Muscle volume evaluation using 3DCT for congenital clubfoot

Background In congenital clubfoot, the lower leg is very thin and the calf muscles are hypoplasic. However, there are few studies reporting real muscle volume. Purpose The purpose of this study is to assay the muscle volume in congenital clubfoot using 3DCT and to quantify the degree of the hypoplasia. Material and methods From January 2015 to December 2016, nine consecutive patients, seven male and two female, with unilateral congenital clubfeet were recruited for CT scans. Axial transverse sectional CT scans were acquired from the delineation of the fibular head to the tibial plafond. From the data, we rendered the entire muscle in 3D for muscle volume assay, and further segmented the posterior musculature for comparison between the normal and affected sides. Results The whole muscle volume on the normal side was 291.23 cm3 (181.23–593.49) and that on the affected side was 225.08 cm3 (120.71–429.08), for an affected side to normal side ratio of 0.79 (0.72–0.9), which was significantly smaller ( p < .01). Posterior muscle volume on the normal side was 175.81 cm3 (103.72–376.32) and that on the affected side was 106.52 cm3 (58.3–188.39). The ratio of posterior muscle to whole muscle on the normal side was 0.62 (0.46–0.75), and that on the affected side was 0.48 (0.4–0.55), such that the affected side was significantly smaller ( p < .01) Conclusion This study contributes quantitative data supporting the longstanding observations that the posterior calf muscles are significantly smaller on the affected side compared to the normal side in congenital clubfoot, and further underscores the importance of the extending the excursion of these muscles.

Relationship between the Height of Fibular Head and the Incidence and Severity of Knee Osteoarthritis

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.

The treatment of posterolateral tibial plateau fracture with a newly designed anatomical plate via the trans-supra-fibular head approach: preliminary outcomes

Background There are no ideal plates or approaches for anatomical restoration and rigid fixation of posterolateral tibial plateau fractures. This study aimed to evaluate the short-term preliminary outcomes of our novel anatomical plate placed via the trans-supra-fibular approach to treat posterolateral tibial plateau fractures. Methods From May 2016 to May 2018, 23 consecutive patients with posterolateral tibial quadrant fractures underwent open reduction with internal fixation via the trans-supra-fibular-head approach with our newly developed plate. The tibial plateau-tibial shaft angle (TPTSA), lateral posterior tibial slope angle (LPSTA), step-off, and condylar widening were measured on radiological images pre-operatively, 3 days post-operatively, 3 months post-operatively, and at the final follow-up examination. The radiological Rasmussen score was calculated, and the Hospital for Special Surgery (HSS) knee score was assessed to evaluate the functional outcomes. Results The LTPSA, TPTSA, step-off, and condylar widening at 3 days post-operatively, 3 months post-operatively, and at the final follow-up were significantly different (p = 0.001) compared with those pre-operatively, as was the radiological Rasmussen score (p = 0.001). The HSS score at the final follow-up was 89.10 ± 5.94 (range, 78–98), which was significantly higher than that at the 3-month follow-up 84.36 ± 6.76 (range, 74–96); p = 0.001). Conclusions Our newly designed anatomical plate placed via the trans-supra-fibular approach can effectively treat posterolateral tibial plateau fractures. We noted minor trauma, stable fixation, and satisfactory clinical results.

Fabella Syndrome and Common Peroneal Neuropathy following Total Knee Arthroplasty

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.

Varied Presentation and Importance of MR Neurography of the Common Fibular Nerve in Slimmer’s Paralysis

Slimmer’s paralysis refers to a common fibular nerve palsy caused by significant and rapid weight loss. This condition usually results from entrapment of the common fibular nerve due to loss of the fat pad surrounding the fibular head. Several etiologies of common fibular nerve palsy have been proposed, including trauma, surgical complications, improperly fitted casts or braces, tumors and cysts, metabolic syndromes, and positional factors. We present 5 cases of slimmer’s paralysis in patients who had lost 32–57 kg in approximately 1 year. In 2 cases, MR neurogram of the knee demonstrated abnormalities of the common fibular nerve at the fibular head. Two patients underwent a common fibular nerve decompression at the fibular head and attained improved gait and sensorimotor function. Weight loss, diabetes mellitus, and immobilization may have contributed to slimmer’s paralysis in 1 case. Awareness of slimmer’s paralysis in patients who have lost a significant amount of weight in a short period of time is imperative to detect and treat a fibular nerve neuropathy that may ensue.

Multiplanar reformation improves identification of the anterolateral ligament with MRI of the knee

The anterolateral ligament (ALL) is subject of the current debate concerning rotational stability in case of anterior cruciate ligament (ACL) injuries. Today, reliable anatomical and biomechanical evidence for its existence and course is available. Some radiologic studies claim to be able to identify the ALL on standard coronal plane MRI sections. In the experience of the authors, however, ALL identification on standard MRI sequences frequently fails and is prone to errors. The reason for this mainly lies in the fact, that the entire ALL often cannot be identified on a single MRI image. This study aimed to establish an MRI evaluation protocol improving the visualization of the ALL, using multiplanar reformation (MPR) with the goal to be able to evaluate the ALL on one MRI image. A total of 47 knee MRIs performed due to atraumatic knee pain between 2018 and 2019 without any pathology were analyzed. Identification of the ALL was performed twice by an orthopedic surgeon and a radiologist on standard coronal plane and after MPR. For the latter axial and coronal alignment was obtained with the femoral condyles as a reference. Then the coronal plane was adjusted to the course of the ALL with the lateral epicondyle as proximal reference. Visualization of the ALL was rated as “complete” (continuous ligamentous structure with a tibial and femoral insertion visible on one coronal image), “partial” (only parts of the ALL like the tibial insertion were visible) and “not visible”. The distances of its tibial insertion to the bony joint line, Gerdy’s tubercle and the tip of the fibular head were measured. On standard coronal images the ALL was fully visible in 17/47, partially visible in 27/47, and not visible in 3/47 cases. With MPR the ALL was fully visible in 44/47 and not visible in 3/47 cases. The median distance of its tibial insertion to the bony joint line, Gerdy’s tubercle and the tip of the fibular head were 9, 21 and 25 mm, respectively. The inter- (ICC: 0.612; 0.645; 0.757) and intraobserver (ICC: 0.632; 0.823; 0.857) reliability was good to excellent. Complete visualization of the ALL on a single MRI image is critical for its identification and evaluation. Applying multiplanar reformation achieved reliable full-length visualization of the ALL in 94% of cases. The described MPR technique can be applied easily and fast in clinical routine. It is a reliable tool to improve the assessment of the ALL.

