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Common peroneal nerve (CPN) injury is a recognised complication of traumatic knee dislocation with a direct association between the degree of ligamentous injury and the degree of CPN injury. It is essential explore and repair these injuries in good time to reduce morbidity. Often exploration only involves the portion of this nerve associated with the joint as it courses around the fibular head. However, a recent case highlighted the importance of proximal exploration to its branching point from the sciatic nerve, a known point of fragility, even if other defects have been identified.

Background The systems for precisely locating the joint line during primary and revision total knee arthroplasty are still controversial, and they should be better evaluated in the Chinese population. Methods A total of 451 standard anteroposterior knee radiographs from 451 healthy Chinese people (283 males and 168 females, the average age of 33.26 years, range 20–50 years) were included to measure the femoral width (FW) and the distances from the adductor tubercle (AT), the medial epicondyle (ME), the lateral epicondyle (LE), and the fibular head (FH) to the joint line (JL). Correlation between FW and distances from landmarks to the joint line was evaluated using Pearson correlation coefficient, and the ratios of ATJL, MEJL, LEJL, FHJL to FW were calculated. Results The average distances from the AT, the ME, the LE, the FH to the JL were 49.4 ± 5.0 mm, 28.3 ± 3.1 mm, 26.9 ± 2.9 mm, 20.0 ± 4.0 mm, respectively. An excellent linear correlation was found between FW and the distance from AT to the joint line (R = 0.836, R2 = 0.698); it was more reliable than the LE (R = 0.686, R2 = 0.471) and the ME (R = 0.672, R2 = 0.452). The average ratios of ATJL/FW, MEJL/FW, LEJL/FW were 0.553, 0.317, and 0.302, respectively. There were significant differences between our results and the studies based on the Western people. Conclusion The AT can be used as a reliable landmark to locate the JL precisely by the formula (ATJL = 0.548 × FW in males; ATJL = 0.562 × FW in females) in the Chinese population. The LE and ME can be the second choices. Moreover, it may be better to use ratios from the research based on the same race.

Pilon fractures with intact fibula have been associated with low-energy trauma. However, the compression force onto the ankle joint can damage the tibiofibular linkage as in a Maisonneuve fracture. Herein, we describe a case of a patient who had a pilon fracture (AO type 43 C3.2) without a fibular fracture. Three-dimensional preoperative simulation by reduction with the surface registration technique was performed as the fibular length was intact and there was no reference for the tibial length. The preoperative simulation revealed superior fibular head dislocation and shortening of the distal tibia. After emergency external fixation on the day of arrival, a 2-staged surgery was performed. During the first operation, the fibular head was reduced and the tibial posterolateral fragment was fixed to restore the tibia length. During the second operation, medial and anterolateral fragments were fixed in order to reduce joint surface of the distal tibia. In general, proximal fibular head fractures are easily overlooked. In the case of pilon fractures with severe length shortening of the tibia without a fibular fracture, a proximal tibiofibular injury should be suspected.

BACKGROUND: Peroneal nerve impalement is a recognized complication of percutaneous placement of fibular transfixation wires by palpatory method after increase use of ilizarov technique in treatment of Tibial fractures, deformity correction and limb lengthening. The purpose of this study was to identify the relationship between the Common Peroneal Nerve (CPN) and the palpable landmark, fibular head for insertion of proximal fibular transfixation wire, safe zones in proximal tibia and percentage of fibula where nerve crosses the neck. METHODS: Standard 1.8-mm Ilizarov k- wires were inserted in the fibula head of fresh 10 un-embalmed cadaveric knees. Wires were inserted percutaneously to the fibula head by palpatory technique. The course of common peroneal nerve was dissected. Distances from wire entry point to the course of the common peroneal nerve were measured post-wire insertion. RESULTS: The mean distance of the common peroneal nerve from the anterior aspect of the broadest point of the fibular head was 25.10 ± 4.39 mm (range 16–35 mm). Common peroneal nerve was seen to cross the neck of fibula at a mean distance of 32.3 ± 8.53 mm (range 20–50 mm). Wire placement was found to be on average, 46% of the maximal AP diameter of the fibula head and 44% of the distance from tip of fibula to the point of nerve crossing fibula neck. CONCLUSION: We recommend Proximal fibula transfixation wires are safer to pass with in 2 cm from the tip of the styloid process of the fibula, Anterior half of the head of fibula

