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Summary The peroneal nerve can be injured due to direct trauma or non-traumatic causes, with the injury mostly occurring between the fibular head and neck and mostly unilateral. This injury mostly results from prolonged squatting, cross-legged sitting or sitting with one foot tucked under the other leg. In this report, we present three agricultural workers with a history of prolonged squatting who developed bilateral foot drop due to bilateral peroneal nerve injury, two of whom recovered almost completely after physical therapy, and one remained disabled. Agricultural workers should be advised to avoid prolonged squatting for more than 2 h, to extend the knee and to strengthen the muscles around the knee in order to prevent neuropathy.

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.

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.

Common peroneal neuropathy (CPN) is the most common tunnel neuropathy in the lower extremities, many issues of diagnosis and treatment of which require further study.Objective: to analyze the clinical manifestations of CPN, methods of its diagnosis and treatment results.Patients and methods. Eighty patients (31 women and 49 men) aged 18 to 82 years (mean age, 51 years) with compressive CPN were followed up during 2012–2018. Unilateral CPN and bilateral CPN were found in 76 and 4 patients, respectively. Eighty-four common peroneal nerve decompression operations were performed.Results and discussion. There was paralytic CPN in 73 (87%) surgical cases, painful CPN in 8 (9.5%), and intermittent CPN in 3 (3.5%). Diagnostic errors (when CPN was regarded as discogenic radiculopathy or lumbar stenosis) were noted in the painful and intermittent forms of the disease. After surgical treatment, complete recovery of peroneal nerve function was observed in 61 (72.6%) of the 84 surgical cases; its partial recovery in 15 (17.9%). Positive results were seen in all cases of painful and intermittent CPN, whereas they were more often observed in paralytic CPN if the operation was performed early (up to 12 months) after the onset of the disease.Conclusion. Common peroneal nerve decompression is an effective and safe therapeutic method that, in painful and intermittent CPN, leads to complete reversal of symptoms and, in the paralytic form of the disease, it is most effective in the early stages of the disease.

Entrapment neuropathies cover a wide range of isolated nerve injuries along the course of the upper and lower extremity nerves. Electrodiagnostic (EDX) testing is usually an essential part of the evaluation of entrapment neuropathies, and examinations for the most common entrapment neuropathies, carpal tunnel syndrome and ulnar neuropathy at the elbow, constitute a significant part of the daily work in EDX laboratories. Despite this, guidelines for EDX testing are generally sparse or do not exist for entrapment neuropathies, whereas a wide variety of different techniques are available to the clinical neurophysiologist. This study reviews the existing, more or less, detailed EDX criteria or practice parameters that are suggested by consensus groups in peer-reviewed journals for the most common entrapment neuropathies: carpal tunnel syndrome, ulnar neuropathy at the elbow, common peroneal (fibular) neuropathy at the fibular head, and tibial neuropathy at the tarsal tunnel. It is concluded that future research is needed to develop and refine EDX guidelines in entrapment neuropathies.

Motorische Regeneration der Fusheberschwache sowie sensible Regeneration im Versorgungsgebiet des Nervs. Fusheberschwache, gestorte Pronation und Supinationsstellung sowie eine Sensibilitatsstorung im Versorgungsgebiets des N. peroneus, bei positivem Hoffmann-Tinel-Zeichen auf Hohe des Fibulakopfchens sowie Steppergang und Spitzfus. Infektion, Ruckenmarksschadigungen und Ruckenmarkstumoren mit diesbezuglichen Sensibilitatsstorungen und Lahmungen, fortgeschrittene multiple Sklerose, amyotrophe Lateralsklerose, pAVK IV, reinnervationsrefraktare Muskeln bei Denervation >15–18 Monaten, Polyneuropathie, Insult Operation in Seitenlage und Oberschenkelblutsperre. L‑formiger Hautschnitt gemas Anzeichnung. Losung des Nervs durch Fasziotomie nach proximal und distal bis zur Aufteilung des Nervs. Offnung der Blutsperre und Blutstillung. Einlage einer Mini-Redovac-Drainage, Subkutan- und Hautnahte. Kompressionsverband. Eine Vollmobilisation ist ab dem 1. postoperativen Tag moglich. Nach Drainageentfernung kann ggf. eine Elektrostimulationstherapie erfolgen. Nach der Nahtentfernung ist eine Physio- und Ergotherapie indiziert. Klinische Kontrolle und Foto- und Videodokumentation sollten in 3‑Monats-Abstanden durchgefuhrt werden. Vier Monate postoperativ erfolgt eine NLG/EMG. Ein Follow-up sollte fur 24 Monate durchgefuhrt werden. Zwischen den Jahren 2010 und 2018 wurden an der Klinik der Autoren 15 PatientInnen operiert. Untersucht wurden die Sensibilitat, die Motorik und die subjektive Bewertung der PatientInnen. Bei 12 PatientInnen (80 %) wurde eine vollige Regeneration, in einem Fall (6,67 %) eine partielle Regeneration und in 2 Fallen (13,33 %) postoperativ keine Verbesserung erzielt.

