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Background: Anterior Cruciate Ligament Aplasia (ACLA) is a rare condition which can sometimes remain asymptomatic into adult life. Although the quoted incidence is 1.7 per 100,000 live births, it is higher due to these silent cases and can be encountered by the arthroscopy surgeon doing reconstructive procedure for the ACL. The aim of this study is to get information on clinical presentation, imaging, arthroscopy findings and management of the knee in patients with ACL aplasia through a systematic review relevant to the arthroscopy surgeon in making a decision when they encounter such a case. Methods: We performed a systematic review of the literature to get information on this condition that may be relevant to the arthroscopy surgeon from PubMed, Ovid full text, Embase and Ovid Medline databases. After exclusions and inclusions, we found 31 articles relevant to the search which included 101 knees. Results: Most of the publications were case reports due to the rarity of this condition. ACLA is commonly associated with Fibular Hemimelia, Congenital Dislocation of the Knee and Proximal Focal Femoral Deficiency (PFFD). Clinical findings, imaging appearances, other associated findings with ACLA have been listed and management options listed and discussed. Conclusions: Patients with ACLA are often asymptomatic and arthroscopic reconstruction of the ACL appears to be a viable option in selected symptomatic cases only. The arthroscopic surgeon should be aware of the clinical picture and intraarticular findings of ACLA to recognize the condition and make a decision on the optimal management. Further studies are required to report on long-term outcomes of the condition in terms of secondary osteoarthritis development as well as the procedures performed. We recommend forming a global registry to study and further understand the aspects of this condition. Level of Evidence: 4 [ABSTRACT FROM AUTHOR]

Longitudinal fibular deficiency (LFD) is the most common congenital long bone deficiency. This study aimed to objectively assess the physical performance of children and adolescents with LFD compared with unaffected peers, and to examine trends over age for subgroups of the LFD population. Differences between children with LFD and unaffected peers were examined with hand-held dynamometry for lower-limb muscle strength, Six-Minute Walk Test, Timed up and down stairs test, Star Excursion Balance Test, and Standing long jump. Thirty-nine children with LFD and 284 unaffected peers participated. Children with LFD performed at a lower level than their unaffected peers, on all measures of physical performance (mean 2.1 z-scores lower, all p < 0.01), except in long jump (p = 0.27). When comparing the performance of children with LFD to their unaffected peers across four age groups, there was a significant between-groups difference on all strength measures, and on the Six-Minute Walk distance, between children with and without LFD. These differences were smallest in young children (3–6 years) and largest in the older children (15–18 years) (all p < 0.01). Children with no lengthening surgery performed better on the Six-Minute Walk Test, covering a greater distance during the test, than those who had surgery (mean difference 83 metres, p < 0.01). There were no significant differences between children who had or had not undergone an amputation. Children with LFD performed at a significantly lower level than unaffected peers on all measures of physical performance other than jumping. The largest differences were in older children. This paper provides baseline functional data for future interventions in LFD. Cross-sectional study. This paper provides the first baseline functional data using validated objective measures on a consecutive cohort of children and adolescents with longitudinal fibular deficiency. Children with LFD performed significantly worse than their unaffected peers on all measures of physical performance other than jumping, with children falling further behind their peers as they age. Children who undergo an amputation typically have the most severe anatomical presentation and yet perform at an equivalent functional level. This paper identifies multiple modifiable impairments that represent potential opportunities for rehabilitation professionals to target with conservative treatment options to improve functional performance. [ABSTRACT FROM AUTHOR]

PURPOSE OF THE STUDY In this study, our aim is to examine the effect of proximal fibular osteotomy on knee and ankle kinematics with finite element analysis method. MATERIAL AND METHODS One 62-year-old, female volunteer’s radiologic images were used for creating lower limb model. Osteotomized model (OM) which was created according to definition of PFO and non-osteotomized model (NOM) were created. To obtain a stress distribution comparison between the two models, 350 N of axial force was applied to the femoral heads of the models. RESULTS After PFO, the average contact pressure decreased 26.1% at the medial tibial cartilage and increased 42.4% at the lateral tibial cartilage. The Von Mises stresses decreased 57.1% at the femoral cartilage and decreased 79.1% at tibial cartilage. The stress on the tibial cartilage increased 44.6%, and stress on the talar cartilage increased 7.1% at the ankle joint. CONCLUSIONS FEA revealed that main loading at the knee joint shifted from medial tibial cartilage to the lateral tibial cartilage after PFO. Additionally, the stresses on each cartilage were redistributed across a wider and more peripheral area. FEA also demonstrated that the Von Mises stresses of the tibial and talar cartilages of the ankle joint increased after PFO. [ABSTRACT FROM AUTHOR]

Congenital posterior dislocation of fibula with pes valgus deformity is a rare disorder in children and has not been reported in English literature. The parents recognize it when the child starts to bears weight as the foot appears normal non-weight bearing but on standing or bearing weight it goes into valgus. As the foot is manually correctable to neutral plaster correction does not suffice and surgery becomes essential. The differential diagnosis of this condition is the well-described congenital diastasis of inferior tibiofibular joint, where the foot is with equinovarus deformity. We are reporting a child of 2 years of age who presented to us walking on the medial border of sole, a valgus deformity on walking and no other congenital anomalies. We operated upon this case of congenital posterior dislocation of fibula with pes valgus deformity and are reporting it for the abnormal patho-anatomy, surgical steps followed and treatment protocol adopted by us. [ABSTRACT FROM AUTHOR]

