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Background: Involvement of the distal fibula by alveolar soft-part sarcoma is rare. Extensive resection or amputation may be needed; however, distal fibula resection can disrupt foot and ankle biomechanics, leading to ankle joint instability. Reports on joint preservation for maintaining optimal ankle joint function are scarce. Computer-aided design and individualized threedimensional (3D)-printed uncemented implants represent an evolving solution for reconstructing the distal fibula. Case presentation: A 34-year-old woman was diagnosed with alveolar soft-part sarcoma in the right lower leg involving the cortical bone of the fibula. After anlotinib treatment, the tumor size decreased, and the tumor response rate was a partial response (PR); however, the patient continued to experience adverse reactions. With multiple disciplinary team discussions, surgical resection was deemed appropriate. Due to the extensive defect and ankle joint instability after resection, a custom-made 3D-printed prosthesis was designed and fabricated to reconstruct the defect, preserving the lateral malleolus. During the follow-up, the patient achieved favorable ankle function, and no prosthesis-related complications were observed. Conclusion: 3D-printed personalized uncemented implants constitute a novel approach and method for addressing the reconstruction issues of the distal fibula and ankle joint. Through the personalized design of 3D-printed prostheses, the lateralmalleolus can be preserved, ensuring the normal anatomical structure of the ankle joint. They achieve a well-integrated interface between the prosthesis and bone, ensuring satisfactory postoperative function. Additionally, they offer valuable insights for reconstructing distal bone defects near joints in the extremities. However, confirming these findings requires extensive cohort studies. [ABSTRACT FROM AUTHOR]

Purpose: The primary aim was to analyse the lateral malleolus morphology with a focus on the shape of the distal fibula for IM fixation of the fibula in infra- and transsyndesmotic fracture patterns. The secondary aim was to propose a treatment algorithm according to the lateral malleolar anatomy. Methods: 77 healthy, skeletally mature volunteers underwent CT scanning of the ankle. The fibula medullary canal and its cortical thickness were quantitatively analysed at 4 different levels measured from the fibular tip (1.5 cm, 3.0 cm, 4.5 cm, and 6.0 cm). A geometric classification was proposed, and a decision algorithm was developed. Statistical significance was set at a p-value < 0.05. Results: The smallest diameter of the medullary canal of the fibula was at 6.0 cm from the tip of the fibula, in 98.2% of the ankles. The distal fibula can be classified into triangular and rectangular type, according to the cortical thickness index (p < 0.0001). In 16.7% ankles, the internal diameter of the fibula at 6.0 cm was equal or narrower than 3.5 mm (p < 0.05). Conclusion: The shape of the distal fibula as evaluated by CT-guided analysis allows for IM osteosynthesis of the lateral malleolus in 83% of individuals. In our study, the smallest diameter of the medullary canal of the fibula was located 6.0 cm from the tip of the lateral malleolus. Coronal CT evaluation is advantageous in indicating which type of IM implant should be used safely for infra- and transsyndesmotic fracture patterns, potentially reducing intraoperative risks. [ABSTRACT FROM AUTHOR]

Purpose: During study of anatomy of a fractured posterior malleolus of the ankle on CT scans, the authors noticed a prominent crest on the lateral malleolus, which they termed the lateral malleolar crest (LMC). As, in their view, LMC is a clinically important structure which was only briefly mentioned by a few authors without an official term, they focused on the anatomy of this structure. Materials and methods: A total of 352 dry fibulae were analyzed and the following parameters recorded: (F) length of the fibula, (LMC) total length of LMC, (A) length of the part of the examined crest from the superior border of the articular facet of the lateral malleolus (AFLM) to its most proximal intersection with the midline of the fibula, (B) height of the medial triangular rough surface, and (A/F) A/F ratio. Results: The crest was observed in all specimens. (F) was 346.5 ± 26 mm (95% confidence interval [CI] 344–349), (LMC) was 85.4 ± 11.6 mm (95% CI 84.2–86.6), (A/F) was 25% ± 3% (95% CI 24.7–25.3) in the whole group. (A) was 25.9 ± 6.5 mm (95% CI 24.8–26.8) in the whole group, (B) was 34.9 ± 4.7 mm (95% CI 34.3–35.5) in the whole group, 36 ± 6.1 mm (95% CI 35.1–36.9). Conclusion: LMC is an important structure on the lateral malleolus. The knowledge of its anatomy is essential for placement of syndesmotic screws or/and the fibular plate. [ABSTRACT FROM AUTHOR]