Objective: To investigate the correlation between fibular head height and the incidence and severity of varus knee osteoarthritis based on three-dimensional reconstruction of the knee joint.Methods: The data of knee joint imaging in our hospital from June 2018 to June 2020 were collected. The degree of varus deformity of the knee was assessed at the superior hip-knee-ankle angle of the X-rays. Three-dimensional reconstruction of patient computed tomography(CT)data was performed by mimics software. The fibular head height, joint line convergence angle (JLCA) and medial proximal tibial angle (MPTA) were measured in a three-dimensional model. The patients were divided according to the Kellgren-Lawrence grade: group A: grade 0, group B: grade I, group C: grade II, group D: grade III, and group E: grade IV. The differences in age, gender, height, weight, body mass index(BMI), fibular head height, and degree of varus deformity (JLCA, MPTA, and coxa-knee-ankle angle) were compared. Ordinal multivariate logistic regression was used to analyze the correlation between fibular head height and Kellgren-Lawrence grade.Pearson correlation was used to analyze the correlation between fibular head height and Kellgren-Lawrence grade.Results: 232 patients (232 knees) were finally included in the study, with Kellgren-Lawrence grades of 28 in group A, 31 in group B, 49 in group C, 53 in group D, and 71 in group E. The differences in age, gender, height, body mass index, fibular head height, JLCA, MPTA, and hip-knee-ankle angle among the five groups were statistically significant (P < 0.05), and the differences in body weight were not statistically significant (P > 0.05). There were significant differences in fibular head height, JLCA, JLCA and hip-knee-ankle angle between different groups (P < 0.05). Furthermore, there were significant differences in JLCA and hip-knee-ankle angle (P < 0.05), and both JLCA and hip-knee-ankle angle increased with severe aggravation of Kellgren-Lawrence grade. Furthermore, both fibular head height and MPTA decreased as the Kellgren-Lawrence grade was severely aggravated. There was a significant negative correlation between Kellgren-Lawrence grade and fibular head height (r = -0.812, P < 0.001). Furthermore, there was a significant negative correlation between fibular head height and hip-knee-ankle angle (r = -0.7905, P < 0.001). When Kellgren-Lawrence grade III and IV knees were considered as disease, ROC curve analysis showed a cut-off value of 10.63 for fibular head height and an AUC of 0.872.Conclusion: The height of fibular head in patients with varus knee osteoarthritis is smaller than that in non-osteoarthritis patients. In addition to body mass index, fibular head height is a risk factor for the pathogenesis of varus knee osteoarthritis,the smaller the fibular head height, the more severe the severity of osteoarthritis and the more severe the degree of varus deformity.

Leprosy is a chronic infectious peripheral neuropathy caused by Mycobacterium leprae. In this case, we report a case of a patient that was submitted to left ulnar nerve decompression at elbow, left common peroneal release at the fibular head and left posterior tibial nerve release in order to relief neurophatic pain and avoid deformities.

Aneurysmal bone cysts (ABCs) are benign but locally destructive, blood filled reactive lesions of the bone. Although a wider age group may be affected, most commonly they are seen in patients younger than 20 years of age, with a slight female preponderance. Most common sites include metaphysis of femur followed by tibia and then humerus. Vertebral lesions involving the posterior elements are common. Aneurysmal bone cyst of proximal fibula is a rare and uncommon. Here, we report a case of 32 year old male with classic histologic, clinical, and radiographic findings that was treated by en bloc resection.

Bilateral proximal fibular head prominence is a rare case of chronic knee pain and can befound in isolation or as a part of multiple ligamentous or bony knee injuries. There is prominence of proximal fibula on clinical examination with tenderness on palpation. Radiological investigation can confirm the diagnosis;in the case of our patient, both plain radiograph and MRI magnetic resonance imaging (MRI) were performed. MRI helps in the assessment of the intrinsic knee ligament, as well as the course of common peroneal nerve. The prominent proximal fibular head excision was performed successfully under general anaesthesia in different sittings.

