The presence of large segmental defects of the diaphyseal bone is challenging for orthopedic surgeons. Free vascularized fibular grafting (FVFG) is considered to be a reliable reconstructive procedure. Stress fractures are a common complication following this surgery, and hypertrophy is the main physiological change of the grafted fibula. The exact mechanism of hypertrophy is not completely known. To the best of our knowledge, no studies have examined the possible relationship between stress fractures and hypertrophy. We herein report three cases of patients underwent FVFG. Two of them developed stress fractures and significant hypertrophy, while the remaining patient developed neither stress fractures nor significant hypertrophy. This phenomenon indicates that a relationship may exist between stress fractures and hypertrophy of the grafted fibula, specifically, that the presence of a stress fracture may initiate the process of hypertrophy.
Adult ; Female ; Fibula ; pathology ; transplantation ; Fractures, Stress ; pathology ; Humans ; Hypertrophy ; Male ; Middle Aged ; Tibia ; surgery ; Tibial Fractures ; surgery

OBJECTIVETo evaluate the efficacy of allograft fibula in anterior cervical fusion for cervical spondylosis patients treated by Smith-Robinson operation supplemented with anterior instrumentation.

METHODSThe clinical outcome of 38 patients with cervical spondylosis treated by Smith-Robinson operation using allograft fibula supplemented with anterior titanium plate were retrospectively studied. The patients were followed up on average was (9.5 +/- 3.4) months. The average preoperative and postoperative JOA scores were assessed and myelopathy severity was graded using the Nurick myelopathy grading system. Lateral views in neutral position, in flexion, and in extension of preoperative cervical roentgenograms were analyzed in comparison with last follow-up films to identify the changes in the height of intervertebral space and the quality of fusion.

RESULTSStatistical analysis of all patients revealed mean JOA scores of 12.54 +/- 1.62 and 16.07 +/- 1.13 before surgery and at final examination (P < 0.05), respectively. And the mean Nurick grades were 2.46 +/- 0.43 and 0.72 +/- 0.37 before and after surgery (P < 0.05), respectively. Radiographic follow-up revealed that the height intervertebral space and the lordosis of the cervical spine had been restored and no allograft was found displaced or collapsed and also revealed that all grafts obtained union by 5 months after surgery.

CONCLUSIONSFibular allograft can replace autologous iliac crest graft in the treatment of cervical spondylosis patients. This method is safe and efficacious and can avoid bone graft-site morbidity.

Adult ; Aged ; Cervical Vertebrae ; pathology ; Female ; Fibula ; surgery ; Humans ; Male ; Middle Aged ; Spinal Osteophytosis ; surgery ; Transplantation, Homologous

INTRODUCTIONGiant cell tumours of the bone are aggressive and potentially malignant lesions. Juxtaarticular giant cell tumours of the lower end radius are common and present a special problem of reconstruction after tumour excision. Out of the various reconstructive procedures described, non-vascularised fibular autograft has been widely used with satisfactory functional results.

MATERIALS AND METHODSTen patients with a mean age of 33.4 years, with either Campanacci grade II or III histologically proven giant cell tumours of lower end radius were treated with wide excision and reconstruction with ipsilateral non-vascularised proximal fibular autograft. Host graft junction was fixed with dynamic compression plate (DCP) in all cases. Wrist ligament reconstruction and fixation of the head of the fibula with carpal bones and distal end of the ulna using K-wires and primary cancellous iliac crest grafting at graft host junction was done in all cases.

RESULTSThe follow-up ranged from 30 to 60 months (mean, 46.8). At last follow-up, the average combined range of motion was 100.5 degrees with range varying from 60 degrees to 125 degrees. The average union time was 7 months (range, 4 to 12). Non-union occurred in 1 case. Graft resorption occurred in another case. Localised soft tissue recurrence occurred in another case after 3 years and was treated by excision. There was no case of graft fracture, metastasis, death, local recurrence or significant donor site morbidity. A total of 3 secondary procedures were required.

CONCLUSIONSEnbloc resection of giant cell tumours of the lower end radius is a widely accepted method. Reconstruction with non-vascularised fibular graft, internal fixation with DCP with primary corticocancellous bone grafting with transfixation of the fibular head and wrist ligament reconstruction minimises the problem and gives satisfactory functional results.

Adult ; Bone Neoplasms ; pathology ; surgery ; Bone Transplantation ; methods ; Female ; Fibula ; surgery ; transplantation ; Giant Cell Tumor of Bone ; pathology ; surgery ; Humans ; Ilium ; surgery ; transplantation ; Male ; Middle Aged ; Orthopedic Procedures ; methods ; Prospective Studies ; Radius ; pathology ; surgery ; Transplantation, Autologous

BACKGROUNDThe use of a free, vascularized fibular graft is an important technique for the reconstruction of large defects in long bones. The technique has many advantages in strong, tubular bones; a more reliable vascular anatomy with a large vascular diameter and long pedicle is used, minimizing donor-site morbidity. Due to limitations in both fibular anatomy and mechanics, they cannot effectively be used to treat large limb bone defects due to their volume and strength.