Objectives The management of high energy tibial plateau fractures is a surgical challenge. Recently described Luo’s classification is based on CT scans and is more objective with a better inter-observer agreement as compare to Schatzker and AO/OTA classifications. We describe the functional results of a series of 53 cases classified and managed according to the Luo’s column concept. Methods A retrospective review of 53 high energy tibial plateau fractures, operated between January 2012 and March 2015 at a Level I trauma center, was performed. CT scans were used to classify these injuries based on the number of columns involved. Plating configuration and surgical approach were chosen based on the number of independent articular fragments on axial sections at the level of fibular head. Results 1 one-column, 51 two-column and 1 three-column fractures were studied. Triple plating was done in 5 patients. Mean follow-up was 2.7 years and mean Insall Knee score was 95.42. Four patients had varus malalignment and 1 had joint depression in the post-operative period. These were due to imperfect reduction during the surgery itself, and no case of late collapse was detected. Conclusion Utilizing Luo’s classification for treating these complex injuries will assist in better understanding of fracture pattern and hence help in achieving a better functional outcome. Each fractured column needs to be independently addressed.

Summary Background When a small, thin, and durable flap is required for coverage of the foot, the proximal peroneal artery perforator (PPAP) free flap may be a novel option. However, few clinical results and anatomical studies on the PPAP flap have been published. Methods A total of 24 PPAP flaps used in 22 patients from January 2013 to December 2016 were analyzed. All flaps were elevated in the subfascial plane based on a single perforator from the peroneal artery between the soleus and peroneus muscles. Results The average harvested flap size was 18.9 cm 2 (range, 9–40 cm 2 ), pedicle length was 4.3 cm (range, 3.1–5.5 cm), and pedicle artery diameter was 1.1 mm (range, 0.8–1.5 mm). Twenty-three of the 24 PPAP flaps survived. Average time to harvest the flap was 35 minutes (range, 20–55 minutes). Perforator location (ratio by fibula length) was confirmed at the 0.32 site (standard deviation, ±0.04) from the fibular head. Percentages of septocutaneous and musculocutaneous types were 42% (10/24) and 58% (14/24), respectively, for perforator vessel course; average intramuscular course was 1.3 cm (range, 0.7–2.4 cm). Vessel graft was conducted in four cases, with an average length of 2.2 cm (range, 1.5–3.0 cm). Conclusions The PPAP flap is one of the thinnest flaps available and is relatively easy to elevate. Moreover, it can be elevated in the same operative field as the foot, and primary closure is available for the donor site. Thus, the PPAP flap may be a good surgical option for soft tissue coverage of the foot.

Despite technologic advances in the surgical technique for anterior cruciate ligament (ACL) reconstruction, some patients continue to have rotational instability postoperatively. Recently, authors have reported the anatomic and functional characteristics of the anterolateral ligament (ALL), a structure that originates near the lateral epicondyle on the femur and inserts on the tibia between the Gerdy tubercle and the fibular head. Recent biomechanical studies have shown the ALL is an important stabilizer against anterolateral tibial rotation, and its reconstruction has shown excellent initial clinical results. Several techniques have been developed to try to anatomically address this structure in the setting of an ACL reconstruction. This article details a simple anatomic technique to reconstruct the ACL and the ALL of the knee using hamstring tendon autograft and maintaining the semitendinosus insertion.

Quantitative assessment of nerve echogenicity using the MaxEntropy, RenyiEntropy and Yen methods has shown promise in the assessment of ulnar neuropathy at the elbow. The purpose of this study was to determine the clinical usefulness of quantitative echogenicity measurement when using these three automatic thresholding methods in the evaluation of patients with common fibular (CF) neuropathy.High-resolution ultrasonography (HRUS) images of the CF nerve from 45 patients with CF neuropathy were compared to 42 healthy controls.With all three methods patients with CF neuropathy had significantly higher mean hypoechoic fraction than healthy controls at the level of the fibular head (FH): MaxEntropy 87.4% versus 71.9% (p0.001), RenyiEntropy 84.7% versus 68% (p0.001) and Yen 87.6% versus 68.2% (p0.001). Patients with CF neuropathy could be differentiated from healthy controls at a hypoechoic fraction cut-off point of 82% (MaxEntropy), 80% (RenyiEntropy) and 80% (Yen) with a sensitivity of 82%, 82% and 84% respectively, and a specificity of 93%, 95% and 83% respectively. Similar results were found for sonographic measurements above the FH.Quantitative assessment of nerve echogenicity using the MaxEntropy, RenyiEntropy and Yen methods can be used to distinguish between patients with CF neuropathy and healthy controls with high sensitivity and specificity.These three proven automatic thresholding methods can be used to assess nerve echogenicity in future studies. Quantitative echogenicity assessment with HRUS shows promise for the future as a potential diagnostic tool in daily clinical practice.