Despite its clinical relevance in the context of ankle fractures, little is known about the bone microarchitecture and strength of the distal fibula, especially regarding age‐, sex‐, and subregion‐specific effects. To address this gap of knowledge, we obtained fibulae from 30 skeletally intact donors at autopsy (each 15 male and female), which were analyzed by high‐resolution peripheral quantitative computed tomography including micro‐finite element analysis. Scans were performed in a 7‐cm volume of interest and evaluated in three subregions according to the Danis‐Weber fracture classification. Group comparisons and linear regression analyses were applied to evaluate the effects of age, sex, and subregion. From distal to proximal, we observed an increase of cortical parameters and a decrease of trabecular parameters. Age was primarily associated with a cortical decrease in all subregions (Danis‐Weber type A, B, and C) in women. While women showed a greater magnitude of decline, men also exhibited an age‐associated decrease for some parameters, including cortical area and cortical thickness in the type C subregion. Stiffness and failure load were highest in the type C subregion in both women and men. A critical age‐related decline in bone strength parameters in the type B subregion was observed in women, providing an explanation for the increased incidence of low‐traumatic type B fractures in the elderly. Together, these findings extend the current understanding of distal fibular microarchitecture, likely explaining the epidemiologic features of distal fibula fractures and emphasizing the need for age‐adapted treatment algorithms. [ABSTRACT FROM AUTHOR]

Purpose: Posttraumatic fibular malunion alters ankle joint biomechanics and may lead to pain, stiffness, and premature osteoarthritis. The accurate restoration is key for success of reconstructive surgeries. The aim of this study was to analyze the accuracy of a novel three-dimensional (3D) registration algorithm using different segments of the contralateral anatomy to restore the distal fibula. Methods: Triangular 3D surface models were reconstructed from computed tomographic data of 96 paired lower legs. Four segments were defined: 25% tibia, 50% tibia, 75% fibula, and 75% fibula and tibia. A surface registration algorithm was used to superimpose the mirrored contralateral model on the original model. The accuracy of distal fibula restoration was measured. Results: The median rotation error, 3D distance (Euclidean distance), and 3D angle (Euler's angle) using the distal 25% tibia segment for the registration were 0.8° (− 1.7–4.8), 2.1 mm (1.4–2.9), and 2.9° (1.9–5.4), respectively. The restoration showed the highest errors using the 75% fibula segment (rotation error 3.2° (0.1–8.3); Euclidean distance 4.2 mm (3.1–5.8); Euler's angle 5.8° (3.4–9.2)). The translation error did not differ significantly between segments. Conclusion: 3D registration of the contralateral tibia and fibula reliably approximated the premorbid anatomy of the distal fibula. Registration of the 25% distal tibia, including distinct anatomical landmarks of the fibular notch and malleolar colliculi, restored the anatomy with increasing accuracy, minimizing both rotational and translational errors. This new method of evaluating malreductions could reduce morbidity in patients with ankle fractures. Level of evidence: IV [ABSTRACT FROM AUTHOR]

(1) Background: Restoration of ankle biomechanics after distal fibula (DF) resection in bone sarcomas can be performed with different techniques. We report the functional and oncological outcomes of a case series; (2) Methods: Ten patients (5 females and 5 males) with a mean age of 27 years (range 10–71) were retrospectively evaluated. Following the resection, different techniques were used to reconstruct the ankle: tibiotalar arthrodesis, residual lateral malleolus fixed to the tibia, non-vascularized or rotational vascularized fibula transposition and intercalary allograft. All complications were recorded, and the functional outcomes were evaluated; (3) Results: The mean follow-up time was 54 months (range, 13–116). Six patients were free of disease while four patients died of disease. All patients had a stable ankle and bone union, which was achieved after a mean of 9.4 months (range 3–20). The mean MSTS Score was 26.7 (range 21–30). Chronic ankle pain and peroneal external nerve palsy were observed. Patients underwent additional surgeries for deep infection and for equinus ankle deformity. No local recurrence was observed. Metastasis occurred in four patients after a mean of 14.7 months (range 2–34); (4) Conclusions: After DF resection, the restoration of ankle biomechanics gives acceptable functional results, but a larger series of patients with long-time follow-up are required to confirm the durability of the reconstruction. [ABSTRACT FROM AUTHOR]

Reconstruction of skin and soft tissue wounds can pose a unique surgical challenge. This is especially true for cases of exposed bone and tendon where soft tissue loss is extensive and opportunities for tissue advancement or rotation are limited. A clinical case is presented describing an experience with dehydrated human amnion/chorion membrane (dHACM, EpiFix®/AmnioFix®, MiMedx Group, Marietta, GA) graft to obtain granulation over an open fracture with desiccated bone. The 22-year-old female trauma patient presented with high-grade bilateral lower extremity soft tissue loss after being run over and dragged by a semitruck. Despite several weeks of serial debridemonts, the right distal fibula and left medial femur remained desiccated and infected. Both extremities had cavernous tissue landscapes with minimal granulation tissue and neither was hospitable for split thickness skin grafting. Four separate applications of dHACM (combination of EpiFix® and AmnioFix®) to the affected areas of exposed bone were successful at stimulating a robust granulation bed. On hospital days 44 and 61, the wounds were successfully skin grafted. The authors suspect that the dHACM applications contributed to successful granulation coverage to the affected bones that were otherwise not amendable to other coverage options. This contributed to limb salvage and a successful outcome. [ABSTRACT FROM AUTHOR]