METHODSFrom 1990 to 2001, 16 clinical cases of large bone defects were treated using vascularized double-barrel fibular grafts. Patients were evaluated for an average of 10 months after surgery.

RESULTSAll the patients achieved bony union; the average bone union took 10 months post surgery, and no stress fractures occurred. Compared with single fibular grafts, the vascularized double-barrel fibular grafts greatly facilitate bony union and are associated with fewer complications, suggesting that the vascularized double-barrel fibular graft is a valuable procedure for the correction of large bone defects in large, long bones in addition to enhancing bone intensity.

CONCLUSIONSThe vascularized double-barrel fibular graft is superior to the single fibular graft in stimulating osteogenous activity and biological mechanics for the correction of very large bone defects in large, long bones. Free vascularized folded double-barrel fibular grafts can not only fill up large bone defects, but also improve the intensity margin. Therefore, this study also widens its application and enlarges the treatment targets. However, in the case of bone deformability, special attention should be paid to bone fixation and protection of donor and recipient sites.

Adolescent ; Adult ; Bone Diseases ; pathology ; surgery ; Bone Transplantation ; methods ; Female ; Fibula ; pathology ; surgery ; Humans ; Lower Extremity ; pathology ; surgery ; Male ; Middle Aged ; Models, Biological ; Reconstructive Surgical Procedures ; methods ; Reproducibility of Results

PURPOSE: To report long term treatment outcomes of osteofibrous dysplasia and association with adamantinoma. PATIENTS AND METHODS: From January 1984 to July 2001, 14 patients with osteofibrous dysplasia were followed for an average of 108 months (78 to 260 months). Our patient group consisted of 6 men and 8 women, with a mean age of 13.9 years (2 to 65 years). We reviewed the clinical and pathological features of all 14 patients. RESULTS: Thirteen patients had a lesion in the tibia, while one patient had lesions in both the tibia and the fibula. Initial treatments were observation after biopsy (6 patients), curettage with or without a bone graft (3 patients), resection followed by a free vascularized fibular bone graft (4 patients), or resection and regeneration with the Ilizarov external fixation (1 patient). Curettage was performed on 6 patients due to recurrence or progression after the initial treatment. Among these patients, one was diagnosed with AD from the biopsy of the recurrent lesion. This patient was further treated by segmental resection and pasteurization. After the initial pathology slides of the 13 patients were reviewed with immunohistochemical cytokeratin staining, one patient diagnosis was changed from osteofibrous dysplasia to osteofibrous dysplasia-like adamantinoma. CONCLUSION: Some patients with osteofibrous dysplasia require close observation because of the high association risk between osteofibrous dysplasia and adamantinoma, Immunohistochemical staining may be helpful in differentiating these two diagnoses.
Adamantinoma/metabolism/pathology/*surgery ; Adolescent ; Adult ; Aged ; Child ; Child, Preschool ; Female ; Fibrous Dysplasia of Bone/metabolism/pathology/*surgery ; Fibula/chemistry/radiography/surgery ; Humans ; Immunohistochemistry ; Keratins/analysis ; Male ; Middle Aged ; Tibia/chemistry/radiography/surgery