Highlights • Osteochondroma are the most common benign tumors. • Disease affecting knee joint in 94% of all cases. • Clinicians should be aware of the possible tumoral lesions in drop foot etiology., Following median and ulnar nerves, peroneal nerve entrapment is the most frequent nerve involvement in the body Katirji and Wilbourn (1998) [1]. Osteochondromas are the most common benign bone tumors comprising 9% of all bone tumors and 35% of benign bone tumors Porter (2000) [2]. Hereditary exostoses (HME) is an autosomal dominant disorder with variable penetrance characterized by multiple osteochondromas near joints. It is one of the most commonskeletal dysplasias with a frequency of about 1.18%. In this study, we aimed to present a case with a drop foot resulting from osteochondromas of proximal tibia and fibula and help to guide the clinicians in differential diagnosis according to SCARE criteria Agha (2016) [3].

The purpose of this article is to present the author׳s experience with fibular head−based surgical procedures for the treatment of posterolateral instability of the knee. The surgical techniques presented are the biceps tendon transfer procedures, and the fibular head−based figure of 8 posterolateral reconstruction using free grafts. Each of these techniques is combined with capsular repair or posterolateral capsular shift or both procedures in all cases. The decision points for surgical technique selection, the surgical technique itself, the postoperative rehabilitation, and the outcomes of these surgical procedures are presented, including a comparison of the biceps tendon procedures with the free graft procedure.

Objective Ultrasound (US) and neurophysiological examination are useful tools in the evaluation of common fibular mononeuropathy. There is only a report comparing US and electrophysiological parameters in patients with common fibular nerve (CFN) conduction block at fibular head. We investigated the correlation between US and neurophysiologic findings in this condition. Methods We retrospectively reviewed patients with CFN assessed in our lab during last 2 years. Each patient underwent to clinical, neurophysiological and ultrasound evaluations. Cross sectional area (CSA) of CFN at fibular head was assessed. Results Twenty-four patients were included. Motor nerve conduction study showed a reduction of distal compound muscle action potential (CMAP) amplitude in 10 patients (mean 1.3 mV). US showed an increased CSA in 10 patients. Statistical analysis revealed a strong correlation between the increased CSA and the CMAP reduction of CFN. Conclusion Our data suggest that usually US examination is normal in CFN conduction block at fibular head. However the association with axonal damage is frequently accompanied by an increase of CSA. Significance Ultrasound evaluation may represent a powerful diagnostic/prognostic tool in cases with CPN conduction block at fibular head because it usually shows normal pattern in pure conduction block and increase of CSA in associated axonal damage.

Summary Introduction and aim Endoprosthetic reconstruction is considered the mainstay of limb salvage in periarticular bone tumours. However, this procedure has limited durability especially when performed in young patients. The free fibula head flap including the proximal articular surface represents one option for hemiarthroplasty reconstruction. The aim of this study was to investigate the role of the fibula head flap for joint reconstruction after osteoarticular resections. Patients and methods All patients who underwent hemiarthroplasty procedures between 2000 and 2006 using the free fibula head flap were included in the study. Functional assessments were performed using the American Musculoskeletal Tumor Society (AMTS) classification. Results There were five males and two females (mean age: 22.6 ± 15.9 years). Five patients underwent reconstruction following resection of malignant bone tumours and two for chronic osteomyelitis of the distal humerus. In three patients, the fibula was used for distal radius and wrist joint reconstruction, and the remaining four patients for reconstruction of the distal humerus and elbow joint. A vascularised growth plate transfer based on the lateral geniculate vessels was performed in two patients. Atechnetium-bone scan confirmed viability of all flaps 10 days after surgery, and radiographic bony union was confirmed on average 5 months following surgery. There were no complications with the recipient or donor site after a median follow-up of 71 months (range: 12 months to 10 years). All patients achieved reasonable return of function and were able to perform all activities of daily living. Conclusions We demonstrate that the hemiarthroplasty procedure using the free fibula flap with its proximal head is a safe procedure with good functional results. Performing autologous arthroplasty using a free fibula head flap may be a promising alternative to an endoprosthesis or alloplastic reconstruction with a low risk of complications and morbidity.

The proximal attachments of the popliteus muscle exhibit some variability in the literature, leading to questions regarding function. The anatomic variability of the proximal attachments of popliteus muscles in Thais was studied in order to compare with the previous reported literature by carefully tracking its fibers caudo-cephalically. The sites of the proximal attachments of popliteus muscles found in this study were at the lateral femoral condyle (100%), the posterior horn of the lateral meniscus (63%) and the fibular head (52.1%). Our result also reveals the difference of the strength of the attachment at the lateral meniscus, having some relationship with the attachment at the fibular head, which corresponds with the concept of form and function.