Popliteal artery injury is a rare but devastating complication of open-wedge high tibial osteotomy (OWHTO). The objectives of this study were: to document the location of the artery in the virtual osteotomy plane (VOP), to measure the minimal distance between the popliteal artery and three virtual saw-progression lines (VSLs), and to present a safe sawing technique for OWHTO. In total, 45 computed tomography angiographies were reconstructed and virtual osteotomy was simulated using 3D image-processing software. The VOP was defined as an inclined plane commencing 3.5 cm below the articular plane towards the fibular head. VSLs were defined as saw-progression guidelines that lie on the VOP: “VSL-mid” runs from the midpoint of the tibial medial cortex towards the fibular head; “VSL-ant” starts from the same point as VSL-mid, but runs 10° anterior to the fibular head; and “VSL-post” runs 10° posterior to the fibular head. The distances between the popliteal artery and the three VSLs were measured, and the risk of injury was assessed. The popliteal artery was located 20.7° posterior to VSL-mid and 51 mm from the starting point. The minimum distance between the popliteal artery and VSL-mid was 18 mm (99% confidence interval 9–27 mm). When the saw was moved along VSL-mid, 42% of the arteries were susceptible to injury. However, when it followed VSL-ant, there was no risk of injury. Sawing toward the fibular head carries a risk of popliteal artery injury and should not be performed. When sawing in OWHTO, the recommended target should be 10° anterior to the fibular head. This technique eliminates the risk of popliteal artery injury.

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.

There is a tendency of orthopaedic surgeons to elevate joint line (JL) in revision total knee arthroplasty (RTKA). Here, we ascertain the use of the spacer block tool (SBT) to determine JL more accurately for less experienced RTKA surgeons. To perform more precise restoration of JL, an SBT with markers was developed and produced using computer software and three-dimensional printers. The study was planned prospectively to include patients who received either condylar constrained or rotating hinge RTKA between January 2016 and December 2019. To determine JL, distance from fibular head (FH), adductor tubercle (AT), and medial epicondyle (ME) were measured on contralateral knee preoperative radiographs and on operated knee postoperative radiographs. Patients were randomized and grouped according to the technique of JL reconstruction. In Group 1, conventional methods by evaluating aforementioned landmarks and preoperative contralateral knee measurements were used to determine JL, whereas in Group 2, the SBT was used. The main outcome measure was the JL change in revised knee postoperatively in contrast to contralateral knee to compare effective restoration of JL between the groups. Twenty-five patients in Group 1 (3 males, 22 females, 72 years, body mass index [BMI] 32.04 ± 4.45) and 20 patients (7 males, 13 females, 74 years, BMI 30.12 ± 5.02) in Group 2 were included in the study. JL measurements for the whole group were FH-JL = 18.3 ± 3.8 mm, AT-JL = 45.8 ± 4.6 mm, and ME-JL = 27.1 ± 2.8 mm preoperatively, and FH-JL = 20.7 ± 4.2 mm, AT-JL = 43.4 ± 5.2 mm, and ME-JL = 24.7 ± 3.1 mm postoperatively. JL level differences in reference to FH, AT, and ME in Group 1 were 3.6 ± 3.1, 3.6 ± 3.5, and 3.4 ± 3.1 mm, respectively, and in Group 2 were 1.0 ± .0.9, 1.3 ± 1.3, and 1.1 ± 1.3 mm, respectively. There were statistically significant differences between the two groups in JL changes referenced to all of the specific landmarks (p

Background. About 1/3 of tibial plateau fractures are associated with proximal fibula fractures, but most proximal fibula fractures are often ignored. The aim of this study was to precisely explain the classification and treatment strategies of six injury types of the fibular column associated with tibial plateau fractures. Methods. Patients with ipsilateral proximal fibula and tibial plateau fractures treated in our hospital were retrospectively reviewed from Aug 2007 to Mar 2020. Two experienced surgeons and two radiologists divided fibular column injury into 6 injury types according to the AO classification and four-column nine-segment classification. The treatment scheme (surgically treated or conservatively treated) was also recorded. Results. In total, 355 proximal fibula fractures were included. Type 2 fibular head fracture was the most common type of injury in 122, and the segregate of superior tibiofibular syndesmosis was the rarest type in 3. In avulsion injury proximal of fibular pattern, the proportion of patients who need surgical intervention is the highest. Conclusions. Six injury types in the four-column nine-segment classification covered all types of bony and soft tissue injuries of the fibular column and concisely explained the injury mechanism. The classification is helpful for the precise judgement and decision-making of the concomitant fibular column injuries in tibial plateau fractures.