BACKGROUND: The authors report the long-term effect of acquired pseudoarthrosis of the fibula on ankle development in children during skeletal growth, and the results of a long-term follow-up of Langenskiold's supramalleolar synostosis to correct an ankle deformity induced by an acquired fibular segmental defect in children. METHODS: Since 1980, 19 children with acquired pseudoarthrosis of the fibula were treated and followed up for an average of 11 years. Pseudoarthrosis was the result of a fibulectomy for tumor surgery, osteomyelitis of the fibula and traumatic segmental loss of the fibula in 10, 6, and 3 cases, respectively. Initially, a Langenskiold's operation (in 4 cases) and fusion of the lateral malleolus to the distal tibial epiphysis (in 1 case) were performed, whereas only skeletal growth was monitored in the other 14 cases. After a mean follow-up of 11 years, the valgus deformity and external tibial torsion of the ankle joint associated with proximal migration of the lateral malleolus needed to be treated with a supramallolar osteotomy in 12 cases (63%). These ankle deformities were evaluated using the serial radiographs and limb length scintigraphs. RESULTS: In all cases, early closure of the lateral part of the distal tibial physis, upward migration of the lateral malleolus, unstable valgus deformity and external tibial torsion of the ankle joint developed during a mean follow-up of 11 years (range, 5 to 21 years). The mean valgus deformity and external tibial torsion of the ankle at the final follow-up were 15.2degrees (range, 5degrees to 35degrees) and 10degrees (range, 5degrees to 12degrees), respectively. In 12 cases (12/19, 63%), a supramalleolar corrective osteotomy was performed but three children had a recurrence requiring an additional supramalleolar corrective osteotomy 2-4 times. CONCLUSIONS: A valgus deformity and external tibial torsion are inevitable after acquired pseudoarthrosis of the fibula in children. Both Langenskiold supramalleolar synostosis to prevent these ankle deformities and supramalleolar corrective osteotomy to correct them in children are effective initially. However, both procedures cannot maintain the permanent ankle stability during skeletal maturity. Therefore any type of prophylactic surgery should be carried out before epiphyseal closure of the distal tibia occurs, but the possibility of a recurrence of the ankle deformities and the need for final corrective surgery after skeletal maturity should be considered.
Adolescent ; *Ankle Joint/growth & development/surgery ; Child ; Child, Preschool ; Female ; Fibula/*pathology/surgery ; Follow-Up Studies ; Humans ; Infant ; Joint Deformities, Acquired/*etiology/surgery ; Male ; Osteotomy ; Pseudarthrosis/*complications/pathology/surgery ; Young Adult

OBJECTIVEThe anterolateral approach to the tibia has been popularized for the management of tibial pilon fractures. For complex fracture patterns a combined anterolateral/anteromedial approach is suitable but a high rate of complication has been reported. In our retrospective study a two-choice strategy adopting a medial tibial approach was proposed for the treatment of pilon fractures with anterior or posterior fragmentation.

METHODSBased on an anatomic study of tibial pilon fractures, we retrospectively analyzed the fractures with primary posterior, posterior-lateral or anterior, anterior-lateral (Tillaux-Chaput) involvement of the distal tibia. This retrospective study consisted of 18 patients with a closed tibial plafond fracture. The inclusion criteria were: (1) pre- sence of an anterior/anterolateral type fragment or a posterior (Volkmann) type fragment involving larger than 25% of the articular surface, (2) a minimum follow-up of 12 months, (3) a fibula fracture associated with a medial column fracture of the distal tibia, and (4) soft tissue conditions at the time of operation that did not compromise the choice of surgical access (Tscherne classification for closed fractures: grade 0 and grade 1). Tibial plafond fractures were classified into two groups: one presenting anterior and the other with posterior rim (Volkmann) fragments.

RESULTSMost patients achieved a good clinical recovery in terms of range of motion and Olerud-Molander scale scores. Only three patients presented a grade 2 osteoarthritis at the 12 month follow-up.

CONCLUSIONOur two-choice strategy highlights concepts which have been previously debated and described in the literature. But a new extended protocol for surgical approach to the distal tibia, including more fracture patterns and their association should be further investigated.

Adult ; Female ; Fibula ; injuries ; Follow-Up Studies ; Fracture Fixation ; methods ; Humans ; Intraoperative Complications ; Male ; Middle Aged ; Retrospective Studies ; Tibia ; Tibial Fractures ; pathology ; surgery ; Treatment Outcome

OBJECTIVETo study the clinical effect of three dimensional diaplasis fixation in fracture of tibia and fibula.

METHODSTwenty-one cases of fracture of tibia and fibula were treated with three dimensions fixation (12 males, 9 females, with an average age of 46 years). There were 5 cases in open fracture, 16 cases in closed fracture, and 4 cases in up-segment fracture, 8 cases in mid-segment fracture, 9 cases in below-segment fracture. Oblique fracture were in 10 cases, thrypsis were in 8 cases, multisegmental fracture were in 3 cases.

RESULTS(1) Conditions of diaplasis fracture: dissected diaplasis were in 11 cases, closely dissected diaplasis in 9 cases, functional diaplasis in 1 case. (2) Clinical healing time: the minimum time was 43 days and maximum time was 85 days with an average of 62 days. (3) Conditions of functional recovery: all the patients were followed up from 4 to 12 months, 13 cases were excellent, 8 cases were good. (4) Time of backouting three dimensional diaplasis fixation: the minimum time was 6 weeks and the maximum 12 weeks with an average time of 8.5 weeks.

CONCLUSIONThe three dimensional diaplasis fixation and the fracture extremity from such a three dimensional solid that it can satisfy crus biomechanics for treating fracture of tibia and fibula with unstressed barrier and uncentric stress. Moreover, the three dimensional diaplasis fixation is elastic, it's structure is so fixed that it can be favorable for bone union.

