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Introduction: Dissociation of the knee joint, or knee dislocations (KD), can lead to severe complications, often resulting in multiligament injuries. A subset of these injuries are irreducible by closed reduction and require open reduction. Identifying KDs that necessitate surgical intervention is crucial for optimal outcomes. While previous studies have explored various risk factors, the influence of associated fractures is less understood. Materials and Methods: We queried the Trauma Quality Improvement Program (TQIP) database from 2017 to 2021, for non-congenital closed knee dislocations requiring surgery. Demographic variables were collected, and ICD-10 codes were used to identify associated tibia, femur, acetabular, and fibula fractures. ICD-10 codes were also used to identify nerve injuries and vascular injuries. Multivariate logistic regression was used to assess factors influencing the need for surgical reduction (SR). Results: A total of 1,467 patients with KDs were included in the study, of which 411 (28.0%) underwent open surgical reduction (SR) while 1,056 (72.0%) were treated with nonsurgical closed reduction (nSR). Factors associated with SR included concomitant tibia fracture (OR = 1.683, C.I: 1.255-2.256, p < 0.001) and fibula fracture (OR = 1.457, C.I: 1.056-2.011, p = 0.022). Vascular injury had lower odds of SR (OR = 0.455, C.I: 0.292-0.708, p < 0.001). Conclusion: Our study demonstrated that KDs presenting with concomitant tibia and/or fibula fractures are more likely to require SR. The difficulty posed to closed reduction may be due to the influence of these fracture patterns on surrounding soft tissue as well as the lack of a stable bone structure necessary for achieving proper reduction. Physicians should be aware of the potential risk of this fracture pattern when caring for patients with KDs. [ABSTRACT FROM AUTHOR]

Background: The two‐staged prefabricated vascularized fibula free flap is used in maxillofacial reconstruction. We describe the possible cause and management of two cases of fibula fracture after implant placement. Methods: The patients were treated with two‐stage reconstruction with a prefabricated vascularized fibula free flap. Six dental implants were placed in both fibulas. Fibula fractures occurred during the osseointegration period before the second procedure. The reconstruction was continued as planned. Results: Both fibulas fractured in the distal segment, possibly due to a thinner cortex more distally. Harvesting of a fractured fibula flap is more difficult than normally due to callus formation and fibrosis. Both transplants became fully functional with extended healing and additional surgery. Conclusion: The fracture apparently did not compromise the vascularisation of the fibula and proved still sufficient for successful harvest and transfer of the flap. The patient should be made aware that additional corrective surgery may be indicated. [ABSTRACT FROM AUTHOR]

Objective The management of distal third tibial fractures remain controversial. The aim of the present study was to evaluate whether concurrent fibular fixation changes union rates and aids in alignment in the case of distal third tibia fractures. Material and Method The study included 106 distal third tibia fracture operation cases in which the distance from the fracture to the plafond was between 3-12 cm at a single centre between January 2016 and June 2020. The patients were divided into three groups according to the status of the fibula: Group 1 (without fibular fixation with the presence of a fibula fracture, 47 cases), Group 2 (concurrent fibular fixation with the presence of a fibular fracture, 38 cases) and Group 3 (intact fibula, 21 cases). All fibular fixation surgeries were performed with locked plates (LCP) and tibial fixation with either LCP or intramedullary nailing (IMN). The primary outcome measures were union and alignment. Age, gender, AO classification, fibula fracture location, presence of an open fracture, implant type and time delay for surgery were also assessed. Results None of the variables except the presence of an open fracture was significant for the union rates or alignment. The union rate was significantly less if there was an open fracture in the concurrent fibular fixation group (p<0.001). Closed fractures were associated with better union rates according to the logistic regression analysis (OR=5,00 (%95 CI 2,24-11,48). Conclusion The present study suggests that a concurrent fibular fixation in the case of distal third tibia fractures improves neither the union rates nor the alignment. Therefore, we conclude that a fibular fixation is not a necessity in achieving better results and should not be performed in case of an open fracture considering the lesser union rate and the burden involved with an additional surgery. [ABSTRACT FROM AUTHOR]

Surgical treatment of lateral distal fibula fractures is associated with high risk of reoperation and complications. The primary aim was to report risks of surgical site infection (SSI) and reoperation ≤1 year after treatment with one-third tubular plate, locking compression plate (LCP) or distal anatomical LCP. Secondary to investigate associations between patient, fracture and operative factors and risk of SSI and reoperation. Retrospectively, we evaluated a consecutive cohort of 588 patients having osteosynthesis of distal fibula with a one-third tubular plate (n = 417), LCP (n = 115) or distal anatomical LCP plate (n = 56) at Bispebjerg Hospital, Denmark from January 2010 to December 2015 with 1-year follow-up. The risk of SSI was 15% (95% confidence interval [CI] 12-18) after treatment with one-third tubular plate, 30% (95% CI 23-39) after LCP and 41% (95% CI 29-54) after distal anatomical LCP. We found a significant association of SSI and LCP (p =.005) and distal anatomical LCP (p <.001). Other factors associated with increased risk of SSI were age>70 years (p <.001), smoking (p =.004), DM (p =.007), surgery time ≥90 minutes (p =.006) and surgery delay of 3-6 days (p =.007). The risk of reoperation ≤1 year was 10% (95% CI 6-11) for one-third tubular plate, 21% (95% CI 14-29) for LCP and 25% (95% CI 16-38) for distal anatomical LCP. We found a significant association between distal anatomical LCP and risk of reoperation (p =.008). The only other risk factor associated with risk of reoperation was surgery delay of more than 7 days (p =.004). We conclude that LCP plate and the distal anatomical LCP plate should only be used after careful considerations. [ABSTRACT FROM AUTHOR]

The article presents the discussion on highlighting the importance of surgical restoration of fibular length, rotation, and alignment. Topics include geriatric ankle fractures presenting specific challenges for surgical management due to an overall decrease in bone density and an overall increase in postoperative wound complications; and releasing the stress otherwise applied by the reduction clamp on the osteoporotic bone during the reduction.