Case. A 62-year-old man presented with persistent lateral knee pain 15 months following an uncomplicated total knee arthroplasty. There was a tendinous snapping structure over the lateral aspect of the knee in deep flexion with positive Tinel’s sign over the fibular head. The patient underwent an uncomplicated flabella excision. The patient was cleared to return to work and full duty at two months postoperatively. Conclusion. Flabella syndrome is a rare but increasingly common mechanism of persistent lateral knee pain following total knee arthroplasty. Surgeons should be aware of this etiology of persistent lateral knee pain and offer treatment modalities to address this pathology.

Common peroneal neuropathy is the most common compressive neuropathy in the lower extremities. The anatomical relationship of the fibular head with the peroneal nerve explains entrapment in this location. We report the case of a 14-year-old boy admitted with a left foot drop. The diagnosis was an osteochondroma of the proximal fibula compressing the common peroneal nerve. The patient underwent surgical decompression of the nerve and resection of the exostosis. Three months postoperatively, there was a complete recovery of the deficits. The association of osteochondroma and peroneal nerve palsy is rare. Early diagnosis is required in order to adjust the management and improve the results. It is worth to underscore that surgical resection is proven to be the appropriate treatment method ensuring high success rates.

The anterior tibial artery (ATA) is the most critical anatomical structure at risk at the distal border of the posterolateral approach to the tibial plateau. This study aimed to use available lower extremity digital subtraction angiography (DSA) images to determine the distal safe limit of this approach by measuring the distance from the tibial joint line to the ATA where it pierces the interosseous membrane. Tibial plateau mediolateral width (TP-ML-W) and the perpendicular distances from the ATA to the tibial joint line and fibular head were measured on DSA images in 219 lower extremities. To normalize the distances according to the tibial dimensions, each distance was divided by the TP-ML-W, and a ratio was obtained. Popliteal artery branching pattern was categorized according to the classification proposed by Kim et al. Comparative analysis between right and left extremities, genders, and anatomical variations were performed. There were 102 male and 26 female subjects with a mean age of 60.7 ± 15.7 years (range, 17–92 years). Ninety-one subjects had bilateral lower extremity DSA; thus, a total of 219 extremities were analyzed. The TP-ML-W was wider in male (78.3 ± 7.0) than female (70.5 ± 7.3) subjects (p = 0.001). The ATA coursed through the interosseous membrane at 50.9 ± 6.9 mm (range, 37.4–70.2 mm) distal to the tibial plateau joint line, and it was 66.5 ± 7.2% of the TP-ML-W. The ATA coursed through the interosseous membrane at 36.5 ± 6.0 mm (range, 21.9–53.8 mm) distal to the fibular head, and it was 47.7 ± 6.6% of the TP-ML-W. All measured variables were similar between the regular branching pattern of the popliteal artery (type 1A) and other observed variations among male subjects. The safe length of dissection in the posterolateral approach is average 66.5% (range, 45.7–86.7%) of the TP-ML-W. This ratio is valid for both genders. The use of a ratio instead of a distance, which is subject to personal variations, seems to be more logical and practical for planning this surgery, but the wide range should still not be ignored.

The aims of this study were (1) to collect prospectively all tibial plateau fractures admitted to our department, over two ski seasons, and to classify them according to the Schatzker and AO classifications; (2) to assess if these classifications are accurate enough to include all types of fractures; and (3) to compare theses fractures with the series found in the literature, which included very few or no skiing accidents. During the 2016-2017 and 2017-2018 ski seasons, we prospectively included 116 tibial plateau fractures caused by downhill skiing accidents. All patients underwent standard X-rays and 2D and 3D CT scans. The fractures were classified according to the AO and Schatzker revisited classifications. The full series consisted of 56 males (48%) and 60 females (52%), aged 49 ± 16 years (18-77). There were 60 type B (52%) and 56 type C fractures (48%) for AO classification and 45.5% types I, II and III and 54.5% types IV, V and VI for Schatzker classification. Thirty-five frontal fractures (30%) were not differentiated under the AO classification and, likewise, associated tibial spine fractures (28.5%) were not differentiated in the Schatzker classification. We were also unable to classify anterior tibial tuberosity fractures (14.5%) and fibula head fractures (8%). The anatomo-pathological types were not so different from road traffic accidents. Contrary to our hypothesis, the anatomical-pathological damage in tibial plateau fractures resulting from downhill skiing accidents was barely any different from those found in road traffic accidents. However, despite progress in classifications with the emergence of 3D CT scans, it is still not always possible to categorise all fractures within a given classification.