Adolescent ; Adult ; Aged ; Female ; Fibula ; injuries ; physiopathology ; surgery ; Fracture Fixation ; instrumentation ; Fracture Healing ; Humans ; Male ; Middle Aged ; Orthopedic Fixation Devices ; Recovery of Function ; Tibial Fractures ; pathology ; physiopathology ; surgery ; Time Factors ; Young Adult

OBJECTIVEto study the clinicopathologic features and differential diagnosis of low-grade central osteosarcoma (LGCOS).

METHODSnine cases of LGCOS were retrieved from the archival consultation files. The clinical, radiologic and pathologic features were analyzed, with literature review.

RESULTSthe mean age of the patients was 31 years. The male-to-female ratio was 3:6. All of the patients presented with painful mass and/or swelling. The sites of involvement included thigh (n = 4), tibia (n = 1), fibula (n = 1), cervical vertebra (n = 1), lumbar vertebra (n = 1) and maxilla (n = 1). Radiologic examination showed mixed lytic/blastic lesions with soft tissue shadow in 5 cases and associated periosteal reaction in 3 cases. The tumors were treated by surgical excision, with no adjuvant therapy given. The duration of follow up ranged from 2 to 43 months. Four cases had recurrence which occurred at 8 to 25 months after the operation. Gross examination showed that the tumors were fragmented on submission in 5 cases and en bloc in 4 cases. They had solid and firm cut surface, with various degree of grittiness. Histologically, LGCOS was characterized by the presence of hypocellular fibroblastic stroma associated with focal osteoid production. The spindly tumor cells showed mild degree of nuclear pleomorphism, with occasional mitotic figures demonstrated in all of the 9 cases. The newly formed neoplastic woven bone did not have any osteoblastic rimming. The bony trabeculae were slender and seam-like. Parallel arrays of woven bone were seen in 6 cases. Some of the bony trabeculae appeared irregularly branched and curved. The tumor cells permeated adjoining pre-existing bony trabeculae and bone marrow in all cases. Three cases also showed soft tissue involvement.

CONCLUSIONSLGCOS often posses important diagnostic pitfalls due to the relatively bland-looking tumor cell morphology and associated large woven or longitudinal seams of lamellar-like bone. Thorough understanding of the histologic features, when coupled with clinical and radiologic findings, are essential in arriving at a correct diagnosis.

Adolescent ; Adult ; Bone Neoplasms ; diagnostic imaging ; pathology ; surgery ; Diagnosis, Differential ; Female ; Fibrous Dysplasia of Bone ; pathology ; Fibula ; diagnostic imaging ; Histiocytoma, Benign Fibrous ; pathology ; Humans ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Neoplasm Recurrence, Local ; Osteosarcoma ; diagnostic imaging ; pathology ; surgery ; Radiography ; Radionuclide Imaging ; Reoperation ; Thigh ; diagnostic imaging ; pathology ; Young Adult

INTRODUCTIONSpiral and oblique fractures of distal 1/3 of tibia-fibula are relatively common fractures of long bones. Due to their types, aetiology, limited coverage and blood supply, these fractures often lead to union and soft tissue problems.

MATERIALS AND METHODSTwenty-seven patients with spiral and oblique fractures of distal 1/3 of tibia-fibula were treated with circular external fixator (CEF) between January 1997 and August 2000. All the fractures were closed. The type of fractures based on AO classification were A1 (n = 8), A2 (n = 6), B1 (n = 11) and C1 (n = 2).

RESULTSThe mean framing time was 14.1 +/- 1.8 weeks (range, 12 to 19 weeks), and the mean treatment time was 18.8 +/- 2.2 weeks (range, 15 to 24 weeks). The patients were followed up for 36 to 78 months (mean follow-up time: 51.9 +/- 10.4 months). The results were evaluated for shortness, angulation, rotation, ankle stiffness, pain and infection. After removal of the frames, 11 patients had ankle pain and stiffness, and 3 patients had loss of range of motion in the ankle even after rehabilitation. None of the patients suffered any complications such as shortness, angulation, rotational deformity and infection, and none had loss of motion in the knee.

CONCLUSIONSCEF might be a preferable alternative treatment for distal tibia-fibula fractures due to its easy application, fewer major complications such as shortness and angulation, early mobilisation and shorter treatment time.

Accidental Falls ; Accidents, Traffic ; Adult ; Aged ; Athletic Injuries ; External Fixators ; Female ; Fibula ; injuries ; surgery ; Fractures, Bone ; etiology ; pathology ; surgery ; Fractures, Malunited ; surgery ; Humans ; Ilizarov Technique ; Male ; Middle Aged ; Outcome Assessment (Health Care) ; Pilot Projects ; Range of Motion, Articular ; Tibial Fractures ; etiology ; pathology ; surgery ; Turkey