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Can a fibular malunion be corrected by a Z-shaped fibular osteotomy?

  • Alexej BargEmail author
  • Timothy L. Kahn
  • Graham Dekeyser
  • Yantarat Sripanich
  • Victor Valderrabano
Originalien

Abstract

Background

The aim of this study was to assess the short-term clinical and radiographic outcomes in patients who underwent realigning Z‑shaped fibular osteotomy.

Methods

Between January 2007 and December 2014, 28 patients with a painful fibular malunion underwent a Z-shaped realignment fibular osteotomy. The mean age was 42.2 ± 14.1 years (range 19.1–67.8 years) and the mean follow-up was 7.0 ± 1.7 years (range 4.0–9.7 years), with no loss to follow-up. Weight-bearing radiographs were used to determine the distal fibula alignment based on Weber’s criteria. Degenerative changes of the tibiotalar joint were assessed using the Kellgren-Lawrence scale. Clinical assessment included pain evaluation, measurement of ankle range of motion (ROM), sports activities, and quality of life outcomes.

Results

There were no intraoperative or perioperative complications. No delayed unions or nonunions were observed. One patient had radiographic progression of degenerative changes in the tibiotalar joint. Postoperative complications included removal of hardware (n = 15) and arthroscopic tibiotalar joint debridement (n = 2). At the last follow-up the mean visual analog scale (VAS) decreased from 6.5 ± 1.1 to 2.1 ± 1.1 (p < 0.001),the ROM improved from 39º ± 6º to 45º ± 4.5º (p < 0.001), the short form health survey questionnaire (SF-36) physical and mental outcome scores improved from 49 ± 8 to 84 ± 7 (p < 0.001) and from 61 ± 4 to 83 ± 5 (p < 0.001), respectively.

Conclusion

The Z‑shaped realignment osteotomy of the distal fibula can provide pain relief and functional improvement in the treatment of fibular malunion. Further studies are needed to address long-term outcomes in this patient cohort.

Keywords

Surgical procedures, operative Retrospective study Clinical outcome Radiographic outcome Weber’s criteria 

Abbreviations

AOFAS

American Orthopaedic Foot and Ankle Society

AP

Anteroposterior

LoE

Level of evidence

ROM

Range of motion

SF-36

Short form health survey questionnaire

VAS

Visual analog scale

Kann eine fibulare Fehlstellung durch eine Z-förmige fibulare Osteotomie korrigiert werden?

Zusammenfassung

Hintergrund

Ziel dieser Studie war die Beurteilung der klinischen und radiographischen Kurzzeitergebnisse von Patienten, bei denen eine Z‑förmige fibulare Korrekturosteotomie durchgeführt wurde.

Methoden

Zwischen Januar 2007 und Dezember 2014 unterzogen sich 28 Patienten mit einer schmerzhaften fibularen Fehlstellung einer Z‑förmigen Korrekturosteotomie. Das Durchschnittsalter lag bei 42,2 ± 14,1 Jahren (Range: 19,1–67,8 Jahre), und der durchschnittliche Follow-up betrug 7,0 ±1,7 Jahre (Range: 4,0–9,7 Jahre), ohne „loss to follow-up“. Mittels belasteter Röntgenaufnahmen wurde die Ausrichtung der distalen Fibula mittels der Weber-Klassifikation bestimmt. Degenerative Veränderungen des oberen Sprunggelenks wurden mit der Kellgren-Lawrence-Skala bewertet. Die klinische Untersuchung umfasste die Schmerzbeurteilung, die Messung des Bewegungsumfangs (ROM) des Sprunggelenks, sportliche Aktivitäten und die Lebensqualität.

Ergebnisse

Intra- oder perioperative Komplikationen gab es keine. Es wurde weder eine verzögerte Heilung noch eine Nichtheilung beobachtet. Ein Patient wies eine radiographische Progression degenerativer Veränderungen im oberen Sprunggelenk auf. Postoperative Komplikationen waren die Entfernung von Metallteilen (n = 15) und das arthroskopische Débridement des Sprunggelenks (n = 2). Beim letzten Follow-up sank der mittlere Wert der visuellen Analogskala (VAS) von 6,5 = 1,1 auf 2,1 = 1,1 (p < 0,001), der ROM verbesserte sich von 39 ± 6º auf 45 ± 4,5º (p < 0,001), die Kurzform des Health-Survey-Fragebogens (SF-36) verbesserte sich von 49 ± 8 auf 84 ± 7 (p < 0,001) (körperliches Befinden) bzw. von 61 ± 4 auf 83 ± 5 (p < 0,001) (mentales Befinden).

Schlussfolgerung

Die Z‑förmige Korrekturosteotomie des distalen Wadenbeins kann eine Schmerzlinderung und funktionelle Verbesserung bei der Behandlung fibularer Fehlstellungen bewirken. Weitere Studien sind erforderlich, um die langfristigen Ergebnisse in dieser Patientenkohorte zu untersuchen.

