of fibula similar to the pre-operative dimensions as early as six months in 71 % of cases. There were no clinical morbid findings as assessed at six months follow up despite non-continuity being observed in 29 % of cases. The predominant site for non-continuity was middle third-distal third junction.

CONCLUSIONS

Periosteal preserving non-vascularized fibula grafting was a low morbidity procedure. In two-third of the cases, there was regeneration of fibula comparable to pre-operative dimensions as early as six months. The non-continuous regeneration had no clinical implications.

Fibular donor site following non vascularized harvest: clinico-radiological outcome at minimal five year follow-up

PURPOSE

The long-term donor site outcome of non vascularized fibular harvest in paediatric age group is not well studied. We evaluated clinical and radiological characteristics of fibular harvest site in children at a minimum five year follow-up.

METHODS

The patients with donor legs underwent both physical and radiographic examination. Clinical parameters evaluated were pain, neuromuscular weakness, and standing tibiocalcaneal hindfoot valgus in the donor limb. Radiologically, longitudinal non continuity in regeneration, medullary canal reformation, Malhotra grading, and lateral distal tibial angle (LDTA) were documented.

RESULTS

Sixteen patients (18 legs) were available for follow-up. The average follow-up was 6.23 ± 1.1 years. None of the patients reported pain or neuromuscular weakness related to the donor leg. Five patients reported cosmesis issues related to exaggerated ankle valgus. Medullary canal restoration was seen in 3/14 regenerated fibulae. Harvested legs had overall higher fibular station than contralateral unintervened ankles. Non continuity in regeneration were seen in 4/18 legs. There was clinical hindfoot valgus, abnormal LDTA, and fibular station in these patients. Clinical valgus matched better with a combination of fibular station and LDTA (83.3%) rather than fibular station or LDTA (75%) alone.

CONCLUSIONS

Fibular regeneration was complete in more than 75% legs at follow-up of > five years but remodeling and reformation of medullary canal was delayed. Long-term fibular non regeneration was persistently responsible for development of ankle valgus deformity. Middle lower third fibular junction is critical area for non restoration of medullary canal and non continuity.

Late Treatment of Syndesmotic Injuries

Normal syndesmosis anatomy and alignment are essential to ankle function. Although injuries to the syndesmosis are common with ankle injuries, accurate diagnosis and reduction continue to be a challenge. Late reconstruction for syndesmosis is reviewed. A surgical technique for late reconstruction is outlined in detail.

Association between condylar position changes and functional outcomes after condylar reconstruction by free fibular flap

OBJECTIVES

Stable and appropriate condyle positioning is necessary for maintaining temporomandibular joint function. It is unclear if this position remains stable in patients after free fibular flap (FFF) condylar reconstruction. We investigated whether condylar position deviated after reconstruction, and whether this affected functional recovery.

MATERIALS AND METHODS

We retrospectively reviewed 43 patients who underwent conventional FFF condylar reconstruction, and 5 patients who underwent reconstruction by computer-assisted three-dimensional (3D) printing methods. Three-dimensional models were built from cone-beam computed tomography images obtained immediately postoperatively and 1-year postoperatively. The glenoid fossa and fibular condyle centers were used to measure the fibular condyle position in the models. Clinical examination indices, including maximum mouth opening (MMO), pain during chewing/mouth opening, and patient satisfaction with mastication and 1-year outcomes were assessed.

RESULTS

Fibular condyle position changed significantly over 1 year in both groups (P < 0.05). Clinical examination at 1 year after the surgery showed that in the conventional group, the MMO range was ≥ 35 mm in 76.7% of patients and < 35 mm in 23.3% of patients; 4.7% experienced pain during chewing/mouth opening, and 7% were dissatisfied with treatment outcomes. In the 3D printing group, all patients had an MMO range exceeding 35 mm, none had pain, and all were satisfied with functional outcomes.

CONCLUSIONS

The position of the fibular condyle deviates after reconstructive surgery, but it is unlikely to affect functional recovery.

CLINICAL RELEVANCE

These findings can form the basis for evaluation of functional outcomes of patients who have previously undergone condylar reconstruction by FFF.

Staged treatment of pilon fractures

AIM

To evaluate outcomes following staged anterolateral plating of pilon fractures.

METHODS

Over a 5 year period, patients with pilon fractures received four treatment regimens (staged anterolateral plating, staged medial plating, definitive external fixation, early total care). We defined five outcomes (reduction, soft tissue complications, infection, non-union, malunion) and assessed the outcome of fractures treated by these interventions.

RESULTS

Staged anterolateral plating or staged medial plating achieved comparable reduction and soft tissue complications. Staged medial plating had higher infection rates, malunion and non-union rates.