Background This is an experimental study conducted to assess whether the fibular head is a reliable reference point to identify the position of the common peroneal nerve at the posterolateral corner of the knee. Materials and methods Twelve cadaveric knees were dissected through the lateral approach. The common peroneal nerve was identified and traced. The location where the common peroneal nerve crossed the posterior border of the biceps femoris and the posterior border of the fibular neck were designated as points B and N, respectively. The tip of the fibular head was designated F. Distances FB and FN were measured and the triangular area FBN was calculated at various degrees of knee flexion. Results During knee motion, distance FN showed minimal change and was not affected by variation in degrees of knee flexion (p = 0.131). Distance FB and distance BN were affected by variation in degrees of knee flexion (p 2 and subsequently decreased with further knee flexion. Conclusion The common peroneal nerve can consistently be found at approximately 20.7 ± 1 mm on the fibular neck with respect to the tip of the fibular head. The tip of the fibular head is a consistent landmark that can be used to predict the position of the exit point of the common peroneal nerve at the posterolateral corner of the knee.

The aim of the study was to evaluate the anatomical details of the articular branch of the peroneal nerve to the proximal tibiofibular joint and to project the height of its descent in relation to the fibular length. Twenty-five lower extremities were included in the study. Following identification of the common peroneal nerve, its course was traced to its division into the deep and superficial peroneal nerve. The articular branch was identified. The postero-lateral tip of the fibular head was marked and the interval from this landmark to the diversion of the articular branch was measured. The length of the fibula, as the interval between the postero-lateral tip of the fibular head and the tip of the lateral malleolus, was evaluated. The quotient of descending point of the articular branch in relation to the individual fibular length was calculated. The articular branch descended either from the common peroneal nerve or the deep peroneal nerve. The descending point was located at a mean height of 18.1 mm distal to the postero-lateral tip of the fibular head. Concerning the relation to the fibular length, this was at a mean of 5.1%, starting from the same reference point. The articular branch of the common peroneal nerve was located at a mean height of 18.1 mm distal to the the postero-lateral tip of the fibular head, respectively, at a mean of 5.1% of the whole fibular length starting from the same reference point. These details represent a convenient orientation during surgical treatment of intraneural ganglia of the common peroneal nerve, which may result directly from knee trauma and indirectly from ankle sprain.

Several surgical techniques have been described to treat posterolateral corner (PLC) injuries. These include advancement of the osseous attachment of the arquate ligament complex [1], proximal advancement of the posterolateral complex [2], biceps tenodesis [3], and tibial sling procedures [4]. More recently, in an attempt to address these injuries with a more anatomic perspective, other techniques have been described. Currently, the two more common groups of PLC reconstructions are considered those involving tunnels in the fibular head [5–7], and those combining this transfibular tunnel with a tibial sling [8, 9].

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.

Cevallos F, Rodriguez A, Montero M. Fibula head fracture: report of a case. Colombian Journal of Orthopedics and Traumatology, Bogota - Colombia, 2019. (in press)...

Background Foot drop can be caused by a variety of diseases and injuries. Although it is a common condition, its overall incidence has not been reported to date. Foot drop markedly restricts the everyday activities of persons suffering from it. There is, therefore, a need for an optimized strategy for its diagnosis and treatment that would be standardized across the medical specialties encountering patients with this problem. Methods This article consists of a review on the basis of pertinent publications re- trieved by a search in the Pubmed/MEDLINE and Cochrane databases, as well as a description of the authors' proposed strategy for the diagnosis and treatment of foot drop. Results Foot drop can be due to a disturbance at any central or peripheral location along the motor neural pathway that terminates in the dorsiflexor muscles of the foot, or at multiple locations in series. Optimal localization of the lesion(s) is a pre- requisite for appropriate treatment and a successful outcome. The most common causes are L5 radiculopathy and peroneal nerve injury. An operation by a neuro- surgeon or spinal surgeon is a reasonable option whenever there is a realistic chance that the nerve will recover. In our opinion, any patient with a subjectively disturbing foot drop and a clinically suspected compressive neuropathy of the peroneal nerve should be informed about the option of surgical decompression of the nerve at the fibular head, which can be performed with little risk. In case of a permanent foot drop, some patients can benefit from muscle-transfer surgery. For spastic foot drop, the option of botulinum toxin injections should be evaluated. Conclusion The care of patients with foot drop could be optimized by interdisciplin- ary foot-drop clinics involving all of the relevant specialists. The goals of treatment should always be improved mobility in everyday life and the prevention of falls, pain, and abnormal postures.