Neuropathy Case Seen After Bariatric Surgery

Peroneal neuropathy is a rare complication after bariatric surgery, but it occurs in 15% of mononeuropathy. The etiology of peroneal neuropathy is multifactorial and is often blamed for these factors due to rapid weight loss and nutritional imbalance. Emine Karaca, 25 years old, female Patient 1 year ago, she had a stomach reduction (obesity surgery) surgery due to her weight of 130 kg. Six months after the operation, it decreased to 60 kg. Meanwhile, numbness in his right foot began to be pain and loss of strength after the operation. In the EMG performed on May 10, 2016, he was diagnosed with Fibulahead entrapment neuropathy-low foot. He was tied to lie in the same position for a long time during the operation. After this diagnosis, 15% prolotherapy was applied around the peroneal nerve of the fibular head on 11.05.2016. Prolotherapy was applied 2 times with 10 days intervals. L4-5 and L5-S1 segmental neural therapy in the lumbar region and neural therapy around the fibular head of the peroneal nerve and along its trace were applied twice a week. After a total of 2 prolotherapy and 6 neuraltherapy applied in 3 weeks, complete clinical recovery was achieved. This complete recovery was confirmed by EMG. Since electrophysiological findings of denervation occur after 2-3 weeks, it is recommended that EMG examination be performed 3 weeks later. Treatment includes relief of complaints (analgesics and gabapentin), physical therapy applications and support immobilizers. In cases that do not respond to treatment, nerve exploration and relaxation is provided with a surgical approach. Prolotherapy and neural therapy, among complementary medicine modalities, can also be used in peroneal nerve neuropathy.

A Case Report of Proximal Migration of Fibular Head with Intact Peroneal Nerve in a Post-Operative Infected Tibia Gap Non-union Managed by Ilizarov Technique

Introduction: We hereby present a rare case of proximal fibular head migration associated with Ilizarov technique for infected tibia gap non-union due to follow-up failure in post-operative management during the coronavirus disease (COVID) pandemic. Case Report: A 45-year-old male patient had undergone primary external fixation with wound debridement for a compound tibia shaft fracture Grade 3 A Gustilo class which later on with a healed external wound with a discharging sinus at the fracture site was confirmed to be infected non-union and subsequently managed by Ilizarov ring fixation over an antibiotic coated intramedullary nail and local gentamycin beads after a necrotic bone fragment of around 6 cm was excised. Post-operative protocol of compression and distraction was initiated and the patient educated regarding the same before discharge. As the world over was hit by the COVID pandemic and the lockdown limited all possible movements in our country, the patient could not follow up for monitoring the Ilizarov limb lengthening procedure. He presented to us after 4 months after the relaxation of lockdown with radiological union at the docking site but with a shortening of about 3 cm. Vigorous knee range physiotherapy failed to improve range beyond 90° which prompted us to check X-ray the knee joint and revealed the complication of proximal fibular head migration of 4 cm but with no neurodeficit and currently the patient is being managed with full weight mobilization with the help of crutch and shoe raise and an improved knee range till 100° of flexion with no pain tenderness or any other complaints. Conclusion: Having knowledge of this possible rare complication and the need for follow-up and monitoring with the importance of patient education makes practicing orthopedic surgeons equipped to handle and anticipate such undesirable complications. Keywords: Bony union, fibula migration, fibula resection, Ilizarov technique, infected non-union.

Temporary Proximal Tibial Epiphysiodesis for Correction of Leg Length Discrepancy in Children—Should Proximal Fibular Epiphysiodesis Be Performed Concomitantly?

The need for concomitant proximal fibular epiphysiodesis (PFE) when correcting leg length discrepancy (LLD) with temporary proximal tibial epiphysiodesis (PTE) in children is controversially discussed. This single center, retrospective cohort study analyzes proximal fibular growth in patients treated by PTE with and without concomitant PFE. Radiographic measurements were conducted before implantation and at implant removal. The position of the fibular head in relation to the tibia was assessed with recently established radiographic reference values. All patients (n = 58, 19 females) received PTE to treat LLD at a mean age of 12.2 years (range 7 to 15). In 27/58 (47%) concomitant PFE was performed. Mean follow-up was 36.2 months (range 14.2 to 78.0). The position of the proximal fibula at implant removal was within physiological range in 21/26 patients (81%) with PFE and in 21/30 patients (70%) without PFE. Proximal fibular overgrowth newly developed in 2/26 patients (8%) treated with PFE and in 5/30 patients (17%) treated without PFE (p = 0.431). Peroneal nerve injury or discomfort due to proximal fibular overlength was not reported. The position of the proximal fibula should be critically assessed preoperatively under consideration of reference values before PTE. In consequence of this study, the authors do not routinely perform PFE concomitantly with PTE for correction of moderate LLD in children if the proximal fibula is localized within physiological radiographic margins determined by the established reference values.