Schlüsselwörter

Chirurgische Eingriffe, operativ Retrospektive Studie Klinisches Outcome Radiographisches Ergebnis Weber-Klassifikation 

Notes

Author Contribution

Alexej Barg: surgery, measurements, statistical analysis, manuscript writing; Timothy L. Kahn: measurements, manuscript review; Graham Dekeyser: measurements, manuscript review; Yantarat Sripanich: revision of manuscript, manuscript review; Victor Valderrabano: surgery, manuscript review.

Compliance with ethical guidelines

Conflict of interest

A. Barg, T.L. Kahn, G. Dekeyser, Y. Sripanich and V. Valderrabano declare that they have no competing interests.

Ethical standards

This retrospective study was approved by the institutional review board (University of Basel) with a waiver of informed consent. For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.

References

  1. 1.
    Anderson JG, Bohay DR, Maskill JD, Gadkari KP, Hearty TM, Braaksma W et al (2015) Complications after popliteal block for foot and ankle surgery. Foot Ankle Int 36:1138–1143PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Barg A, Bailey T, Richter M, de Cesar Netto C, Lintz F, Burssens A et al (2018) Weightbearing computed tomography of the foot and ankle: emerging technology topical review. Foot Ankle Int 39:376–386PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Barg A, Saltzman CL (2014) Single-stage supramalleolar osteotomy for coronal plane deformity. Curr Rev Musculoskelet Med 7:277–291PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Barg A, Wiewiorski M, Paul J, Wurm M, Jacxsens M, Nykytina K et al (2017) Supramalleolar osteotomy in asymmetric ankle osteoarthritis : short-term clinical and radiographic results. Orthopade 46:761–775PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Bozkurt M, Tonuk E, Elhan A, Tekdemir I, Doral MN (2008) Axial rotation and mediolateral translation of the fibula during passive plantarflexion. Foot Ankle Int 29:502–507PubMedCrossRefGoogle Scholar
  6. 6.
    Brin YS, Palmanovich E, Massarwe S, Nyska M, Kish B (2013) Using a cervical spine cage to reconstruct malunited fibular fractures. Int Orthop 37:447–450PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Cerrato RA, Aiyer AA, Campbell J, Jeng CL, Myerson MS (2014) Reproducibility of computed tomography to evaluate ankle and hindfoot fusions. Foot Ankle Int 35:1176–1180PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Chao KH, Wu CC, Lee CH, Chu CM, Wu SS (2004) Corrective-elongation osteotomy without bone graft for old ankle fracture with residual diastasis. Foot Ankle Int 25:123–127PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Chu A, Weiner L (2009) Distal fibula malunions. J Am Acad Orthop Surg 17:220–230PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Dehne R, Connolly JF (1986) Fibular lengthening to correct a malunited ankle fracture. Nebr Med J 71:404–406PubMedPubMedCentralGoogle Scholar
  11. 11.
    Egger AC, Berkowitz MJ (2018) Operative treatment of the malunited fibula fracture. Foot Ankle Int 39:1242–1252PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    El-Rosasy M, Ali T (2013) Realignment-lengthening osteotomy for malunited distal fibular fracture. Int Orthop 37:1285–1290PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Elsoe R, Ostgaard SE, Larsen P (2018) Population-based epidemiology of 9767 ankle fractures. Foot Ankle Surg 24:34–39PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Horisberger M, Valderrabano V, Hintermann B (2009) Posttraumatic ankle osteoarthritis after ankle-related fractures. J Orthop Trauma 23:60–67PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Huskisson EC (1974) Measurement of pain. Lancet 2:1127–1131PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Jend HH, Ney R, Heller M (1985) Evaluation of tibiofibular motion under load conditions by computed tomography. J Orthop Res 3:418–423PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Ann Rheum Dis 16:494–502PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M (1994) Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 15:349–353PubMedCrossRefGoogle Scholar
  19. 19.
    Kohn MD, Sassoon AA, Fernando ND (2016) Classifications in brief: Kellgren-Lawrence classification of osteoarthritis. Clin Orthop Relat Res 474:1886–1893PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174CrossRefGoogle Scholar
  21. 21.
    Lepojarvi S, Niinimaki J, Pakarinen H, Leskela HV (2016) Rotational dynamics of the normal distal tibiofibular joint with weight-bearing computed tomography. Foot Ankle Int 37:627–635PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Lindsjo U, Danckwardt-Lilliestrom G, Sahlstedt B (1985) Measurement of the motion range in the loaded ankle. Clin Orthop Relat Res 199:68–71Google Scholar
  23. 23.