CONCLUSIONS

Staged anterolateral plating is superior to staged medial plating in the management of pilon fractures.

The implants used for intramedullary fixation of distal fibula fractures: A review of literature

BACKGROUND

Ankle fractures are amongst the most common surgically treated musculoskeletal injuries. Intramedullary (IM) fixation of the lateral malleolus had been attempted as early as the 1990s. In recent years, dedicated implants have emerged. This review evaluates the design characteristics of the technology used to perform IM fixation of distal fibular fractures.

MATERIALS AND METHODS

A search of electronic databases was performed. Medical subject headings (MeSH) and free-text terms were used to optimise search sensitivity and specificity.

RESULTS

We identified 10 different surgical technologies for IM fixation of lateral malleolar fractures reported across 12 articles, including both improvised and custom-designed Orthopaedic implants. Most implants were inserted through percutaneous surgical techniques.

CONCLUSION

Advances in technology have improved the feasibility of intramedullary fixation as a treatment option for lateral malleolus fractures. The implants we reviewed had very diverse morphological and mechanical properties. Intra-medullary fixation may outperform extra-medullary fixation of the lateral malleolus, particularly in patients at high risk of soft tissue complications. Robust scientific evidence is awaited.

LEVEL OF EVIDENCE

Level IV evidence.

An original fibular shortening osteotomy technique in tibiotalar arthrodesis

Tibiotalar arthrodesis (TTA) is the gold-standard treatment for advanced ankle osteoarthritis. We describe an original fibular shortening osteotomy (FSO) performed during TTA, to allow complete talar ascension and reduce the nonunion rate. Forty-two FSOs were associated to TTA (19 fixed by cross-screwing and 23 by anatomic plates) and assessed clinically and radiographically. At 24.7 months' follow-up, fusion rates were 97.6% for TTA and 100% for FSO, with mean fusion time of 5.2 months. One infection and 1 nonunion (4.7%) required further surgery, with complete resolution. Radiological and clinical outcome in TTA, lack of specific complications of FSO and ease of implementation encourage us to publish the technique.

Accelerated workflow for primary jaw reconstruction with microvascular fibula graft

Introduction

Major facial defects due to cancer or deformities can be reconstructed through microvascular osteocutaneous flaps. Hereby CAD/CAM workflows offer a possibility to optimize reconstruct and reduce surgical time. We present a retrospectiv observational study regarding the developement of an in-house workflow allowing an accelerated CAD/CAM fibula reconstruction without outsourcing.

Case description

Workflow includes data acquisition through computertomography of head and legs, segmentation of the data and virtual surgery. The virtual surgery was transferred into surgical guides and prebent osteosynthesis plate. Those were sterilized and used in surgery.

Evaluation

The workflow was used in 30 cases. Minimum planning period took 4 days from CT to surgery, average time was 8 days. Planning could be transferred to surgery every time. Intraoperative complications regarding osteotomy, assembly and fixation did not occur.

Discussion/Conclusion

An in-house workflow for CAD/CAM fibula reconstruction is feasible within a few days providing an accelerated procedure even in urgent cases.

Mid-term results of ankle fractures with and without syndesmotic rupture

BACKGROUNDS

This study investigated the effect of short term removal of syndesmotic screws on the ankle function after 6 years, as there still exists controversy on the duration of screw stabilization.

METHODS

Patients with an ankle fracture who received surgery between 1998 and 2004 were reviewed. One group was composed of patients with an ankle fracture needing a syndesmotic repair with screws. The second was composed of operated patients that did not need syndesmotic repair. The primary scoring used was the Olerud-Molander Ankle Score (OMAS).

RESULTS

A total of 59 patients were studied with comparable characteristics, with no significant difference on the OMAS after 6 years between the repair group (81.9) and the non-repair group (90.4). On additional clinical scoring groups remained the same. Joint degeneration was seen in both groups (86.7% vs. 55.5%).

CONCLUSIONS

Patients with ankle fractures using syndesmotic repair and screw removal after 8 weeks and operated patients without syndesmotic injury have comparable results after 6 years.

Increased rate of pseudarthrosis in the anterior intersegmental gap after mandibular reconstruction with fibula free flaps: a volumetric analysis

OBJECTIVES

Pseudarthrosis after mandibular reconstruction leads to chronic overload of the osteosynthesis and impedes dental rehabilitation. This study evaluates the impact of gap site on osseous union in mandible reconstruction using a new volumetric analysis method with repeated cone-beam computed tomography (CBCT).