Background: Isolated Weber B, AO (Association for the Study of Internal Fixation) type 44B ankle fractures with no fracture to the medial side are the most common type of ankle fracture and may be treated with internal fixation or without surgery. This study aimed to determine if surgery is superior to nonsurgical management for the treatment of these fractures after a minimum 5-year follow-up. Methods: Design: A pragmatic, multicenter, single-masked, randomized controlled trial with minimum 5-year follow-up. Setting/participants/interventions : Participants between 18 and 65 years with AO type 44B ankle fracture and minimal talar shift were recruited from 22 hospitals in Australia and New Zealand. Participants willing to be randomized were randomly allocated to undergo surgical fixation followed by mobilization in a walking boot for 6 weeks. Those treated nonsurgically were managed in a walking boot for 6 weeks. Outcome assessors were masked for the treatment allocation. Primary outcomes : Patient-reported ankle function using the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Questionnaire (FAOQ) and the physical component summary (PCS) of the SF-12v2 General Health Survey at 12 months postinjury and at minimum 5 years post injury. Primary analysis was intention-to-treat. Results: Of the 160 (80 surgical, 80 nonoperative) randomized patients included in the CROSSBAT analysis, 77 (40 surgical, 37 nonoperative) were followed up for repeat analysis at minimum 5-year follow-up (mean 7.3 years, range 5.1-8.9). This cohort demonstrated that surgery was not associated with clinically or statistically significant differences compared to nonoperative management for the FAOQ (51.7 vs 49.6; mean difference 2.1, 95% CI –2.1 to 6.2, P =.95), or the PCS (51.5 vs 49.1; mean difference 2.3, 95% CI –2.0 to 6.7, P =.54). The surgical cohort had a higher rate of any adverse events (odds ratio 3.7, 95% CI 1.2-11.6, P =.04). Conclusion: The results of this study suggest that surgical management is not superior to nonsurgical management in type B ankle (fibula) fractures with minimal talar shift over a 5-year period and is associated with increased adverse events. Level of Evidence: Level II, randomized clinical trial. [ABSTRACT FROM AUTHOR]

Objective. The purpose of this preliminary study is to investigate whether the use of a carbon plate fixation system for distal fibula fracture, applied to an intensive rehabilitation protocol, is a good method to accelerate the return to play of professional athletes. Methods. This is a longitudinal case series with 6 months of total follow-up. Athletes of various sports, each with a minimum Tegner's activity score of 7, who underwent fibular ORIF with carbon fiber plates in our institute for Weber B fracture were considered. The primary outcomes were: return to play (RTP) at the previous level, radiological union, and the complication rate (nonunion, hardware failure, and infection). Secondary outcomes were the AOFAS score, VAS on everyday activities and VAS after sport tested at 1, 2, 3, and 6 months. Results. Considering primary outcomes, the mean RTP measured was 75.64 days ± 10.96; for the union rate 3 patients satisfied union criteria at 1 month follow-up, 7 at 2 months, and 4 at 3 months. No complication occurred during follow-up. Conclusions. The improved elastic compatibility of the carbon plate, with respect to the bone, allows for an "extended" safety zone to accelerate the patient's rehabilitation and return to a pre-injury athletic level. [ABSTRACT FROM AUTHOR]

Purpose: There is currently no consensus regarding the need for fixation of concomitant fibula fractures in patients with surgically treated distal tibia fracture. Although studies have shown it to be beneficial for fractures involving the syndesmosis, it remains unclear for suprasyndesmotic fractures. This study evaluates what effect the fixation of such suprasyndesmotic fibula fractures had on patients who underwent fixation of distal tibia fractures. Methods: This retrospective cohort study included all consecutive adult patients who received surgical treatment for an extra-articular or simple intraarticular distal tibia fracture between 2012 and 2020 and had a concomitant fibula fracture proximal to the syndesmosis. Two groups were formed depending on whether the fibula was stabilized. The need for revision surgery, the occurrence of complications, fracture healing, rotational and angular malalignment were evaluated for both groups. Results: This study included 120 patients, of which 40 (33.3%) had operative treatment of the fibula fracture. Of those with stabilized fibula fractures, 28 (70%) were treated with a plate and 12 (30%) with a titanium elastic nail. The group of patients with surgically treated fibula fractures had significantly more angular malalignments (10% vs 1.2%, p = 0.042), while there was no difference regarding rotational malalignment or fracture healing. Further, infections of the fibular surgical site occurred in 15% of surgically treated patients leading to significantly more revision surgeries in this group (40% vs 20%, p = 0.03). All infections occurred when a plate was used. Conclusion: This study was unable to show any benefit from stabilizing concomitant, suprasyndesmotic fibula fractures in surgically treated distal tibia fractures. On the contrary, infection, revision surgery and angular malalignment were more frequent when the fibula was fixed. Therefore, such concomitant fibula fractures should not routinely be fixed and if stabilization is deemed necessary, the implant should be chosen carefully. [ABSTRACT FROM AUTHOR]

Chondroma is a benign tumor formation that occurs through the proliferation of cartilaginous tissue. It can be located centrally (enchondroma) or peripherally, often appears between 10-30 years of age, and is commonly discovered incidentally. This case report describes a 46-year-old woman presenting with pain in the left calf and partial functional impotence. The onset of her symptoms was affirmatively marked by a mild skiing-related trauma. Following protocol, X-ray imaging (antero-posterior and lateral views) of the calf was performed, with the only finding being a solitary bony lesion, with internal calcifications, sclerotic margin and radiolucent internal matrix. Facing the uncertainty of diagnosis from a clinical and radiographic standpoint, it was decided to admit the patient for further evaluation and start the standard protocol of imaging investigations - computed tomography, magnetic resonance imaging, and bone scintigraphy - and determine the subsequent therapeutic behavior. Differential diagnosis between enchondroma and low-grade chondrosarcoma can be difficult due to their histopathological similarity. The therapy of choice in enchondroma comprises non-surgical treatment (observation) if the lesion remains unaltered in imaging, or curettage/filling with bone substitutes/allografts, but considering the advanced age and interruption of the bone cortex in our case, we opted for curative surgical treatment., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Ethics Committee of University Emergency Hospital Bucharest issued approval no. 40570. The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of University Emergency Hospital Bucharest (no. 40570). Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Costache et al.)