    Lubbeke A, Salvo D, Stern R, Hoffmeyer P, Holzer N, Assal M (2012) Risk factors for post-traumatic osteoarthritis of the ankle: an eighteen year follow-up study. Int Orthop 36:1403–1410PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Lundberg A (1989) Kinematics of the ankle and foot. In vivo roentgen stereophotogrammetry. Acta Orthop Scand Suppl 233:1–24PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Malek IA, Machani B, Mevcha AM, Hyder NH (2006) Inter-observer reliability and intra-observer reproducibility of the Weber classification of ankle fractures. J Bone Joint Surg Br 88:1204–1206PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Marti RK, Raaymakers EL, Nolte PA (1990) Malunited ankle fractures. The late results of reconstruction. J Bone Joint Surg Br 72:709–713PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Obremskey WT, Pappas N, Attallah-Wasif E, Tornetta P 3rd, Bhandari M (2005) Level of evidence in Orthopaedic Journals. J Bone Jt Surg Am 87:2632–2638CrossRefGoogle Scholar
  28. 28.
    Offierski CM, Graham JD, Hall JH, Harris WR, Schatzker JL (1982) Late revision of fibular malunion in ankle fractures. Clin Orthop Relat Res 171:145–149Google Scholar
  29. 29.
    Pagenstert G, Leumann A, Hintermann B, Valderrabano V (2008) Sports and recreation activity of varus and valgus ankle osteoarthritis before and after realignment surgery. Foot Ankle Int 29:985–993PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Pinsker E, Daniels TR (2011) AOFAS position statement regarding the future of the AOFAS clinical rating systems. Foot Ankle Int 32:841–842PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Ramsey PL, Hamilton W (1976) Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am 58:356–357PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Reidsma II, Nolte PA, Marti RK, Raaymakers EL (2010) Treatment of malunited fractures of the ankle: a long-term follow-up of reconstructive surgery. J Bone Joint Surg Br 92:66–70PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Roberts C, Sherman O, Bauer D, Lusskin R (1992) Ankle reconstruction for malunion by fibular osteotomy and lengthening with direct control of the distal fragment: a report of three cases and review of the literature. Foot Ankle 13:7–13PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Rolfe B, Nordt W, Sallis JG, Distefano M (1989) Assessing fibular length using bimalleolar angular measurements. Foot Ankle 10:104–109PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Saltzman CL, Salamon ML, Blanchard GM, Huff T, Hayes A, Buckwalter JA et al (2005) Epidemiology of ankle arthritis: report of a consecutive series of 639 patients from a tertiary orthopaedic center. Iowa Orthop J 25:44–46PubMedPubMedCentralGoogle Scholar
  36. 36.
    Sinha A, Sirikonda S, Giotakis N, Walker C (2008) Fibular lengthening for malunited ankle fractures. Foot Ankle Int 29:1136–1140PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    Thordarson DB, Motamed S, Hedman T, Ebramzadeh E, Bakshian S (1997) The effect of fibular malreduction on contact pressures in an ankle fracture malunion model. J Bone Joint Surg Am 79:1809–1815PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B (2009) Etiology of ankle osteoarthritis. Clin Orthop Relat Res 467:1800–1806PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Valderrabano V, Pagenstert G, Horisberger M, Knupp M, Hintermann B (2006) Sports and recreation activity of ankle arthritis patients before and after total ankle replacement. Am J Sports Med 34:993–999PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    van Wensen RJ, van den Bekerom MP, Marti RK, van Heerwaarden RJ (2011) Reconstructive osteotomy of fibular malunion: review of the literature. Strategies Trauma Limb Reconstr 6:51–57PubMedPubMedCentralCrossRefGoogle Scholar
  41. 41.
    Ward AJ, Ackroyd CE, Baker AS (1990) Late lengthening of the fibula for malaligned ankle fractures. J Bone Joint Surg Br 72:714–717PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Ware JE Jr., Sherbourne CD (1992) The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 30:473–483PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Weber BG (1977) Die Verletzungen des oberen Sprunggelenks. Huber, Bern Stuttgart WienGoogle Scholar
  44. 44.
    Weber BG (1981) Lengthening osteotomy of the fibula to correct a widened mortice of the ankle after fracture. Int Orthop 4:289–293PubMedPubMedCentralGoogle Scholar
  45. 45.
    Weber BG, Simpson LA (1985) Corrective lengthening osteotomy of the fibula. Clin Orthop Relat Res 199:61–67Google Scholar
  46. 46.
    Weber D, Friederich NF, Muller W (1998) Lengthening osteotomy of the fibula for post-traumatic malunion. Indications, technique and results. Int Orthop 22:149–152PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Yablon IG, Leach RE (1989) Reconstruction of malunited fractures of the lateral malleolus. J Bone Joint Surg Am 71:521–527PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2020

Authors and Affiliations

  • Alexej Barg
    • 1
    Email author
  • Timothy L. Kahn
    • 1
  • Graham Dekeyser
    • 1
  • Yantarat Sripanich
    • 1
  • Victor Valderrabano
    • 2
  1. 1.Department of OrthopaedicsUniversity of UtahSalt Lake CityUSA
  2. 2.SWISS ORTHO CENTERSchmerzklinik Basel, Swiss Medical NetworkBaselSwitzerland

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