Background: Fibular hemimelia is the most common congenital long bone deficiency. It is often associated with femoral and tibial deficiencies which result in a clinically evident leg length discrepancy. The primary soft tissue concern is ACL/PCL deficiency. If treatment includes bony lengthening, joint stability is imperative to avoid complications. In this study, we detail a novel technique for long bone lengthening and ACL reconstruction in a single, cohesive surgery. This consolidates the need for multiple procedures and offers improved limb length symmetry and knee stability for this patient population. Clinical outcomes of pediatric patients with hemimelia who underwent either femoral or tibial lengthening with PRECICE® nail and concomitant ACL reconstruction are presented., Methods: After IRB approval, we identified five patients with complex fibular hemimelia who underwent ACL reconstruction and concomitant lengthening with at least two years of follow-up. Two patients (40%) presented with congenital short femur, and three (60%) with congenital short tibia. In each case, ACL reconstruction and either femoral or tibial guided growth via PRECICE® nail were performed. Operative techniques involving both soft tissue and bony methodology are described in detail., Results: All patients had objective improvement in knee stability as assessed both intra and post operatively, as well as successful intermedullary lengthening without complications related to joint stability. Three patients had minor complications unrelated to joint stability that did not interfere with overall result., Conclusion: Fibular hemimelia associated with hypoplasia of bony and soft tissue structures can be successfully addressed with concomitant ligamentous reconstruction at the time of implantation of lengthening devices. This addresses knee instability and reduces both number of operative procedures and potential complications related to joint instability while pursuing bony lengthening. Level of Evidence: V ., Competing Interests: Disclosures: The authors report no potential conflicts of interest related to this study., (Copyright © The Iowa Orthopaedic Journal 2024.)

Background: Stabilization methods for distal tibiofibular syndesmotic injuries present risk of malreduction. We compared reduction accuracy and biomechanical properties of a new syndesmotic reduction and stabilization technique using 2 suture buttons placed through a sagittal tunnel in the fibula and across the tibia just proximal to the incisura with those of the conventional method. Methods: Syndesmotic injury was created in 18 fresh-frozen cadaveric lower leg specimens. Nine ankles were repaired with the conventional method and 9 with the new technique. Reduction for the conventional method was performed using thumb pressure under direct visualization and for the new method by tightening both suture buttons passed through the fibular and tibial tunnels. Computed tomography was used to assess reduction accuracy. Torsional resistance, fibular rotation, and fibular translation were evaluated during biomechanical testing. Results: The new technique showed less lateral translation of the fibula on CT measurements after reduction (0.06 ± 0.06 mm) than the conventional method (0.26±0.31 mm), P = .02. The new technique produced less fibular rotation during internal rotation after 0 cycles (new -2.4±1.4 degrees; conventional -5.0±1.2 degrees, P = .001), 100 cycles (new -2.1± 1.9 degrees; conventional -4.6 ± 1.4 degrees, P = .01), and 500 cycles (new -2.2 ± 1.6 degrees; conventional -5.3 ± 2.5 degrees, P = .01) and during external rotation after 100 cycles (new 3.9±3.3 degrees; conventional 5.9±3.5 degrees, P = .02) and 500 cycles (new 3.3 ± 3.2 degrees; conventional 6.3 ± 2.6 degrees, P = .03). Fixation failed in 3 specimens. Conclusion: The new syndesmotic reduction and fixation technique resulted in more accurate reduction of the fibula in the tibial incisura in the coronal plane and better rotational stability compared with the conventional method. [ABSTRACT FROM AUTHOR]

Isolated congenital pseudarthrosis of the fibula is a rare entity with a limited number of cases reported in the literature. Treatment is challenging because of recalcitrant nonunion and because no consensus about the best treatment plan exists. We report a case of isolated congenital fibular pseudarthrosis with valgus deformity of the ankle. The patient had a history of two failed operations. We used a novel surgical plan that combined tibiofibular synostosis with fibular segment transfer through a unilateral external fixator. The patient showed good early results with fibular union. We advocate the combination of tibiofibular synostosis and fibular segment transfer to restore the integrity and stability of the ankle in recalcitrant isolated congenital fibular pseudarthrosis cases with a history of failed surgery.

Background: Fibular hemimelia is the most common congenital long-bone deficiency. It is usually unilateral and results in a limb-length discrepancy. The literature generally subscribes to the concept of constant inhibition, a process by which limb-length ratios between the shorter and longer extremity remain constant throughout growth, but scientific data supporting this concept are sparse. Additionally, recent literature suggests that these children have abnormal skeletal maturation.Objective: To elucidate the lower-extremity long-bone growth patterns and skeletal maturation of children with unilateral fibular hemimelia.Materials and Methods: We reviewed medical records of children with unilateral fibular hemimelia seen at a large pediatric hospital over a 17-year period. Inclusion criteria were: at least two scanograms prior to any shortening/lengthening procedure, and no other congenital or acquired disorders. We collected the study cohort's femoral and tibial lengths (scanogram reports), plotted them against patient chronological ages and compared them to published growth standards. When these children's bone ages (Greulich and Pyle) were available, we plotted them against the children's chronological ages.Results: Twenty-three children were included (total=115 scanograms). At least 1 bone-age assessment was performed in 19 children (total=84 bone ages). All bone growth curves were within normal growth standards for the femur and tibia. Length ratios between shorter and longer limbs remained constant. Skeletal maturation was within two standard deviations of normal in 90% of bone ages.Conclusion: Lower-extremity long bones of children with unilateral fibular hemimelia have relatively normal growth curves, supporting and confirming the concept of constant inhibition. Most children show normal skeletal maturation. [ABSTRACT FROM AUTHOR]