Pilon fractures are intra-articular injuries involving the tibial plafond and have a wide range of complexity. The timing and type of fixation in these injuries is dictated by soft tissue status and energy imparted to the distal tibial plafond. We had a unique clinical situation in which axial loading of the talus caused severe comminution of the tibial plafond and fracture of the distal third of the fibula. Further action of these forces caused displacement of the fibular segment into dorsum of the foot along with part of the articular surface of the tibial plafond without causing any external wound. This case was challenging because displacement of the distal fibula resulted in disruption of important syndesmotic and lateral ankle ligaments. Fibular segment was without any soft tissue attachment and was reimplanted in the ankle mortise like a free fibula graft. Near normal ankle biomechanics were achieved in this case through anatomic reduction of the articular surface, reimplantation of the fibula in the ankle mortise, and repair of syndesmotic and lateral ankle ligaments. There was satisfactory clinical and radiological outcome on follow-up of more than 4 years. To our knowledge, this is the only case in Standard English literature where in the case of pilon fracture, the fibula had displaced in the foot without external wound. [ABSTRACT FROM AUTHOR]

Background: Distal fibular fractures are extremely common, yet there remains controversy about which type of plating technique is the most appropriate. We aimed to compare clinical and biomechanical outcomes following posterior antiglide plating and lateral neutralization plating for Weber B distal fibular fractures. Methods: A systematic review and meta-analysis of the literature was conducted by two independent reviewers according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included all comparative studies of distal fibular fracture fixation with either a posterior antiglide plate or a lateral neutralization plate. Our primary outcome of interest was reoperation for hardware removal. Secondary outcomes included hardware discomfort, peroneal tendon irritation, infection, wound complications, and mechanical torque to failure. Results: A total of 1122 patients with Weber B ankle fractures were included across nine eligible clinical studies, and 76 cadaveric ankles were subject to testing across three eligible biomechanical studies. Meta-analyses revealed a two-fold greater odds of requiring removal of hardware in the lateral plating group compared to the posterior plating group (odds ratio [OR] 2.48, 95% CI 1.58 to 3.91, P <.0001), and a three-fold greater odds of experiencing hardware discomfort in the lateral plating group compared to the posterior plating group (OR 2.96, 95% CI 1.83 to 4.80, P <.0001). There were no significant differences in rates of peroneal tendon irritation, infection, wound complications, operative time, and torque to failure when comparing the two plating methods. Conclusion: The results of this review indicate that using posterior antiglide plating for distal fibular Weber B–type fractures is associated with significantly fewer reoperations due to hardware complications and less hardware discomfort compared to lateral neutralization plating. This technique does not appear to increase the risk of peroneal tendon irritation or increase operative time. [ABSTRACT FROM AUTHOR]

Locking plates were initially designed to provide improved stability to ankle fractures with poor bone quality but are currently widely used. The aim of this study was to compare the reoperation risk when using locking plates compared with nonlocking plates in patients with simple ankle fractures. This study was a population-based register study. Data regarding patients with AO type 44A1/2 and 44B1/2 injuries who were treated with either locking or nonlocking plates were obtained from the Danish Fracture Database. The follow-up period was 24 months. Major complications were defined as complications requiring surgical intervention, with the exception of simple hardware removal 6 weeks after primary surgery, which was defined as a minor complication. Multivariate regression analysis was performed to determine relative risk (RR), adjusted for age, sex, American Society of Anesthesiologists physical status classification (ASA)-score, and level of the surgeon's experience. A total of 2177 ankle fractures were included, among which 718 (33%) were treated with locking plates, and 1459 (67%) were treated with nonlocking plates. Data were linked with the Danish National Patient Registry to ensure complete information was obtained regarding reoperations, which were divided into major and minor complications. In both groups, the risks for major and minor complications were 3% and 22%, respectively, resulting in adjusted RRs of 1.00 (0.66; 1.66) for major reoperation comparing locking with nonlocking plates and 0.92 (0.76; 1.11) for minor reoperations. We conclude that no significant association with reoperation exists for locking compared with nonlocking plates among patients with surgically treated simple ankle fractures. [ABSTRACT FROM AUTHOR]

Purpose: Despite the fact that open reduction and internal fixation with a plate, either non-locked or locked, is the standard of care for managing lateral malleolus fractures, intramedullary (IM) fixation of the fibula has been recently introduced as an alternative, mainly for some potential complicated situations. We hypothesized that almost all patterns of distal fibula fracture can be safely fixed with an IM device, with the potential benefit of providing biomechanical efficiency, but using a soft-tissue friendly implant. Here, we present a multicenter case series based on a proposed algorithm. Patients and methods: Sixty-nine consecutive patients were managed with fibular IM fixation for closed malleolar fractures. Twenty patients were managed by IM screw fixation and 49 by fibular nailing. Outcome was measured both according to the American Orthopaedic Foot and Ankle Society (AOFAS) score for ankle and hindfoot, and the time to bone union. Results: The mean AOFAS for Group I was 99.35 ± 1.95 points and that for Group II was 89.30 ± 16.98 points. There were no significant differences between the fracture pattern, according to the Lauge-Hansen classification, and post-operative levels of pain and functional activity among patients in both groups (p > 0.05). All fractures healed uneventfully in both groups. The mean time to union for Group I was 8.15 weeks and for Group II was 8.25 weeks (p > 0.05). Conclusion: In this multicenter case series, intramedullary fixation for the lateral malleolus fracture presented itself as a viable and safe option for the treatment of almost all patterns of fibula fracture in adults. Overall, we were able to demonstrate the potential indications of the proposed algorithm for the choice of IM implant for the lateral malleolus fracture in terms of the Lauge-Hansen staged classification. [ABSTRACT FROM AUTHOR]