Summary: We report the case of a 53-year-old female, treated by bisphosphonate for 12 years, who presented atraumatic fractures of both fibulas. Her X-rays showed bilateral distal fibula fractures with radiological features similar to atypical femur fractures. The distal fibula should be considered as a potential site for stress fractures in bisphosphonate users. Bisphosphonates are the most widely used drugs in the treatment of osteoporosis. During the last decade, the occurrence of atypical fractures, mostly subtrochanteric and diaphyseal femoral fractures, has been acknowledged in patients with long-term use of bisphosphonates. We report the case of a 53-year-old female on alendronate therapy for the past 12 years who presented with a few months history of atraumatic right, and subsequently left, lateral ankle pain. Her X-rays showed bilateral distal fibula fractures with radiological features similar to atypical femur fractures. She had been treated conservatively with walking boots and her treatment with bisphosphonate had been stopped 5 months prior to the fractures. Callus was progressively seen on serial follow-up X-rays, and both fractures healed completely within a reasonable period of 1 year. Investigations did not reveal any secondary causes of osteoporosis or metabolic bone disorders. To our knowledge, this is the first reported case of bilateral distal fibula fractures in a patient on long-term bisphosphonate therapy. [ABSTRACT FROM AUTHOR]

Objective This study aimed to investigate the feasibility of single incision for plating for the treatment of distal tibia and fibula fractures by a gross anatomic study. Methods The anatomical structures of the anterolateral lower legs were identified. The lower leg length was measured from the top of fibular head to the tip of lateral malleolus. The distances between the extensor digitorum longus and anterior border of distal thirds of the tibia as well as the fibula were also measured. Additionally, their mutual relationships to the surrounding anatomical structures were described. Results The distances from the proximal, middle, and distal thirds of the tibia to the extensor digitorum longus were 2.96 ± 0.46, 1.85 ± 0.25, and 2.15 ± 0.30 cm, respectively; the distances from the proximal, middle, and distal thirds of the fibula to the extensor digitorum longus were 1.82 ± 0.28, 2.09 ± 0.31, and 2.30 ± 0.27 cm, respectively. The results indicated that the safe gap from the distal tibia to extensor digitorum longus (EDL) was 1.6-3.4 cm and from the EDL to fibula was 1.5-2.6 cm. In addition, the average number of vascular pedicle in tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus longus, and peroneus brevis was 2-3. Injuries generated by retracting medially and laterally in vascular pedicle could hardly affect the distal muscles. Conclusions Therefore, we suggest that it is feasible to plate fractures of both the distal tibia and fibula through one anterolateral incision. [ABSTRACT FROM AUTHOR]

Objectives: To present a novel single anterior-lateral approach for the treatment of distal tibia and fibula fracture via anatomical study and primary clinical application in order to minimize soft tissue complications. Design: Both a gross anatomic cadaver and retrospective studies of the single-incision technique in patients recruited between June 2004 and January 2010. Setting: Level I trauma center. Patients/participants: Twenty-six legs of 14 adult human cadavers and clinical recruitment of 49 patients (29 males, 20 females) with a mean age of 37.6 years (range 11–68) with fracture of distal 1/3 tibia and fibula. Intervention: A single anterior-lateral incision technique for open reduction and internal fixations of distal tibia and fibula fractures. Main outcome measures: To identify the anatomic structures at risk in the anterolateral aspect of the lower leg and explicit the safe dissection distance from the extensor digitorum longus (EDL) to tibia and fibula, 26 legs of 14 adult human embalmed specimens were recruited in the anatomical study with the distance between the EDL and the anterior edge of the distal thirds of the tibia, as well as the distance between the EDL and the anterior edge of the distal thirds of the fibula were measured, and their mutual relationships to the surrounding anatomical structures described. Mean average standard deviations were also calculated. As for the clinical study, the quality of bone union and soft tissue healing were noted. Results: The mean distances between the distal tibia and the EDL were measured to be 2.96 ± 0.46 cm (proximal), 1.85 ± 0.25 cm (middle), and 2.15 ± 0.30 cm (distal), and that between the fibula and the EDL were 1.82 ± 0.28 cm (proximal), 2.09 ± 0.31 cm (middle), and 2.30 ± 0.27 cm (distal), which means the safe gap from the distal tibia to EDL was1.6–3.4 cm and from the EDL to fibula was 1.5–2.6 cm. The anterior tibial vein and artery and the deep fibular nerve lie on the anterior interosseous membrane over the lateral surface of the distal tibia were excellently visualized. Review of clinical outcomes in 49 patients with combined distal tibial and fibular fractures who underwent reduction and fixation with the single-incision technique, revealed uneventful fracture healings in 47 patients; and two cases of superficial wound necrosis which were treated and healed in 4 months. There was no case of delayed union or non-union. Conclusion: Distal fibula fracture occurring with distal tibia fracture poses a challenge for stable fixation. This has necessitated the need for dual incisions on the distal leg to approach each fracture for reduction and fixation. However, a single anterolateral incision enables the safe approach to the lateral aspects of the distal tibia and fibula thus eliminating the need for two separate incisions and minimizing the soft tissue complication to some extent. Meanwhile, the neurovascular bundle at risk during operation, distal tibia and fibula is clearly exposed in the single anterior-lateral incision. [ABSTRACT FROM AUTHOR]