Highlights • Vascularized fibula could be used to reconstruct wide resected proximal humerus. • Peroneal artery pedicle ensure vascularization of harvested long graft. • Rehabilitation for either recipient or donor site is crucial., Introduction Giant cell tumor (GCT) is benign aggressive tumors with a high rate of recurrence and capacity to metastasize. Wide resection is the treatment of choice, but this creates a flaw at the proximal end of the humerus. There are various methods exist as the treatment option to fixed this problem. Presentation of case We here present our experience on wide resection and free vascularized autogenous fibula head grafting for GCT at the proximal humerus of a 32 years old male. We performed free vascularized fibular head graft (FVFHG) as a reconstruction method followed by sling procedure and used the long head of biceps tendon. Evaluation of anatomical, functional, and radiological outcomes of this management was performed. After 3 years, the patient has a good outcome. Discussion Free vascularized fibula graft is the most favored as a treatment after resection of a tumor on the proximal humerus. The advantages are can be harvested without many difficulties and rapid healing. In our case, we used a free vascularized fibular head graft (FVFHG) for proximal humerus reconstruction after resection giant cell tumor (GCT) on the right proximal humerus. We use the peroneal artery as vascular pedicle due to well vascularity to the peripheral part of fibula. There is no fibula head reabsorption after three years post-operation. Conclusion FVFHG for reconstruction modality as the treatment after resection of GCT grade Campanacci 3 on proximal humerus shows satisfactory result following long term evaluation.

WOS: 000470771800002, PubMed: 31363444, Proximal fibular osteotomy (PFO) is a simple, easy and cheap procedure consisting of removing a 10 mm piece of fibula 6 to 9 cm below the fibular head. Proximal osteotomy of the fibula weakens the lateral fibular support and leads to a correction of the varus deformity and provides a widening on the medial joint space. Unicondylar knee arthroplasty (UKA) is intended to treat isolated medial compartment arthritis. However, knees with a varus deformity and tight medial joint space might cause both technical difficulties and poorer outcomes. A 68-year-old female with complaints of pain on the medial side of both knees for more than two years underwent bilateral UKA. While inserting the trial meniscal bearing was not easy due to the varus tight knee, at that stage, instead of performing a deeper cut, a PFO procedure was considered which provided widening of the medial joint space. We report, to our knowledge, the first simultaneous application of these two procedures. Despite being a single case with very short term results, our results suggest that the combination of PFO and UKA may reduce the loads over the implants on the medial compartment based on the widening of the joint space and varus deformity correction.

Snapping biceps femoris tendon (BFT) over the fibular head is an uncommon cause of lateral knee pain. This study reports a case of nontraumatic painful snapping of the BFT due to a prominent fibular head that was persistent intraoperatively after fibular head resection. We describe a novel surgical technique of release of the anterior arm of the biceps tendon followed by soft tissue tenodesis to the popliteofibular ligament, as opposed to the remaining fibular head, to prevent iatrogenic fracture.

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.

Background: The conventional fibular composite flap with its various components tethered together is not maneuverable enough to cover the complex three dimensional defects. An in-depth anatomical study into the peroneal vascular system was performed to explore the possibility of harvesting various the fibular chimeric composite. Methods: 30 cadaveric lower extremities with perfusion of red latex in their arteries were used for this study. The fibular head and the lateral malleolus were used as the landmarks and the calf was divided into the upper, middle and lower segments, respectively. Dissection of the calves was carried out to investigate mainly the muscuo (septo) cutaneous perforators and periosteal branches given off from the peroneal artery. Results: An average of 4.8±0.9 cutaneous perforators was given off from the peroneal artery to nourish the lateral aspect of the lower leg. An average number of 4.7±1.3 periosteal branches were given off from the peroneal artery to the surface of the fibula. In 40% of the cases, a periosteal branch to the tibia with an external diameter of about 0.8 mm was found to originate from the peroneal artery. In 60% of cases, 2 to 3 periosteal branches with an external diameter of about 0.6 mm were found to originate from the peroneal artery. Several patterns of the chimeric fibular composite flap can be harvested based on the peroneal artery. Conclusions: It is anatomically practical to harvest various patterns of chimeric fibular composite flaps based on the peroneal artery to reconstruct three-dimensional complex defects.

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.