Abstract Background Minimally invasive plate osteosynthesis (MIPO) has been reported to be superior to open reduction and internal fixation (ORIF) in the treatment of different long bone fractures. Nevertheless, in distal fibula fractures, the evidence of MIPO remains scarce. The aim of this retrospective study was to compare the clinical and radiological outcomes of the minimally invasive techniques applied to the distal fibula with open reduction and internal fixation within a 12 months follow-up. Methods A consecutive series of patients who underwent surgery using either ORIF or MIPO for the treatment of distal fibula fractures between 2010 and 2014 were retrospectively analyzed. All distal fibular fractures requiring an operative treatment (Danis-Weber type B ≙ AO type 44 B1, 2, 3 and Danis-Weber type C ≙ AO type 44 C1, 2) were included (ORIF n = 35, MIPO n = 35). Patients were assessed for postoperative pain using a visual analog scale (VAS) for pain (ranging from 0 to 10) and classified into 4 groups: “no pain” for VAS = 0, “low” for VAS = 1–3, “moderate” for VAS = 3–5, and “severe” for VAS = 5–10. In addition, complications of postoperative fracture-related infection, wound healing disorders, vascular and nerve injury and development of nonunion were evaluated and analyzed. Radiologic outcome measures assessing the talocrural angle, lateral and medial clear space, tibiofibular overlap, and talar tilt angle were evaluated postoperatively. Results The overall complication rate showed to be lower in the MIPO group compared to the ORIF group (14% vs. 37%, p = 0.029). Even though not statistically significant, specific surgery-related complications such as skin necrosis (3% vs. 9%, p = 0.275), nonunion (0% vs. 6%, p = 0.139), infections and wound healing disorders (9% vs. 20%, p = 0.141), as well as postoperative pain (17% vs. 26%, p = 0.5) were found more frequently in the ORIF group. The tibiofibular overlap demonstrated to be significantly lower in the ORIF group (3.3 mm vs. 2.7 mm, p = 0.033). The talocrural angle, talar tilt angle, and lateral and medial clear space showed to be equivalent in both groups. Conclusion In this retrospective single-center consecutive series, MIPO was superior to ORIF in the surgical treatment of distal fibula fractures with respect to the overall complication rate. Trial registration EKNZ Project-ID: 2019-02310 , registered on the 20th of December 2019 with swissethics

Abstract Background The role of locking plate in lateral malleolar fracture fixation for the elderly remains unclear. The aim of our study is to compare radiological and functional outcomes in older patients (> 50 years) with AO/OTA 44B lateral malleolar fractures after locking plate (PLP) or one-third non-locking tubular plate (TP) lateral fixation. Methods We retrospectively reviewed the medical records of 72 patients (PLP group, 34 patients; TP group, 38 patients; mean age, 61.9 ± 7.6 years; range, 51–80 years; follow-up, 1 year). Patients with open fractures, syndesmosis injuries, and a previous ankle trauma or surgery were excluded. Demographic data, union rate, complications, radiographic outcomes, visual analog scale (VAS) scores, and foot and ankle outcome scores (FAOSs) between the groups were recorded and compared. We also investigated the association of clinical features with pain and function. Statistically, the Fisher’s exact test was used for categorical variables and the Mann-Whitney U test for the continuous variables. The final model for the multiple regression analysis was used to predict factors related to functional outcomes. Results There were no significant between-group differences in demographic data, complication rates, immediately postoperative distal fibula lengths, ankle osteoarthritis (OA) grades, talar tilt angles (TTAs) ≥ 2°, or reduction accuracy. All fractures achieved union. The PLP group had significantly lower rates of distal screw loosening, fibula shortening > 2 mm, OA grade progression, and TTAs ≥ 2°, and better FAOSs and VAS scores than was the case for the TP group after 1 year of follow-up (all p < 0.05). The severity of OA, TTA ≥ 2°, and distal screw loosening were positively associated with VAS scores, and negatively associated with FAOSs. Conclusions When treating AO/OTA 44B fractures in patients over 50 years of age, PLPs provided better VAS scores, FAOSs, and radiological outcomes, including less fibula shortening > 2 mm, less osteoarthritic (OA) ankle progression, less implant removal rate, and fewer TTAs ≥ 2° than was the case for TPs after a 1-year follow-up. Level of evidence Therapeutic level III

Abstract Background Open reduction and internal fixation remains the standard treatment for displaced unstable ankle fractures. Plate fixation represents the most frequently used instrumentation option in fibula fractures and favourable outcomes have been reported. Recently, intramedullary nailing techniques have been suggested as a viable alternative resulting in less soft tissue disruption. The objectives of this study are to describe the surgical technique and to evaluate the safety and efficacy of using an intramedullary nail in patients undergoing surgical fixation of their fibula fracture. Methods A total of 30 skeletally mature patients with unstable ankle fracture who underwent intramedullary fixation of their fibula fractures from February 2016 to July 2017 were included in this retrospective study. Patients were evaluated using the Short Form-36 (SF-36) and the American Orthopaedic Foot and Ankle Society (AOFAS) at 18 months after surgery. Results All patients went on to fracture union. Two patients required a secondary surgical procedure. No patient included in this series developed any wound complications. The mean Physical Component Summary (PCS) of the SF-36 was 53.90 ± 13.3 and the mean Mental Component Summary Score (MCS) was 52.63 ± 11.12. The AOFAS subscale scores were 34.67 ± 1.03 for pain, 42.40 ± 0.2997 for function and 9.50 ± 0.2785 for alignment. Conclusions Our study demonstrates promising outcomes associated with intramedullary nail fixation of unstable fibula fractures. We recommend intramedullary nail fixation of fibula fractures to be a safe procedure with a low complication rate. Level of evidence Level 4 retrospective case series.