METHODS

The degree of bone regeneration was evaluated in 16 patients after mandible reconstruction with a fibula free flap and patient-specific reconstruction plates. Percentual bone volume and width changes in intersegmental gaps were retrospectively analyzed using a baseline CBCT in comparison to a follow-up CBCT. Patients' characteristics, plate-related complications, and gap sites (anterior/posterior) were analyzed. Detailed assessments of both gap sites (buccal/lingual/superior/inferior) were additionally performed.

RESULTS

Intersegmental gap width (p = 0.002) and site (p < 0.001) significantly influence bone volume change over two consecutive CBCTs. An initial larger gap width resulted in a lower bone volume change. In addition, anterior gaps showed significantly less bone volume changes. Initial gap width was larger at posterior segmental gaps (2.97 vs 1.65 mm, p = 0.017).

CONCLUSIONS

A methodology framework has been developed that allows to quantify pseuarthrosis in reconstructed mandibles using CBCT imaging. The study identifies the anterior segmental gap as a further risk factor for pseudarthrosis in reconstructions with CAD/CAM reconstruction plates. Future research should evaluate whether this outcome is related to the biomechanics induced at this site.

Ankle deformity secondary to acquired fibular segmental defect in children

Background

The authors report the long-term effect of acquired pseudoarthrosis of the fibula on ankle development in children during skeletal growth, and the results of a long-term follow-up of Langenskiold's supramalleolar synostosis to correct an ankle deformity induced by an acquired fibular segmental defect in children.

Methods

Since 1980, 19 children with acquired pseudoarthrosis of the fibula were treated and followed up for an average of 11 years. Pseudoarthrosis was the result of a fibulectomy for tumor surgery, osteomyelitis of the fibula and traumatic segmental loss of the fibula in 10, 6, and 3 cases, respectively. Initially, a Langenskiold's operation (in 4 cases) and fusion of the lateral malleolus to the distal tibial epiphysis (in 1 case) were performed, whereas only skeletal growth was monitored in the other 14 cases. After a mean follow-up of 11 years, the valgus deformity and external tibial torsion of the ankle joint associated with proximal migration of the lateral malleolus needed to be treated with a supramallolar osteotomy in 12 cases (63%). These ankle deformities were evaluated using the serial radiographs and limb length scintigraphs.

Results

In all cases, early closure of the lateral part of the distal tibial physis, upward migration of the lateral malleolus, unstable valgus deformity and external tibial torsion of the ankle joint developed during a mean follow-up of 11 years (range, 5 to 21 years). The mean valgus deformity and external tibial torsion of the ankle at the final follow-up were 15.2° (range, 5° to 35°) and 10° (range, 5° to 12°), respectively. In 12 cases (12/19, 63%), a supramalleolar corrective osteotomy was performed but three children had a recurrence requiring an additional supramalleolar corrective osteotomy 2-4 times.

Conclusions

A valgus deformity and external tibial torsion are inevitable after acquired pseudoarthrosis of the fibula in children. Both Langenskiöld supramalleolar synostosis to prevent these ankle deformities and supramalleolar corrective osteotomy to correct them in children are effective initially. However, both procedures cannot maintain the permanent ankle stability during skeletal maturity. Therefore any type of prophylactic surgery should be carried out before epiphyseal closure of the distal tibia occurs, but the possibility of a recurrence of the ankle deformities and the need for final corrective surgery after skeletal maturity should be considered.

Non-ossifying fibromas: Case series, including in uncommon upper extremity sites

AIM

To investigate non-ossifying fibromas (NOFs) common fibrous bone lesions in children that occur in bones of the lower extremities.

METHODS

We analyzed 44 cases of NOF including 47 lesions, which were referred with a working diagnosis of neoplastic lesions. Lesions were located in the upper extremities (1 proximal humerus, 1 distal radius) and the lower extremities (25 distal femurs, 12 proximal and 4 distal tibias, and 4 proximal fibulas).

RESULTS

Three cases had NOFs in multiple anatomical locations (femur and fibula in 1 case, femur and tibia in 2 cases). Overall, larger lesions > 4 cm and lesion expansion at the cortex were seen in 21% and 32% of cases, respectively. Multiple lesions with bilateral symmetry in the lower extremities suggest that these NOFs were developmental bone defects. Two patients suffered from fracture and were treated without surgery, one in the radius and one in the femur. Lesions in the upper extremities (i.e., humerus of a 4-year-old female and radius of a 9-year-old male) expanded at the cortex and lesion size increased with slow ossification.

CONCLUSION

NOFs in the lower extremity had fewer clinical problems, regardless of their size and expansiveness. In these two upper extremity cases, the NOFs had aggressive biological features. It seems that there is a site specific difference, especially between the upper extremity and the lower extremity. Furthermore, NOFs in the radius are predisposed to fracture because of the slender structure of the radius and the susceptibility to stress.