Tuberculous osteomyelitis of long tubular bone is uncommon, the reported incidence is about 2-3 %. Tuberculous osteomyelitis of fibular head is very rare and it mimics neoplasm. Here we report a case of a 28 year old male presenting with unremitting right knee pain with swelling around fibular head with knee radiography showing lytic lesion of proximal fibula,excisional biopsy was done and histopathological report confirmed it as tuberculous osteomyelitis. Journal of Society of Surgeons of Nepal, 2015; 18 (2), page: 33-35

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 femoral attachment of the anterolateral ligament (ALL) of the knee is still under debate, but the tibial attachment is consistently between Gerdy's tubercle and the fibular head. The structure is less identifiable and more variable in younger patients. The ALL likely plays a role in rotational stability, but its impact on anterior stability is less clear. Numerous ALL reconstruction techniques have been described. Biomechanical analysis of these techniques has not shown clear benefits, but this literature is limited by the heterogeneity of techniques, graft choices, and study methodology. Clinical studies of combined anterior cruciate ligament (ACL) and ALL reconstruction are few but promising in lowering the risk of an ACL reinjury. To our knowledge, there are no studies showing the clinical outcomes of combined ACL and ALL reconstruction in pediatric patients, who are at higher risk for ACL graft failure than adults.

Bolat, Necdet/0000-0003-2427-5351; Turker, Hande/0000-0002-8124-6074 WOS: 000452890300006 PubMed: 30541235 Background/aim: Peroneal neuropathy at the fibular head (PNFH) is one of the most common entrapment neuropathies. Our aim in this study was to analyze the efficiency of ultrasonography in the diagnosis of PNFH. Materials and methods: The study included 15 peroneal nerves of 12 patients with PNFH and 24 peroneal nerves of 12 healthy controls. PNFH confirmation was based on clinical and electrophysiological findings. All patients and controls underwent ultrasonographic evaluations for peroneal nerves. The cross-sectional area (CSA) was measured. Echogenicity of the nerve was evaluated by comparing it with the adjacent connective tissue deep under the subcutaneous fat. Results: CSA measurement of the peroneal nerve is a valuable diagnostic tool in predicting PNFH (AUC: 0.87, 95% CI: 0.73-1.00, P < 0.01). the CSA cutoff value for diagnosing PNFH was found to be 0.115 cm(2) with 80% sensitivity and 99% specificity. Hypocchoic peroneal nerve in patients with PNFH was very frequent. Conclusion: Ultrasonography is a useful technique in diagnosing PNFH. In addition to clinic and electrophysiological findings, it may improve diagnostic performance.

A 23-year-old male active duty soldier presented with a biceps femoris tendon snapping over the fibular head with flexion of the knee beyond 90°. Surgical release of anomalous anterolateral tibial and lateral fibular insertions provided relief of snapping with no other repair or reconstruction required. The soldier quickly returned to full running and active duty. Snapping biceps femoris tendon is a rare but potential cause of pain and dysfunction in the lateral knee. The possible anatomical variations and the cause of snapping must be considered when determining the operative approaches to this condition.

Introduction Ultrasound (US) evaluation of peripheral nerves is a noninvasive, cost-effective approach to diagnosing focal mononeuropathies and guiding surgical management. We used the intranerve ratio to evaluate for possible cut-off values in diagnosis of fibular mononeuropathies (FNs). Methods A retrospective analysis of FN confirmed by electrodiagnosis (EDx) was performed to identify intranerve ratio values between affected and unaffected limbs at the fibular head and popliteal fossa. Results The optimal fibular head/popliteal fossa intranerve ratio to discriminate between limbs with and without disease was 1.25 (sensitivity, 51%; specificity, 71%). There was no statistically significant difference between affected vs unaffected limbs (ratio, 1.13; P = .15) nor in subgroup analyses. However, 25% of patients had structural lesions amenable to surgery. Discussion The utility of US in diagnosis of FN is limited using intranerve ratio data, but US has a distinct advantage over EDx for identifying treatable structural lesions.

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.

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 eight posterolateral reconstruction using free grafts. Each of these techniques is combined with capsular repair and/or posterolateral capsular shift 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.

Originally described in the 1970s, vascularized bone grafting has become a critical component in the treatment of bony defects and non-unions. Although well established in the lower extremity, recent years have seen many novel techniques described to treat a variety of challenging upper extremity pathologies. Here the authors review the use of different techniques of vascularized bone grafts for the upper extremity bone pathologies. The vascularized fibula remains the gold standard for the treatment of large bone defects of the humerus and forearm, while also playing a role in carpal reconstruction; however, two other important options for larger defects include the vascularized scapula graft and the Capanna technique. Smaller upper extremity bone defects and non-unions can be treated with the medial femoral condyle (MFC) free flap or a vascularized rib transfer. In carpal non-unions, both pedicled distal radius flaps and free MFC flaps are viable options. Finally, in skeletally immature patients, vascularized fibular head epiphyseal transfer can provide growth potential in addition to skeletal reconstruction.