Abstract Background Tricho-rhino-phalangeal syndrome (TRPS) is a rare autosomal dominant genetic disorder characterized by distinctive craniofacial and skeletal abnormalities, while non-ossifying fibroma (NOF) is a common benign bone tumour in children and adolescents. To date, no case of TRPS coexisting with NOF has been reported. This report presents a 12-year-old girl who had the characteristic features of tricho-rhino-phalangeal syndrome and non-ossifying fibroma with a fibula fracture. Case presentation A 12-year-old girl was admitted to the Department of Endocrinology and Diabetes for evaluation of brachydactyly and a right fibula fracture. Clinical examination revealed sparse scalp hair, a characteristic bulbous pear-shaped nose, and brachydactyly with significant shortening of the fourth metatarsal. Neither intellectual disability nor multiple exostoses were observed. Radiography of both hands showed brachydactyly and cone-shaped epiphyses of the middle phalanges of the digits of both hands with deviation of the phalangeal axis. Genetic analysis of TRPS1 identified a heterozygous germline sequence variant (p.Ala932Thr) in exon 6 in the girl and her father. Approximately 1 month before being admitted to our department, the girl experienced a minor fall and suffered a fracture of the proximal fibula in the right lower limb. The pathological cytological diagnosis of the osteolytic lesion was NOF. Ten months following the surgery, the lesion on the proximal fibula of the girl disappeared. Conclusions In conclusion, the present study is the first to report a rare case of NOF with a pathologic fracture in the fibula of a girl with TRPS. The identification of a missense mutation, (p.Ala932Thr), in exon 6 of TRPS1 in this kindred further suggested that the patient had type I TRPS and indicated that mutations in this exon may be correlated with more pronounced features of the syndrome. Radiological techniques and genetic analysis played key roles in the definitive diagnosis.

Ankle torque is the most frequent injury mechanism encountered in traumatology. It usually develops as an ankle sprain, and often produces an ankle fracture. Signs and symptoms are very unspecific on the differential diagnosis, and conventional radiographs must be obtained to confirm it. This study compares ultrasound and standard X-ray images values found in ankle sprain-related fracture diagnoses. A 3-month prospective study was carried out on 52 patients with ankle torque. First, an ultrasound diagnosis was made by the first researcher at their arrival to the emergency department, usually consisting of a longitudinal section of the fibula, tibia, and V metatarsal. Then, a blinded independent investigator carried out the usual diagnosis protocol using traditional radiographs. When the required number was obtained, a third independent investigator evaluated the results. A Chi-squared test was used to contrast the outcomes between sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) comparing a non-inferiority hypothesis of our protocol against standard X-ray images screening. Echography showed to be at least as good as standard radiographs on the screening of ankle torque-related fractures (p = 0.02). In our series of patients, nearly 8% of fractures are misdiagnosed with plain radiographies, which concurs with the lower limit found in the bibliography. All the false negatives on radiographs were true positives in the first ultrasound assessment. The average time for the ultrasound protocol was 42 s. An ultrasound is at least as effective as conventional X-ray images when used in diagnosing ankle sprain-related fractures, regardless of age or sex and could in fact be better. The use of echography could reduce the number of radiographies performed when diagnosing these kinds of fractures, thereby reducing the amount of radiation exposure and expediting the diagnostic process as well as the "in situ diagnosis". Level of clinical evidence 2 [prospective cohort (N > 30 patients) study]. [ABSTRACT FROM AUTHOR]

Background: The role of locking plate in lateral malleolar fracture fixation for the elderly remains unclear. The aim of our study is to compare radiological and functional outcomes in older patients (> 50 years) with AO/OTA 44B lateral malleolar fractures after locking plate (PLP) or one-third non-locking tubular plate (TP) lateral fixation. Methods: We retrospectively reviewed the medical records of 72 patients (PLP group, 34 patients; TP group, 38 patients; mean age, 61.9 ± 7.6 years; range, 51–80 years; follow-up, 1 year). Patients with open fractures, syndesmosis injuries, and a previous ankle trauma or surgery were excluded. Demographic data, union rate, complications, radiographic outcomes, visual analog scale (VAS) scores, and foot and ankle outcome scores (FAOSs) between the groups were recorded and compared. We also investigated the association of clinical features with pain and function. Statistically, the Fisher's exact test was used for categorical variables and the Mann-Whitney U test for the continuous variables. The final model for the multiple regression analysis was used to predict factors related to functional outcomes. Results: There were no significant between-group differences in demographic data, complication rates, immediately postoperative distal fibula lengths, ankle osteoarthritis (OA) grades, talar tilt angles (TTAs) ≥ 2°, or reduction accuracy. All fractures achieved union. The PLP group had significantly lower rates of distal screw loosening, fibula shortening > 2 mm, OA grade progression, and TTAs ≥ 2°, and better FAOSs and VAS scores than was the case for the TP group after 1 year of follow-up (all p < 0.05). The severity of OA, TTA ≥ 2°, and distal screw loosening were positively associated with VAS scores, and negatively associated with FAOSs. Conclusions: When treating AO/OTA 44B fractures in patients over 50 years of age, PLPs provided better VAS scores, FAOSs, and radiological outcomes, including less fibula shortening > 2 mm, less osteoarthritic (OA) ankle progression, less implant removal rate, and fewer TTAs ≥ 2° than was the case for TPs after a 1-year follow-up. Level of evidence: Therapeutic level III [ABSTRACT FROM AUTHOR]