Although it is common practice to assess alignment prior to total knee arthroplasty, preoperative knee alignment and its effect on patient-reported outcomes (PROs) postoperatively has not been well studied. The purpose of this retrospective study was to determine if there are differences in PROs between patients with valgus deformities and patients with varus deformities. Further, this study assessed the baseline differences between these 2 groups preoperatively. Patients were placed into either the valgus or the varus group. Data collected included age, sex, race, height, weight, body mass index, knee alignment, Kellgren-Lawrence grade, and 2 PRO measures. Patient-reported outcomes were assessed preoperatively and at 5 scheduled follow-up visits during the first year postoperatively. The authors found that a higher percentage of female patients had a valgus deformity (84.9%). The varus group tended to have a higher body mass index. Radiographs revealed differences in tibia and femur deformities. The overall deformity was less in patients with a valgus deformity than in patients with a varus deformity (mean, 6.6° [SD, 4.4°] vs 8.6° [SD, 4.8°], P=.010). Preoperative Knee injury and Osteoarthritis Outcome Score symptoms were significantly worse in the valgus group (P=.033). After adjusting for the significant baseline differences, all patients reported improved PROs during the postoperative period (P<.0001). Preoperatively, patients with valgus deformities and patients with varus deformities do not appear to be mere opposites of one another. The groups differed by sex, Knee injury and Osteoarthritis Outcome Score symptoms, and tibia, fibula, and overall deformity. Postoperatively, there were no significant differences in PROs during and up to 1 year. [Orthopedics. 2018; 41(6):e783-e788.]. [ABSTRACT FROM AUTHOR]

Adult-acquired flatfoot deformity is a progressive flattening of the arch of the foot that results from posterior tibial tendon insufficiency with a predilection for middle-aged women. A lateralized force vector associated with hindfoot valgus in adult-acquired flatfoot produces lateral ankle pain due to impingement at the lateral hindfoot, which can even lead to stress fractures of the distal fibula. Here, we present the rare case of a 73-year-old woman who presented with stress fractures of the bilateral taluses and unilateral distal fibula accompanied by severe adult-acquired flatfoot deformities. [ABSTRACT FROM AUTHOR]

Introduction: Composite perigenual defects (CPGDs) are exacting the expertise of the reconstructive surgeons. Segmental skeletal defects continue to be a challenge for both orthopedic and plastic surgeons. There are many techniques available for the reconstruction of segmental skeletal defects in the perigenual region. This study explores the outcomes of pedicled chimeric propelled osteomyocutaneous fibula flap reconstruction of post traumatic and post excisional composite perigenual defects (CPGDs) MATERIALS AND METHODS: It was a retrospective study conducted from 2011 to 2016 including 16 patients (5 post excisional defects and 11 post traumatic defects). 14 males and 2 females were included. Ages of the patients were ranging from 24 to 46 years. All had their CPGDs reconstructed with chimeric pedicled propelled fibula osteomyocutaneous flap RESULTS: All 15 patients on an average of 26 months follow-up assumed pain free unrestrictive walking. Fracture of hardware and transferred fibula occurred in one case 2 1/2 years following the surgery. Other patients had good functional recovery in an average of 26 months follow up. The average MSTS score of 15 patients was 23.9.Conclusion: This anatomically construed procedure will be addendum to the armamentarium of reconstruction in both post excisional limb salvage milieu and secondary posttraumatic context for the perigenual composite defects. With high healing potential, infection culling capacity, high osteogenic potential and good supportive hardwares the pedicled osteomyocutaneous fibula flap may usher in better outcome in composite perigenual defects reconstruction. [ABSTRACT FROM AUTHOR]

Background: The classic metaphyseal lesion (CML) is strongly associated with infant abuse, but the biomechanics responsible for this injury have not been rigorously studied. Radiologic and CT-pathological correlates show that the distal tibial CML always involves the cortex near the subperiosteal bone collar, with variable extension of the fracture into the medullary cavity. Therefore, it is reasonable to assume that the primary site of bone failure is cortical, rather than intramedullary.Objective: This study focuses on the strain patterns generated from finite element modeling to identify loading scenarios and regions of the cortex that are susceptible to bone failure.Materials and Methods: A geometric model was constructed from a normal 3-month-old infant's distal tibia and fibula. The model's boundary conditions were set to mimic forceful manipulation of the ankle with eight load modalities (tension, compression, internal rotation, external rotation, dorsiflexion, plantar flexion, valgus bending and varus bending).Results: For all modalities except internal and external rotation, simulations showed increased cortical strains near the subperiosteal bone collar. Tension generated the largest magnitude of cortical strain (24%) that was uniformly distributed near the subperiosteal bone collar. Compression generated the same distribution of strain but to a lesser magnitude overall (15%). Dorsiflexion and plantar flexion generated high (22%) and moderate (14%) localized cortical strains, respectively, near the subperiosteal bone collar. Lower cortical strains resulted from valgus bending, varus bending, internal rotation and external rotation (8-10%). The highest valgus and varus bending cortical strains occurred medially.Conclusion: These simulations suggest that the likelihood of the initial cortical bone failure of the CML is higher along the margin of the subperiosteal bone collar when the ankle is under tension, compression, valgus bending, varus bending, dorsiflexion and plantar flexion, but not under internal and external rotation. Focal cortical strains along the medial margins of the subperiosteal bone collar with varus and valgus bending may explain the known tendency for focal distal tibial CMLs to occur medially. Further research is needed to determine the threshold of applied forces required to produce this strong indicator of infant abuse. [ABSTRACT FROM AUTHOR]