Background The anatomical relationship of the fibular head with the fibular nerve is a critical point in regard to injuries of peripheral nerves in the lower extremities. In this location, the peroneal nerve may be injured due to several mechanisms, and osteophyte-like lesions can be considered as a differential diagnosis. Methods The suitable literature concerning this association is reviewed and a case is presented. A 15-year-old adolescent boy presented with right peroneal nerve palsy on admission. The radiological examinations (computed tomography and magnetic resonance imaging) demonstrated an osteophytic lesion in the head of the right fibula. The patient underwent surgical decompression of the nerve and resection of the lesion. Postoperatively, there was a complete recovery of the deficits. Conclusions The association of osteophyte-like bone changes and peroneal nerve palsy is rare. The differential diagnoses of these lesions include cartilaginous exostoses and osteochondromas, which may be related to hereditary multiple exostoses syndrome. The timing of the treatment plays an important role in the neurological recovery.

We report the case of bilateral peroneal neuropathy following massive weight loss after bariatric surgery. A few months after a gastric by-pass, the patient developed sequentially within 6 months a L2-L3 herniated disc that required surgery, a severe right peroneal nerve palsy that led to decompressive surgery and finally contralateral peroneal nerve palsy also operated. The electrophysiological analysis confirmed the clinical suspicion of peroneal nerve compression at the fibular head. Postoperative course was favorable. Literature reports peroneal nerve palsy after slimming, mostly when weight loss is fast and marked although the issue is rarely bilateral.

Unilateral fibula head dislocation is an uncommon injury. Ogden in 1974 reviewed the literature and detected 108 cases [J. Bone Joint Surg. 56(A) (1974) 145–154]. There since have been few reported cases. Bilateral fibula head dislocation only has been reported once [Rheumatol. Int. 5(1) (1984) 45–47]. We report a patient who had developed bilateral fibula head dislocations, each side independently over a 5-year period. We emphasise the rarity of the injury, the necessity of prompt recognition and reduction, and the uncertainty for best management of this injury.

Objective To explore new surgical procedure for repairing and reconstructing medial malleolus and soft tissue defect. Methods According to the size of medial malleolus and composite soft tissue defect, vascular fibular head composite tendon bone flap free grafting using anterior tibial recurrent vessel as the perforating branch was designed to reconstruct the medial malleolar saddle and triangular ligament, and composite back broadest muscle flap free grafting was designed to repair the medical malleolar wound surface. From January 2000 to December 2006, the technique was used in 5 male patients who were injured by machine or in traffic accidents, causing bone and soft tissue defect. The size of wound surface ranged from 19 cm × 12 cm to 24 cm × 12 cm. Results The wound surface was healed at the first stage in 4 cases, and the other case had infection and was cured in 6 months with anti infection therapy. Postoperative follow-ups from 6 months to 6 years showed that grafted bones and free cutaneous flaps were healed well, malleolar joints were stable, joint movement was normal, and the appearance was satisfactory. The overall outcome was good. Conclusion Fibular head composite tendon bone flap free grafting is effective for repairing medical malleolar defect.

We report a case of acute post-traumatic snapping of the biceps femoris tendon following a soccer injury. Surgical stabilisation, achieved by re-routing the tendon insertion through a tunnel in the fibular head, resolved the symptoms after conservative management failed. We believe this is the first report of a ‘snapping knee’ resulting from direct injury to the biceps femoris tendon insertion.

We present 5 patients with a peroneal nerve palsy, following a close traumatic knee dislocation, evaluated by clinical, neurophysiologic and ultrasound (US) examination. A follow-up was performed in all of these patients. At the moment of the first US evaluation, the patients presented an increase of the cross sectional area (CSA) of the damaged peroneal nerve, in the tract between popliteal fossa and fibular head. In particular 4 of them showed a CSA four-seven times larger than normal. These 4 patients did not present improvement in clinical, neurophysiologic and ultrasonographic long term follow-up. A patient instead had a CSA of the damaged nerve only double compared to the other side. This subject showed a general improvement in the follow-up. On the basis of these preliminary findings, we may hypothesize that larger is the CSA of the damaged peroneal nerve worse the prognosis. Furthermore, this study suggests that US evaluation can aim the diagnostic process providing data about morphology of the involved nerve, exact site of the injury, conditions of surrounding structures and changes over the time.

The arcuate sign is a well described finding of fibular head avulsion at the insertion site of the arcuate complex. It has been associated with posterolateral corner knee injury and resulting instability. The authors report two patients presenting with the arcuate sign following knee dislocation, which has not been previously described. As unrecognized spontaneously reduced knee dislocation often results in significant morbidity, the authors propose that the arcuate sign should raise clinical suspicion of this injury mechanism.

The authors report an intraneural ganglion of the peroneal nerve at the fibular head, in which the external appearance of the nerve was normal at operation. Only the incision of the epineurium permitted discovery of the lesion.