Fractures of the ankle are common injuries. According to Lauge Hansen's classification, there are five types of ankle fractures. In certain types of fractures tibiofibular syndesmosis injury occurs, a fracture of the fibula above the syndesmosis and a fracture of the medial malleolus or a rupture of the deltoid ligament, and these types are: supination-eversion (SE), pronation-eversion (PE) and pronation-abduction (PA). We presented a group of 46 patients who were treated at the Department of Orthopedic Surgery and Traumatology due to the ankle fracture and rupture of the distal tibiofibular syndesmosis. All underwent surgery immediately after the injury, on average, 28 hours after the injury occurred when osteosynthesis of malleolus and transfixation of syndesmosis with spongiosum screw placed above it were performed. Postoperatively, we placed a plaster splint, which was worn for 3 weeks, and support on the injured leg was banned for up to 6 weeks. After removing the plaster, all patients were included in physical therapy. Osteosynthesis material was removed after 6 months. We have evaluated the results of the treatment according to the Olerud and Molander score. By tracking the subjective and objective signs we have acquired the following results: in the group of excellent and good results there were 34 (73.9%) patients, in the group of satisfactory, there were 7 (15.2%), in the group with poor results there were 5 (10.9%) patients. Lateral malleolus and tibiofibular syndesmosis are key to the anatomical reduction of displaced fractures, and restoring the integrity of the lateral malleolus establishes stability of the ancle. [ABSTRACT FROM AUTHOR]

The evaluation of and treatment protocols for ankle fractures represents an important aspect of the education of podiatric medical students. The objective of this investigation was to examine the feasibility of and student satisfaction with using 3-dimensional (3D) printed bone models representative of the Lauge-Hansen classification. The computed tomography scans of subjects with actual rotational ankle fractures representative of the Lauge-Hansen classification were identified and extracted into a format compatible with a 3D printer. The models were approximately 20 cm in height and made of acrylonitrile butadiene styrene plastic in ivory color. These were subsequently implemented into the curriculum of a traumatology course with third year podiatric medical students in the form of a hands-on workshop. Students expressed high levels of satisfaction with the use of these models, and most recommended their continued implementation within the curriculum. The results of this investigation indicate that 3D technology within podiatric medical education is feasible with high levels of student satisfaction. [ABSTRACT FROM AUTHOR]

Background: Tricho-rhino-phalangeal syndrome (TRPS) is a rare autosomal dominant genetic disorder characterized by distinctive craniofacial and skeletal abnormalities, while non-ossifying fibroma (NOF) is a common benign bone tumour in children and adolescents. To date, no case of TRPS coexisting with NOF has been reported. This report presents a 12-year-old girl who had the characteristic features of tricho-rhino-phalangeal syndrome and non-ossifying fibroma with a fibula fracture. Case presentation: A 12-year-old girl was admitted to the Department of Endocrinology and Diabetes for evaluation of brachydactyly and a right fibula fracture. Clinical examination revealed sparse scalp hair, a characteristic bulbous pear-shaped nose, and brachydactyly with significant shortening of the fourth metatarsal. Neither intellectual disability nor multiple exostoses were observed. Radiography of both hands showed brachydactyly and cone-shaped epiphyses of the middle phalanges of the digits of both hands with deviation of the phalangeal axis. Genetic analysis of TRPS1 identified a heterozygous germline sequence variant (p.Ala932Thr) in exon 6 in the girl and her father. Approximately 1 month before being admitted to our department, the girl experienced a minor fall and suffered a fracture of the proximal fibula in the right lower limb. The pathological cytological diagnosis of the osteolytic lesion was NOF. Ten months following the surgery, the lesion on the proximal fibula of the girl disappeared. Conclusions: In conclusion, the present study is the first to report a rare case of NOF with a pathologic fracture in the fibula of a girl with TRPS. The identification of a missense mutation, (p.Ala932Thr), in exon 6 of TRPS1 in this kindred further suggested that the patient had type I TRPS and indicated that mutations in this exon may be correlated with more pronounced features of the syndrome. Radiological techniques and genetic analysis played key roles in the definitive diagnosis. [ABSTRACT FROM AUTHOR]

Shortening of fibular length is most commonly secondary to fracture, especially in cases of malreduction, malunion or nonunion. In the presence of deltoid ligament incompetence, a shortened fibula causes lateral talar shift, widening of the mortise, decreased tibiotalar contact area and increased incidence of post-traumatic arthrosis. Restoring fibular length is important for normal anatomic relationships and kinematics of the ankle joint. While several techniques have been described for restoring length, some limitations exist. We describe an alternative surgical technique that is straightforward and reproducible that allows for restoration of fibular length and rotation. [ABSTRACT FROM AUTHOR]

This study investigates the efficacy of one-stage surgical intramedullary fibular fixation in managing ankle fractures with associated soft tissue damage. Ankle fractures, often encountered, can lead to complications when coupled with soft tissue injury. Traditional plate and screw fixation can exacerbate infection risks and reduce wound healing. To address this, a minimally invasive approach employing intramedullary fixation of the fibula has been proposed. This retrospective analysis, conducted between 2019 and 2021, explores cases of intramedullary fibular fixation for ankle fractures with stage 2-3 soft tissue injuries. A total of 19 patients were included in the study. The procedure involved either ulna intramedullary nails or locking screws. Results indicate that the approach led to successful union (100%), one superficial infection (5.26%), and no complication was observed. While limitations include the retrospective nature and small sample size, this study contributes valuable insights into the use of intramedullary fibular fixation in one-stage surgery for ankle fractures with concurrent soft tissue damage., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Saygılı et al.)