Objective: To detect venous or arterial obstruction in the pedicle of a free flap we can monitor resistance in the flap bed which is reflected in Pulsatility Index (PI) Therefore if we detect change in the values of the PI in these flaps then we can detect complications in flap due to vascular insufficiency early. Materials and Methods: Seven patients of Free Fibular Flap Reconstruction and ten patients of Free Radial Forearm Flap reconstruction were evaluated over a period of 18 months. In the pre op we recorded PI of Radial and Peroneal artery using colour doppler study. In the Post Operative Period 2 readings of PI at the anastomotic site were taken on Day 1 and Day 7. Results: Both Free Radial Forearm and Free Fibula flaps which were healthy (n = 15) showed a significant decrease in PI values on first Post Op day as compared to Pre Op. Also there was a significant fall in PI on Post Op Day 7 as compared to post op Day 1(P < 0.05) in these flaps. The flaps developing complications (n = 2) had significantly higher Day 1 Post op PI readings as compared to healthy flaps (P < 0.05). Conclusion: PI is an objective index which can indicate changes in perfusion of free flaps used in Head and Neck reconstruction based on which we can predict if a flap is susceptible to circulatory compromise. [ABSTRACT FROM AUTHOR]

Fibular hemimelia presents with foot deformity and leg length discrepancy. Previous classifications have focused on the degree of fibular deficiency rather than the type of foot deformity. Published methods of surgical reconstruction have often failed due to residual or recurrent foot deformity. The purpose of this report is to introduce new classification and reconstruction methods. The Paley SHORDT procedure is used to stabilize the ankle when there is a hypoplastic distal fibulawith a dynamic valgus deformity. It involves shortening and realignment of the distal tibia relative to the fibula. In contrast, the Paley SUPERankle procedure is used when there is a fixed equinovalgus foot deformity. The SUPERankle uses a supramalleolar shortening-realignment osteotomy and/or subtalar osteotomies with anlage resection. Due to the bony instead of soft tissue correction of deformity, residual or recurrent deformity is prevented. Weakening of gastro-soleus and peroneal muscles is avoided by shortening of the tibia instead of tendon lengthening. The limitation of ankle motion is related to ankle dysplasia rather than surgery or lengthening. A plantigrade-stable foot and ankle leads to an excellent functional result comparable or better than a Syme's amputation with prosthetic fitting. Serial lengthening procedures combined with the SHORDT or SUPERankle reconstruction lead to limb length equalization with a plantigrade, painless, functional foot. [ABSTRACT FROM AUTHOR]

Tibial deficiency (also known as tibial hemimelia) is a rare condition with variable presentation. A 2-month-old patient presented with absent bilateral tibias. When the patient was 1 year, a novel reconstructive surgery was done. A bilateral fibular resection with pedicled calcaneus transfer was done, allowing for transfer of the calcaneus along with the overlying glabrous skin and soft tissues to the end of the femur. The patient was permitted to weight-bear after the 4-week postoperative follow-up. At the six-month follow-up, the patient was able to pull to stand and walk with assistance without any reports of pain., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Highlights: [•] The study is focused on the occurrence of nerve abnormalities (size and echotexture) at ultrasonographic examination in fibular nerve conduction block and relationship with neurophysiological findings. [•] The study shows that a normal ultrasound is usually present in a fibular nerve conduction block, but in case of additional axonal damage is associated with an increase of cross sectional area. [•] The importance of our study is the possible diagnostic/prognostic value of the ultrasound in cases of fibular nerve conduction block: normal CSA might indicate a better prognosis. [ABSTRACT FROM AUTHOR]

Fibular hemimelia is defined as a partial or complete absence of the fibula. Alongside fibular deformities, there is a wide spectrum of anomalies, foot deformities, and absent rays. A literature review showed only a handful of cases of prenatal diagnosis of fibular hemimelia. It is a rare disorder that might be isolated or associated with visceral anomalies., (©2022 JOURNAL of MEDICINE and LIFE.)

Background: Congenital longitudinal deficiency of the fibula is the most common lower extremity congenital deficiency, with a broad spectrum of severity and subsequent reconstructive treatment. Published classification schemes do not accurately predict reconstructive treatment currently in practice. Methods: We reviewed all medical records of patients with a dominant deformity of congenital fibular deficiency who were managed at our institution between 1971 and 2005. We assessed the impact of limb-length inequality, foot deformity, bilateral extremity involvement, and extent of fibular preservation on the treatment of the limb deficiency. Results: One hundred and four patients (including twenty-two with bilateral congenital fibular deficiency) with 126 affected extremities had adequate radiographs to be included in the study. Femoral shortening was noted in seventy (85.4%) of eighty-two patients with unilateral limb involvement. Limb-length discrepancy prior to any treatment remained proportional in forty-seven (82.5%) of fifty-seven patients during an average duration of follow-up of ten years and ten months (range, two years to fifteen years and six months). Limb salvage with foot preservation was deemed feasible in thirty-eight (97.4%) of thirty-nine five-rayed feet, thirty (81.1%) of thirty-seven four-rayed feet, twenty (48.8%) of forty-one three-rayed feet, and one of nine feet having fewer than three rays. Twenty-two (41.5%) of fifty-three limbs with an absent or vestigial fibula were not treated with amputation. Of the twenty-two patients with bilateral fibular deficiency, twelve (54.5%) had preservation of both feet, three (13.6%) had unilateral amputation, and seven (31.8%) had bilateral amputation. Conclusions: We propose a simplified classification for congenital fibular deficiency based on the clinical status of the foot and the magnitude of limb shortening as a percentage of the contralateral limb on radiographs. This classification may be effectively applied in infancy to allow the physician and family to anticipate the extent of deformity at maturity and to estimate the amount of treatment required to reconstruct this limb deformity. This system more accurately predicted the management of patients with fibular deficiency who were managed at our institution over the past three decades. [ABSTRACT FROM AUTHOR]

