Clinical and radiological outcome in children following fibulectomy-whether it regenerate or not

Saurabh Kumar; Pankaj Kumar Singh; Manish Kumar; Santosh Kumar

ORIGINAL ARTICLE

Year : 2019 | Volume : 5 | Issue : 2 | Page : 147-149

Clinical and radiological outcome in children following fibulectomy-whether it regenerate or not

Saurabh Kumar¹, Pankaj Kumar Singh¹, Manish Kumar², Santosh Kumar³
¹ Senior resident, Dept. of Orthopedics, IGIMS, Patna, Bihar, India
² Associate Professor, Dept. of Orthopedics, IGIMS, Patna, Bihar, India
³ Professor & Head, Dept. of Orthopedics, IGIMS, Patna, Bihar, India

Date of Submission	22-Jun-2019
Date of Acceptance	25-Jul-2019
Date of Web Publication	12-Aug-2019

Correspondence Address:
Manish Kumar
Associate Professor, Dept. of orthopedics, IGIMS, Patna
India

Source of Support: None, Conflict of Interest: None

Abstract

Background: The non-vascularised fibular graft is unique as fibula regenerates at the donor site .The literature on regeneration of fibula after extracting non- vascularised fibular grafts in children is limited.
Material and methods: This was retrospective study. Analysis of fibular regeneration at the donor site following extraction of non-vascularised fibular graft was done. All these patients were evaluated minimum two years after the index procedure. The radiological regeneration quantified in percentage by calculating the area of both operated and normal limb.
Results: 28 patients were included in this study. The average patient age was 9.38 years. There was no pain or neuromuscular deficit in the operated limb .The mean follow up of 39.8 months. The continuity of the fibula in the longitudinal was restored in 25 cases.

Keywords: Fibulectomy Regenerate, Longitudinal axis, Donor site, Periosteum, Distal migration, Ankle mortise

How to cite this article:
Kumar S, Singh PK, Kumar M, Kumar S. Clinical and radiological outcome in children following fibulectomy-whether it regenerate or not. J Indira Gandhi Inst Med Sci 2019;5:147-9

How to cite this URL:
Kumar S, Singh PK, Kumar M, Kumar S. Clinical and radiological outcome in children following fibulectomy-whether it regenerate or not. J Indira Gandhi Inst Med Sci [serial online] 2019 [cited 2023 Feb 5];5:147-9. Available from: http://www.jigims.co.in/text.asp?2019/5/2/147/301100

Introduction :

The fibula is a commonly used autogenous bone graft site in children. Both non- vascularised and vascularised fibular harvesting have remained an important tool in the hands of the paediatric orthopaedic surgeon. In the last few years, there were reports listing fibular regeneration and complications from vascularised fibular harvest in children. The morbidity has most commonly being associated with vascularised fibular grafts^{[1],[2],[3],[4],[5],[6]}. One of the reasons for complication is absence of fibular regeneration in longitudinal axis. The literature on fibular regeneration and its quantification after procuring non-vascularised fibular graft in children is still few^[7]. The non-vascularised fibular graft has distinction from the vascularized graft as the fibular regeneration occurs at the donor site^[7],[8].

Materials and Methods :

This retrospective study was conducted at IGIMS PATNA conducted between April 18 - october 2018. The operative details were checked from patient’s case records. All patients with age less than 12 years at the time of index procedure, who had undergone any orthopedic operative procedure at least two years ago, utilizing non-vascularised fibular bone graft were included in the study. In all included cases, maximum possible length of fibula was resected. Patient with age & gt;12yr at the time of index procedure, problems in donor leg , bony pathology in ipsilateral tibia / fibula and index procedures requiring smaller graft lengths were excluded. Periosteum preserving technique was used for fibular harvest. Both the ends conserved with a minimum of 10% of total length at either fibular ends to maintain ankle stability at distal end and for safety of deep peroneal nerve at proximal end^[9],[10]. Weight bearing was allowed after pain had subsided. At follow up, clinical parameters evaluated were fibular continuity, pain and neuromuscular deficits in the donor limb, if any. The radiological measurements were done on standardized anteroposterior standing x-ray of both legs including knee and ankle joint with patella facing forward. Now the fibula divided in three equal parts in both the limbs. Diameters measured at the junction of proximal & middle third as well as at junction of middle third & distal third. Mean diameter calculated and area measured using formula length* mean diameter. It was done for both operated as well as normal limb. Now the ratio of areas (regenerated fibular area / normal fibular area) was calculated and expressed in percentage.

Results :

A total of 28 patients included in the study. The harvest of fibula was unilateral in all the patient. The average patient age at time of follow up was 9.38 years (range 6-12 years). The average follow up was39.8 months (range 25-65 months). The continuity of fibula in longitudinal dimension was restored in 25/28 legs (89%) by that time. Clinically, there was no pain or neuromuscular deficit in the examined limbs at final follow up. Further, there was no symptomatology related to harvest limb reported by any child.