Introduction Previous studies have reported a lower extremity stress fracture after total knee arthroplasty (TKA). However, a fibular fracture after TKA is quite rare. We report a case of proximal fibula fracture after TKA in a patient with rheumatoid arthritis (RA). Presentation of case A 45 year old woman with RA had severe knee and foot pain with an antalgic gait disturbance. There was a significant joint deformity in many of lower limb joints. Interval bilateral TKAs were performed two weeks apart. Right TKA was performed using a constraint-type prosthesis, through lateral parapatellar approach. Left TKA was performed using a posterior-stabilized (PS) prosthesis through the more commonly employed, medial parapatellar approach. Seven weeks after the right TKA, the patient was found to have an atraumatic proximal fibular fracture. The fracture went on to heal conservatively. Discussion The fracture was considered to have occurred after the TKA. The callus appeared eleven weeks after the TKA. The factors that contributed to the fracture were thought to be overload of the fragile bone secondarily to disuse osteopaenia, RA or potentially the significant valgus malalignment correction. The surgical approach, the implant or implantation or the persisting joint deformity, were thought to be contributing factors to the aetiology of the stress fracture. The resultant change in clinical outcome/course is outlined in this case report. Conclusion A stress fracture of the proximal fibula has the potential in the aetiology of may cause other stress fractures, joint other instability, and/or malalignment of the total lower extremity. [ABSTRACT FROM AUTHOR]

Purpose: The role of the proximal tibiofibular joint (PTFJ) in tibial plateau fractures is unknown. The purpose of this study was to assess, with finite-element (FE) calculations, differences in interfragmentary movement (IFM) in a split fracture of lateral tibial plateau, with and without intact fibula. It was hypothesized that an intact fibula could positively contribute to the mechanical stabilization of surgically reduced lateral tibial plateau fractures.Methods: A split fracture of the lateral tibial plateau was recreated in an FE model of a human tibia. A three-dimensional FE model geometry of a human femur-tibia system was obtained from the VAKHUM project database, and was built from CT images from a subject with normal bone morphologies and normal alignment. The mesh of the tibia was reconverted into a geometry of NURBS surfaces. The fracture was reproduced using geometrical data from patient radiographs, and two models were created: one with intact fibula and other without fibula. A locking screw plate and cannulated screw systems were modelled to virtually reduce the fracture, and 80 kg static body weight was simulated.Results: Under mechanical loads, the maximum interfragmentary movement achieved with the fibula was about 30% lower than without fibula, with both the cannulated screws and the locking plate. When the locking plate model was loaded, intact fibula contributed to lateromedial forces on the fractured fragments, which would be clinically translated into increased normal compression forces in the fractured plane. The intact fibula also reduced the mediolateral forces with the cannulated screws, contributing to stability of the construct.Conclusion: This FE model showed that an intact fibula contributes to the mechanical stability of the lateral tibial plateau. In combination with a locking plate fixation, early weight bearing may be allowed without significant IFM, contributing to an early clinical and functional recovery of the patient. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this study was to evaluate functional results and the frequency of complications in the distal fibula Danis-Weber type B fractures caused by supination-external rotation injury in a group of lateral and antiglide plate fixation. Methods This prospective study evaluated 44 patients with a minimum of one-year follow-up. Patients were divided into two groups: one lateral plate group (24 patients) and group with an antiglide plate (20 patients). The patients of both groups were always positioned supine, and lateral approach was used. In the lateral plate group, the fracture was anatomically reduced, an optional anteroposterior lag screw was placed perpendicular to fracture line, and then the one-third tubular plate was applied on the lateral fibular site. In the antiglide group, the palate was implemented on the posterolateral surface of the fibula and the fracture was anatomically reduced. An optional lag-screw was used. Distal screw fixation was applied deliberately. Functional assessment according to the American Orthopaedic Foot and Ankle Society hind foot-ankle score (AOFAS) were performed at one year after surgery. The complications were recorded. Results According to Lauge-Hansen classification of supination-external rotation injury, a total of 27 (61.4%) patients was classified as stage 2, 2 (4.5%) patients as stage 3 and 15 (34.1%) patients with stage 4. In the lateral plate group, there were 13 (54.2%) male and 11 (45.8%) female patients. In the antiglide plate group, men comprised 12 (60%) and women 8 (40%) of patients. The AOFAS in the lateral and antiglide group performed one year after surgery was, on average, 93.7 ± 6.1 (range 85–100) and 94.5 ± 6.0 (range 85–100) points respectively. There were no statistically significant differences in both groups (p = 0.37). Complications were observed in 7 (29.3%) patients of lateral plate and 3 (15%) patients of an antiglide plate (p = 0.31). There was no case of tendinopathy. Revision surgery was performed in one patient with superficial infection. Conclusion In the present study, the outcome of the surgically treated Weber type B fractures caused by supination external rotation injury was comparable in both groups. The antiglide plate fixation showed no signs of peroneal tendinopathy, low rate of complications. We believe this technique is safe and a good method of fixation as well as traditional lateral plating. [ABSTRACT FROM AUTHOR]