A syndesmosis is defined as a fibrous joint in which two adjacent bones are linked by a strong membrane or ligaments. This definition also applies for the distal tibiofibular syndesmosis, which is a syndesmotic joint formed by two bones and four ligaments. The distal tibia and fibula form the osseous part of the syndesmosis and are linked by the distal anterior tibiofibular ligament, the distal posterior tibiofibular ligament, the transverse ligament and the interosseous ligament. Although the syndesmosis is a joint, in the literature the term syndesmotic injury is used to describe injury of the syndesmotic ligaments. In an estimated 1-11% of all ankle sprains, injury of the distal tibiofibular syndesmosis occurs. Forty percent of patients still have complaints of ankle instability 6 months after an ankle sprain. This could be due to widening of the ankle mortise as a result of increased length of the syndesmotic ligaments after acute ankle sprain. As widening of the ankle mortise by 1 mm decreases the contact area of the tibiotalar joint by 42%, this could lead to instability and hence early osteoarthritis of the tibiotalar joint. In fractures of the ankle, syndesmotic injury occurs in about 50% of type Weber B and in all of type Weber C fractures. However, in discussing syndesmotic injury, it seems the exact proximal and distal boundaries of the distal tibiofibular syndesmosis are not well defined. There is no clear statement in the Ashhurst and Bromer etiological, the Lauge-Hansen genetic or the Danis-Weber topographical fracture classification about the exact extent of the syndesmosis. This joint is also not clearly defined in anatomical textbooks, such as Lanz and Wachsmuth. Kelikian and Kelikian postulate that the distal tibiofibular joint begins at the level of origin of the tibiofibular ligaments from the tibia and ends where these ligaments insert into the fibular malleolus. As the syndesmosis of the ankle plays an important role in the stability of the talocrural joint, understanding of the exact anatomy of both the osseous and ligamentous structures is essential in interpreting plain radiographs, CT and MR images, in ankle arthroscopy and in therapeutic management. With this pictorial essay we try to fill the hiatus in anatomic knowledge and provide a detailed anatomic description of the syndesmotic bones with the incisura fibularis, the syndesmotic recess, synovial fold and tibiofibular contact zone and the four syndesmotic ligaments. Each section describes a separate syndesmotic structure, followed by its clinical relevance and discussion of remaining questions. [ABSTRACT FROM AUTHOR]

The article presents a study on compression injuries as the most common cause of peroneal neuropathy. It states that leg-crossing and prolonged immobility can cause compression injuries which damage the head of fibula. It mentions the application of ankle-foot orthotsis (AFO) devices can serve as a primary remedy for peroneal neuropathy or foot drop and that treatments for the condition are not fully based on concrete science. Moreover, the study suggests that foot drop can be prevented.

Background: McCune Albright syndrome is rare with an estimated prevalence of 1 in 100,000 to 1 in 1,000,000 persons. The classical clinical triad consists of fibrous dysplasia of the bone, café-au-lait skin spots and precocious puberty. However, in rare cases, there may be primary hypogonadism and amenorrhea. Case Presentation: An eighteen-year-old female presented with amenorrhea. She had a short stature, round face, thick neck, and short fourth metacarpals and metatarsals. The secondary sexual characters were absent. Serum calcium, phosphorus and parathyroid concentrations were normal, but gonadotropin hormones were very low. Xray examination revealed short fourth and fifth metacarpals, short left metatarsal, and short fibula. Conclusion: These local bony abnormalities along with the biochemical findings helped us to diagnose this case as an unusual presentation of primary hypogonadism with features of McCune Albright's syndrome where there was amenorrhea rather than preocious puberty. [ABSTRACT FROM AUTHOR]

Abstract: E/FA is the combination of ectrodactyly (split hand/foot malformation, SHFM) and fibular aplasia. It is a rare disorder considered to be inherited in an autosomal dominant fashion with reduced penetrance and variable expression. In order to determine recurrence risks for the two patients we describe, the literature on inheritance of E/FA was carefully reviewed. In our opinion, only two of the eight families previously reported as examples of familial E/FA may fit this judgment. Until mutation analysis of all SHFM genes is possible, the question remains whether these familial cases represent autosomal dominant E/FA, or an allelic variant of an SHFM subtype. Many sporadic patients with presumed E/FA may represent the fibular developmental field defect, which is a non-genetic entity with a low recurrence risk. We therefore suggest that the high recurrence risk associated with autosomal dominant inheritance should not be counselled in patients with E/FA unless their family shows the following characteristics: (1) at least one patient shows typical SHFM combined with fibular aplasia, (2) multiple limbs are affected, and (3) multiple family members are affected in at least two generations. [Copyright &y& Elsevier]