Discussion :

The non-vascularised bone graft has distinction of regeneration of fibula^[8],14]. Steinlechner and Mkandawire used non-vascularised fibular grafting for reconstruction of long bone defects after sequestrectomy in a series of seven children. They had six fibulae with regrowth in continuity within 19.3 weeks (range, 6 to 75 weeks)^[14]. The authors opined that early restoration of fibular continuity led to stabilization of the ankle in the donor leg and even suggested reutilization of regenerated fibulae^[14]. The literature on fibular regeneration and other long term impacts on donor site after procuring non-vascularised fibular graft in children is still scanty^[7],[15]. A series of 23 children (24 harvested fibulae) with average age 8.9 years (range, 4-14 years) reported by González-Herranz et al showed incomplete fibular regeneration or non-union in 14 cases (58%)^[15]. There were radiological findings of distal migration of the fibula head in 18 cases (75%, but without clinical relevance), lateral cortical tibial thickening in five cases (21%), talar tilt in 11 cases (46%), proximal migration of the distal end fibula in 13 cases (54%) and diaphyseal valgus of the tibia in five cases (21%). The average follow up in their series was 6.2 years (range 4-11 years). The study however was quite heterogeneous with harvest of different anatomical fibular portions (head, proximal diaphysis, middle diaphysis, distal diaphysis, lateral malleolus) and variable lengths of fibula graft (2-24 cm, average 9.9 cm). There was primary tumour of fibula in seven cases. In half of their cases, the distal tibiofibular joint was stabilised with a suprasyndesmal screw or a Kirschner wire. Periosteum preservation of fibula was also not uniform in all cases^[15]. Another series on harvest of non- vascularised fibula series by Xin et al described 17 children with an average age of years (range, 2-13 years), and mean follow-up of 31 months (range, 7-65 months)^[7]. The fibula was harvested using a periosteum-preserving technique. Variable lengths of fibula were harvested (average 28%; range 10-58%). The authors divided patients into two groups-nine harvest sites were filled with cancellous allograft and eight with calcium sulfate. No significant donor site complications were reported in this series with fibular regeneration being evident in all cases at a mean follow up of 12 weeks (range 4- 21 weeks)^[7]. Our study did not involve resection of either proximal or distal fibular epiphysis and a uniform surgical procedure with periosteal preservation was utilised. The fibular graft site regeneration was a natural process no allograft orcalcium given to augment the harvest site in any of patients. Nathan et al investigated the timing of development of ankle valgus in vascularised fibular grafting^[2]. Children were first noted to have ankle deformity 32 months (range, 20-38 months) after their primary surgical procedures. In our series, we could not predict at what age the ankle valgus started developing as this retrospective analysis was per- formed about 39.4 months (range, 24-83 months) after the index procedure. However, by this time 33% ankles had already developed radiological valgus deformity. A previous report from our institution has prospectively analysed short term donor site characteristics following non- vascularised fibula harvest^[8]. There were 16 children with 21 harvested fibula. There was regeneration of fibula similar to the preoperative dimensions as early as six months in 71% of cases. The non- continuous regeneration (29%) had no clinical implications in short term. During weight bearing, approximately one sixth of the weight is transmitted by fibula^[16]. In a normal ankle, a uniform axial load applied to distal tibia and fibula results in balanced growth of lower tibial epiphysis. In fibular gap nonunion, in weight bearing positions, there is loss of a normal physiological load transmission through fibular side. Further, there is upward dragging of the remaining distal fibula by the contracted fibrous scar around the gap (tethering effect). The epiphyseal growth at the lateral distal tibial epiphysis is thus inhibited by eccentrical ankle loading resulting in progressive ankle valgus^[16]. The fibular resection also leaves a mobile distal remnant which is unable to resist pressure from the talus during weight-bearing. In fact, shortening of the fibula, lateral wedging of the distal tibial epiphysis, and lateral tilt of the talus at the ankle mortise are supposed to be closely related^[11]. The anatomical obliquity of the ankle mortise in a normal child before the age of 10 years, general laxity of ligaments in children, and weakness of the tibialis posterior muscle are other factors postulated for ankle valgus^[1],[2]. There were some limitations of our study. It was a retrospective study where initial and immediate post-operative radiographs of harvest site were not available. The calculation of residual fibula was therefore not possible. Only the dimension of fibula in anteroposterior radiographs was taken into consideration for calculation purpose. The strengths of the current study were a dedicated long term follow up study performed on a homogenous group consisting of only healthy fibular harvest (excluding pathological fibula). These grafts used had the uniformity such as near total fibular resection, preserved proximal and distal epiphysis with a reasonable distal fibular support. Our study showed presence of a regenerated fibula in continuity (89% legs).

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