Reconstructing the natural joint line in knee revision surgery improves clinical and functional outcome but may be challenging when both cartilage and bone were removed during previous operations. Assessing joint lines (JLs) by means of bony landmarks is inadvisable because of large variations in human anatomy. Because of the inherent symmetry of the human body, we hypothesised that JLs may be directly assessed by measuring the distances from the bony landmarks to the JL of the contralateral knee by means of radiographic images. Using scaled weight-bearing radiographs in anteroposterior view of both knees, two independent observers measured the distances from the fibular head, the medial and lateral epicondyle, and the adductor tubercle to the JL. A two-sided p value of ≤0.05 was considered statistically significant. Two hundred knees of 100 patients (50 men and 50 women) were examined. For the fibular head, the mean difference between the treated and the control knee was 0.0 mm with narrow confidence limits ranging from −1.1 to 1.1. As a new assessment method, we have suggested to assess the JL by means of radiographs of the contralateral knee. The most precise parameter was found to be the distance between the fibular head and the JL. The level of arthritis, age, gender, visibility of the landmarks, and misalignment did not influence measurement accuracy. This parameter is the first tibia-related landmark for assessing the JL, which advantageously corresponds to the tibia-first technique in revision surgery. Diagnostic Study, Level II.

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.

Case Pediatric posttraumatic tibiofibular synostosis (PPTFS) is a rare postfracture complication that often leads to growth abnormalities. There are very few reports demonstrating the long-term efficacy of surgical treatment. An 11-year-old boy with PPTFS displayed progressive prominence of the fibular head and shortening of the lateral malleolus subsequent to a fracture suffered at the age of 5 years. He was treated by synostosis resection and a peroneal artery perforator adipofascial flap. Eight years postoperatively, the synostosis had not recurred, and his earlier growth abnormalities were nearly normal. Conclusions Peroneal artery perforator adipofascial flap is effective for pregrowth spurt PPTFS.

Introduction In 30% of patients with common fibular (CF) neuropathy at the fibular head, reliable localization of the site of the lesion by means of electrodiagnostic testing is challenging. Methods We prospectively assessed proximal CF nerve cross-sectional area (CSA) measurements and at the fibular head in 87 patients with CF neuropathy and 16 with a different condition. Reference values were obtained in 64 healthy volunteers. Results Patients with CF neuropathy had a significantly larger CF nerve CSA than controls and patient controls (P 8 mm2 with a sensitivity of 90% (CI 81–95%) and a specificity of 69% (CI 58–78%). Conclusion High-resolution sonography in addition to electrodiagnostic testing improves diagnostic reliability in CF neuropathy. Muscle Nerve, 48: 171–178, 2013

The pivot-shift test is the most specific physical exam to detect the ACL insufficiency and the only manual test capable to predict the knee function and the development of osteoarthrosis after an ACL reconstruction. However, the lack of a standardized maneuver for the pivot-shift test makes the interpretation subjective and dependent on examiner’s experience.

A 25 year old woman presents with transient tingling in both hands after prolonged writing. She had an episode of left foot drop at the age of 24 without a clear cause. Nerve conduction studies reveal bilateral median and ulnar neuropathy and compression of the left peroneal nerve at the fibular head. Genetic testing reveals chromosome 17 deletion confirming the diagnosis of Hereditary neuropathy with liability to pressure palsy.

To clarify the fibular head insertion of the fibular collateral ligament (FCL), popliteofibular ligament (PFL), and biceps femoris tendon and related osseous landmarks on three-dimensional (3-D) images. Twenty-one non-paired, formalin-fixed human cadaveric knees were evaluated in this study. The fibular head insertions of the FCL, PFL and biceps femoris tendon were identified and marked. 3-D images were created, and the surface area, location, positional relationships, and morphology of the fibular insertions of the FCL, PFL, and biceps femoris tendon and related osseous structures were analysed. The fibular head had a unique pyramidal shape, and the relationships of the fibular insertion of the FCL, PFL, and biceps femoris tendon were consistent. The fibular head consists of three aspects: lateral aspect, posterior aspect, and proximal tibiofibular facet. The insertions of the FCL, PFL, and biceps femoris tendon were attached to the centre from the distal side of the lateral aspects of the fibular head, posterior aspect of the fibular styloid process, and lateral aspect surrounding the FCL, respectively. The mean surface areas of the FCL and PFL fibular insertions were 100.1 ± 29.5 and 18.5 ± 7.2 mm2, respectively. This study showed that the relationships between the characteristic features of the fibular head and insertions of the FCL, PFL, and biceps femoris tendon were consistent. The clinical relevance of this study is that it improves understanding of the anatomy of the insertions of the PLC and biceps femoris tendon.