Objective: To assess the prosthesis adaptability at use of pedestal and transtibial prosthesis, recognize the average age of amputation surgery, and the complications of the amputation in patients with fibular hemimelia. Material and methods: 47 patients were evaluated, initially to adjust pedestal prosthesis and when this was not tolerated, we realizes amputation and adaptation of transtibial prosthesis, we valued the average age of amputation surgery, the associate complications and the prosthesis adaptability we use de K system for functional ambulation. Results: Of the 12 patients to actually use pedestal prosthesis 9 (75%) had a K-2 level, 3 (25%) had a K-3 level, of the 35 patients to use transtibial prosthesis 1 (3%) had a K-2 level, 19 (54%) K-3 level, and 15 (43%) in the K-4 level. The average age to amputation surgery was 3.9 years old, one case had a complications. Discussion: The early prosthesis adaptability provides advantages in the functional ambulation, as demonstrated on the results. The goal of the transtibial amputation is to facilitate the prosthesis adaptability, is due to take advantage of the best functional adaptation the child in the first years of life, circumstance that improves the integral rehabilitation of the patient. [ABSTRACT FROM AUTHOR]

Although the Ilizarov device (and technique) to treat problematic fractures and bone deformities has been used since the 1950s in the former Soviet Union, the technique was not introduced to the United States until 1984. Since that time, the technique has become increasingly popular because, in comparison with the alternatives, the Ilizarov technique involves only one surgical procedure and it appears to have fewer complications. In addition, the Ilizarov technique was designed to correct multiple deformities simultaneously. The DATTA panelists thought that the technique was established in terms of safety and effectiveness as a treatment of limb length deformity, bone defects, and angular/rotational deformity of the long bones. The panelists thought that it was promising in terms of safety and effectiveness as a treatment of pseudarthrosis. However, this overall endorsement of the technique was tempered by comments that the technique was associated with a lengthy learning curve, was very labor intensive, and required a large degree of patient cooperation. [ABSTRACT FROM AUTHOR]

Weismann-Netter-Stuhl syndrome is a rarely reported cause of bowed legs; hence a thorough clinical and radiological examination is needed for its diagnosis. In view of the paucity of reports guiding the treatment of the deformity, we propose a one-level/two-level osteotomy with intramedullary nail fixation as a treatment modality for the tibial bowing. [ABSTRACT FROM AUTHOR]

Intramedullary rod fixation is presented as a viable treatment option for distal fibular fractures in the geriatric population. This technique leads to a reduction in wound complications, hardware irritation, procedure time and need for subsequent surgeries as seen with traditional open reduction internal fixation for distal fibular fractures in higher-risk patients. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: For unstable ankle fractures, surgeons typically employ the long-time standard of care; that is, open reduction and internal fixation with plate and screws. For patients with increased risk of soft tissue complications, a relatively newer construct includes intramedullary distal fibula fixation offering a viable option providing similar union rates, fracture alignment, and theoretical lower infection rate. Our study examines an intramedullary system with a novel design featuring fixation by proximal talons ensuring maintenance of alignment, rotation, and prevention of fracture settling. Our research builds on recent published work evaluating this intramedullary device. However, our study is the largest case-series, to our knowledge to assess time to weightbearing, fracture union and union rate as well as the first to assess safety and reproducibility of percutaneous reduction. Methods: A retrospective case-series was conducted on all skeletally mature patients with unstable ankle fractures treated with the same intramedullary distal fibular fixation. Surgeries were performed by a single surgeon between September 2015 and August 2019. Patient post-operative imaging was carefully assessed for quality of reduction, classifying reductions as 'good,' 'acceptable,' or 'poor,' also assessing for union and fracture settling. Patient charts were also assessed for comorbidities, injury pattern, fracture classification, associated injuries, fracture reduction method, perioperative complications, tourniquet time, characteristics of fracture union, time to weight bearing, and need for additional surgery. Results: Fifty-one patients were included in the study. Mean follow-up time was 32.2 weeks. Four fractures were bimalleolar (7.8%), 44 were isolated distal fibula fractures (86.3%), and 3 were trimalleolar fractures (5.9%). Two percent were Weber A, 77% Weber B, and 11% Weber C. Thirty-five (69%) reductions were achieved closed or percutaneously without complications. Based on reduction classification system, 47 fracture reductions (92%) were classified as 'good' and 4 (8%) were 'acceptable'. All but one fracture (98%) went on to union. Average time to union was 10.3 weeks. Average weightbearing in a walking boot was at 6.8 weeks and 11.2 weeks without immobilization. One patient (2%) had a superficial wound infection, and there were no deep infections. Diabetes, smoking, and neuropathy were not predictive of complications. Conclusion: Our study strengthens the growing body of evidence supporting the safety and efficacy for a novel intramedullary device with unique proximal fixation. To our knowledge, this is currently the largest retrospective case-series in the literature evaluating this device. Fracture union and union rates were found to be acceptable for unstable ankle fracture patterns and infections rates were found to be very low, consistent with previous research. Percutaneous reduction of the lateral malleolus did not result in any injury to nearby anatomic structures or unsatisfactory fracture alignment. Lastly, consistent time to weight bearing following surgery could safely be achieved without consequence. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: Truly isolated Weber B distal fibula fractures are stable injuries that usually recover well following nonoperative treatment, however the concern over the possibility of a medial ligament injury, and ankle instability has traditionally lead to regular surveillance in the fracture clinics to exclude delayed talar shift developing. After recent studies suggesting this risk is low we introduced a new functional treatment protocol and present our early results. Methods: 141 consecutive patients presenting acutely with isolated Weber B fractures without talar shift during a 12 months period were included. ED notes and radiographs were reviewed. All patients were splinted in a removable boot, and allowed to fully weight bear up to their comfort levels. Patients without signs of a medial ligament injury were then discharged from follow-up with advice to wear the boot for 6 weeks, an information leaflet and exercise sheet and a helpline number in case of difficulties. If they wanted clinic review this was organised. If signs of a medial ligament injury were documented, or the medial findings were not clear the patient was reviewed with up to date radiographs in the fracture clinic at 4 weeks post-injury. If talar shift developed the patient was to be converted to operative treatment. Olerud and Molander scores were collected between 6 and 12 months postinjury. Results: There were 51 patients without signs of medial ligament injury and of these 23 were discharged according to protocol and 28 patients attended fracture clinic. 89 patients had signs of medial ligament injury or no documented medial findings and of these 65 attended fracture clinic. One discharged patient re-accessed care. Of 93 patients reviewed in the fracture clinic none developed delayed talar shift. One underwent delayed ORIF for ongoing fibula discomfort and the remainder continued with nonoperative treatment. 99 (70%) patients provided outcome scores. The mean Olerud and Molander score at a minimum of 6 months follow-up was 87 and the median score was 100. No significant difference was found between treatment arms. The scores were comparable to those in the published literature. Conclusion: We conclude the risk of delayed talar shift is low and satisfactory outcomes can be safely achieved with our functional protocol. Additional tests/imaging to establish the integrity of the medial ligament may be unnecessary. [ABSTRACT FROM AUTHOR]