Background: Fractures of tibia and fibula are one of the most common fractures of extremities in traumatic patients. Treatment of these fractures usually is surgical fixation of the tibia but there is not plenary study about the fixation of the fibula. Methods: All patients refers to Rasool hospital from Oct. 2009 to Oct. 2011 that achieved including criteria were entered in this prospective education and divided in to two groups: group 1 with 31 patients that was treated with fixation of the tibia and the fibula and group 2 with 34 patients that was treated with fixation of the tibia without fixation of the fibula and then severity of pain after the surgery, time of union, complication of the treatment and duration of the surgery were compared between them. Results: In group 1 severity of the pain and time of the union were significantly less than group 2. No nonunion was observed in group 1 but one was seen in group 2 that finally required surgical management. Duration of the surgery in group 1 was significantly longer than group 2. Conclusion: Although fixation of the fibula has taken longer duration of surgery, have better clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Open fibular fixation with plate osteosynthesis as an adjunct to increase stability has been associated with wound complications. Various percutaneous treatment options have been explored, but incompletely evaluated in comparison to one another in terms of rigidity of fixation at the fracture site. Methods: A biomechanical study was performed with 9 pairs of matched cadavers after creation of a suprasyndesmotic fracture model as occurs in association with a tibial pilon fracture. One group in each pair was assigned to threaded screw and the other to smooth pin fixation. Displacement at the fracture site was evaluated before and after cyclic axial and rotational loading with an MTS frame through video dimensional analysis. Results: In vertical loading alone, smooth pin and threaded screw fixation demonstrated no significant difference in displacement and there was no change in performance before and after loading cycles. With external rotation combined with a modest vertical load, screw fixation demonstrated smaller displacements than pin fixation, but the difference was less than 1 mm. Conclusions: The results suggest that both smooth pin fixation and threaded screw fixation can achieve stable fixation in a transverse fibular fracture. There is less motion with use of a threaded screw when loading in axial rotation and external rotation, potentially recommending this option as a more rigid construct for percutaneous fixation of simple fracture patterns.

Background: Fibular fractures are the most common associated fractures with tibia injuries. The current study aimed at collecting data on segmental fibular fractures in the patients and investigating the prognostic and functional significance of this injury pattern in outcomes. Methods: The charts were retrospectively reviewed from 2013 to 2016 to find patients with segmental fibular fractures. Patients’ history, physical examinations, initial radiographic findings, surgical reports, and follow-up data were evaluated. The patients were also assessed for union status, infection, limb shortening, and complications. Fractures were defined as segmental when the bone was disrupted in 2 points and a segment of bone with circumferential cortices was apart from the main bone proximally and distally. Results: During the 3-year period of the current study, out of 212 patients with leg fracture (tibiofibular fracture) treated in Imam Khomeini hospital, 17 patients (8%) had segmental fibular fractures. In the observed fibular fractures, the number of fracture fragments was between 3 and 6 segments. After 6 months, the rate of union was 70% in the tibia and 88% in the fibula. Overall, 6 patients needed re-operation, 1 of them had below knee amputation, and 5 other had surgeries because of tibial nonunion. Conclusions: The current study results showed that presence of a segmental fibular fracture may be associated with higher rates of complications. Fixation of the fibula in this situation can lead to nonunion. However, more studies are needed to approve or reject this conclusion.

Background: Carbon fiber composite implants are gaining popularity in orthopedics, but with few independent studies of their failure characteristics under supra-physiologic loads. The objective of this cadaveric study was to compare torsional failure properties of bridge plating a comminuted distal fibula fracture with carbon fiber polyetheretherketone (PEEK) composite and stainless steel one-third tubular plates. Methods: Comminuted fractures were simulated in 12 matched pairs of fresh-frozen human fibulas with 2-mm osteotomies located 3 cm proximal to the tibiotalar joint. Each fibula pair was randomized for fixation and implanted with carbon fiber and stainless steel 5-hole one-third tubular plates. The constructs were loaded in external rotation at a rate of 1-degree/sec until failure with a materials testing system. Torsional stiffness and mode of failure, as well as displacement, torque, and energy absorption for the first instance of failure and peak failure, were determined. Statistical analysis was performed with paired t tests and chi-square. Results: There were no significant differences among the 12 pairs for torsional stiffness, first failure torque, peak failure displacement, peak failure torque, or peak failure energy. Stainless steel plates exhibited significantly higher displacement (P < .001) and energy absorption (P = .001) at the first indication of failure than the carbon fiber plates. Stainless steel plates permanently deformed significantly more often than the carbon fiber plates (P = .035). Carbon fiber plates exhibited no plastic deformation with delamination of the composite, and brittle catastrophic failure in 1 specimen. Conclusions: In a comminuted human fibula fracture fixation model, carbon fiber implants exhibited multiple pre-peak failures at significantly lower angles than the first failure for the stainless steel implants, with some delamination of composite layers and brittle catastrophic failure rather than plastic deformation. Clinical relevance: The torsional failure properties of carbon fiber composite one-third tubular plates determined in this independent study provide novel in vitro data for this alternative implant material. [ABSTRACT FROM AUTHOR]

Background: This randomized, parallel-group, non-blinded study was designed to determine the role of fibular fixation in the treatment outcomes of combined distal tibia and fibula fractures. Materials and Methods: Sixty patients with distal tibial and fibular fractures were randomly divided in two groups of case and controls. In the case group, fibula was fixed prior to the fixation of tibia. In the control group, tibia was fixed without fibular fixation. Primary outcomes were varus–valgus angulation, anterior–posterior angulation, union and side effects. Follow-up visit and radiographs were taken 2 and 4 weeks as well as 3, 6 and 9 months after surgery. Results: During the follow-up, 11 out of 60 patients in case and control groups were excluded. We recruited 24 and 25 patients in the case and control group, respectively. Intramedullary nailing was used in 8 patients of case and 11 patients of control group. Plate and screw were used in 16 patients in the case and 14 patients in the control group. Varus/valgus and anterior–posterior angulation were not statistically significant between two groups (P ≥ 0.05). The frequency of tibial and fibula union after 1, 3, 6 and 9 months in case and controls groups were not statistically significant (P ≥ 0.05). The frequency of nonunion of tibia and fibula, infection and nerve injury in studied groups were not statistically significant (P ≥ 0.05). Conclusion: We did not observe any significant improvement using fibular fixation in the treatment outcomes of tibia distal fractures.