Abstract: We present the first ever reported case of bilateral total knee replacements in a congenital amputee with bilateral fibular deficiency. A 60year old woman with bilateral fibular hemimelia presented with advanced osteoarthritis in both her knees for which bilateral total knee replacements was performed. The left knee replacement was followed up at 12months and the right knee at 7years. Oxford knee scores improved from 14 to 40 for the left knee and were 37 for the right knee. She was able to walk independently to a distance beyond 400 m. Modification in the surgical procedure and postoperative rehabilitation is discussed. Mid-term follow-up of 7years reaffirms total knee replacement as a viable option for below knee amputees with knee osteoarthritis. [Copyright &y& Elsevier]

We report a case of vascularised fibula osteocutaneous flap used for composite cervical spinal and posterior pharyngeal wall reconstruction, in a patient with recurrent skull base chordoma, resected by an anterior approach via median labio-mandibular glossotomy approach. Bone stability and pharyngeal wall integrity were simultaneously restored. [ABSTRACT FROM AUTHOR]

Weismann-Netter-Stuhl (WNS) syndrome is a rare skeletal anomaly that affects the diaphyseal part of both the tibiae and fibulae with posterior cortical thickening and anteroposterior bowing. This anomaly is usually bilateral and symmetrical. The patients are generally of short stature. In some cases, a family history suggesting genetic transmission of a mutation with an unknown locus has been reported. In this paper we present an infant with WNS syndrome with bilateral involvement of the femur. Similar clinical findings were defined in three other family members. [ABSTRACT FROM AUTHOR]

Key Clinical Message: We describe a case of association of congenital bone abnormalities. It will allow clinicians to look systematically for other skeletal malformations and teach them how to evaluate these cases for the first time. This early screening will enable appropriate treatment to avoid complications and to preserve functional prognosis. [ABSTRACT FROM AUTHOR]

Objective: To explore the genetic basis for a pedigree affected with Charcot-Marie-Tooth (CMT) disease through high-throughput sequencing., Methods: Potential variants of the genes associated with CMT were screened by next-generation sequencing (NGS) of the members of the pedigree., Results: NGS has revealed that the two affected sisters both harbored homozygous c.1A>G variant of the GDAP1 gene, which caused replacement of the first amino acid Methionine by Valine (p.Met1Val). Their parents were both carriers of the heterozygous c.1A>G variant. The variant was unreported previously and has an extremely low frequency in the population. Meanwhile, one of the sisters and the mother also carried heterozygous c.710A>T variant of the BAG3 gene., Conclusion: The homozygous c.1A>G variant of the GDAP1 gene probably underlay the CMT in both children. Above result has enabled clinical diagnosis and genetic counseling for this pedigree.

The congenital short limb (CSL) with fibular deficiency has traditionally been graded by plain radiography. The most popular orthopedic classification sorts the fibular dysmorphologies into three radiographic groupings: IA (thinned), IB (proximally truncated), or II (absent). In contrast, the soft tissues have been relatively neglected. Since bone formation of the fibula progresses from the anlage, a scaffolding cartilage mold intermediate, cartilage transformation to bone is dependent upon timely embryonic arterial invasion. Absences of the requisite arteries predicate specific skeletal dysmorphologies. The usual arterial supply of the fibula is comprised primarily of the anterior tibialis artery (ATA), which uniquely supplies the proximal portion of the fibula, and also joins the peroneal artery (PA) in supplying the mid to distal fibular shaft. Combinations of the two nutrient arteries allow four potential variations of fibular vascular supply, among which the ATA and PA conjoin to supply the normal fibula and variably supply the three dysmorphic fibular models. The IA and IB deformities conform, respectively, to the absences of the PA and the ATA. Combined ATA and PA absences present in the radiographically "absent" fibula. Thus, each of the four fibular (dys)morphologies conforms to a specific embryonic pattern of arterial development. The term "dystrophism" most accurately characterizes such malformed long bones., (© 2019 American Association for Anatomy.)

Purpose: Fibula hemimelia is the most common congenital deficiency of long bones. Primary treatment options include amputation with prosthetic fitting or limb reconstruction. The aim of our study was to conduct a systematic review comparing amputation with limb reconstruction for fibula hemimelia., Methods: MEDLINE, EMBASE, Web of Science, Elsevier Scopus, and the Cochrane Registry of Clinical Trials were searched from 1951 to 2019 for studies that evaluated amputation versus limb reconstruction for fibula hemimelia. Random effect models were utilized for the meta-analytic comparisons of amputation versus limb reconstruction for patient satisfaction and surgical complications. Descriptive, quantitative, and qualitative data were extracted., Results: Seven retrospective cohort studies were eligible for the meta-analysis, with a total of 169 fibula hemimelia cases. Amputation resulted in an odds ratio of 6.8 (95% confidence interval: 2.4, 19.2) when compared with limb reconstruction in terms of patient satisfaction. Furthermore, limb reconstruction was found to have an odds ratio of 28 (95% confidence interval: 7.8, 100.3) for complications. The total surgical complication rates in the amputation and limb reconstruction groups were 0.2 and 1.2 complications per limb. The rate of surgical procedures per patient was 1.5 and 4.2 for amputation and limb reconstruction, respectively., Conclusions: The cumulative evidence at present indicates better patient satisfaction with less surgical complications and less number of procedures with amputation for fibula hemimelia when compared with limb reconstruction. Absence of uniform protocols make it difficult to compare results accurately., Level of Evidence: Level III-therapeutic.

Background: Patients with congenital fibular deficiency often develop genu valgum secondary to lateral femoral condylar hypoplasia. Guided growth strategies are often performed to correct limb alignment when adequate skeletal growth remains., Methods: A retrospective review of patients with postaxial hypoplasia of the lower extremity managed with an amputation strategy and who had a guided growth procedure for coronal plane limb malalignment during their course of treatment was performed. Clinical and radiographic data, including measures of coronal plane deformity and alignment, type of amputation, subsequent operative procedures, and complications were recorded., Results: Seventeen patients (20 extremities) met study inclusion criteria (mean follow-up 8.8 y). Foot ablation and hemiepiphysiodesis for valgus deformity of the knee was performed in all extremities. The average age at the time of initial hemiepiphysiodesis was 11.2 years at an average of 8.8 years from the initial amputation procedure. The mean preoperative mechanical axis deviation was 26.5 mm, which was corrected to a mean mechanical axis deviation of 7.0 mm. Fifteen (75%) of the extremities had correction of the deformity to neutral alignment after the initial procedure. Lack of correction occurred in 3 extremities, and overcorrection occurred in 2 extremities. Additional procedures were required in 5 extremities for rebound valgus deformity after hardware removal., Conclusions: In patients with postaxial hypoplasia, regular monitoring of the residual limb for growth-related changes must occur to ensure optimal function and prosthetic fit. Timing of the guided growth procedure is critical, as younger patients may be more likely to experience rebound deformity. Families and patients should be made aware that growth might be unpredictable in this population with risks of both overcorrection and undercorrection., Level of Evidence: Level IV-case series.

Background: Congenital pseudarthrosis of the fibula (CPF) is a rare disorder characterized by a deficiency in the continuity of the fibula and can lead to progressive ankle valgus malalignment. An existing classification system for CPF is imperfect and may contribute to heterogeneity in reporting and discrepancy of outcomes in the literature., Methods: Fifteen patients with CPF treated at our institution between 1995 and 2017 were retrospectively identified. Only patients with dysplasia leading to spontaneous fracture or pseudarthrosis were included in this series. The median age at presentation was 2.5 years (range: 3 mo to 13.4 y). The median duration of follow-up from the initial presentation was 11.8 years (range: 2.0 to 24 y). Chart review and serial radiographs were analyzed to assess natural history and outcomes following surgery., Results: The coexistence of tibial dysplasia in CPF is very common. Patients were classified into 3 groups based on the degree of tibial involvement-group 1: no evidence of tibial dysplasia, group 2: mild tibial dysplasia, and group 3: significant tibial dysplasia. Age at presentation and age at which fibular fracture occurred were progressively younger with a greater degree of tibial involvement (P<0.05). In the absence of surgical intervention, group 1 patients did not undergo progressive ankle valgus (defined as the valgus change in tibiotalar angle by ≥4 degrees), whereas all patients in groups 2 and 3 did (P<0.001). Fibular osteosynthesis was performed in 6 patients, with union seen only in group 1 patients. Ten patients underwent distal tibiofibular fusion, with no cases of nonunion seen. Distal tibiofibular fusion with or without medial distal tibial hemiepiphysiodesis halted the progression of ankle valgus in 8 of the 10 patients. Further progression of ankle valgus occurred only in patients who did not undergo concurrent medial distal tibial hemiepiphysiodesis and with considerable wedging of the distal tibial epiphysis at the time of fusion., Conclusions: Tibial dysplasia and CPF are intimately related. Grouping patients on this basis may help guide natural history and treatment and may explain discrepancies in findings in the literature. Fibular osteosynthesis, distal tibiofibular fusion, and medial distal tibial hemiepiphysiodesis may all have an important role in the treatment of CPF., Level of Evidence: Level IV-case series.

Background: congenital posteromedial bowing of tibia (CPMBT) is a very rare birth defect, characterized by shortened bowed leg and ankle deformity. We described a single institution experience in the management of CPMBT., Methods: we identified 44 CPMBT in 44 children. The age at presentation was 5.5 ± 5.6 years and the mean age at the final review was 10.1 ± 4.8 years. Radiographic evaluation included the antero-posterior and lateral inter-physeal angle (AP-IPA and L-IPA), the limb length discrepancy (LLD), the morphology of the distal tibia and the lateral distal tibial angle (LDTA). During the study period, 26 children underwent surgical treatment., Results: the estimated curves showed a progressive spontaneous correction of both AP-IPA and L-IPA during growth, but a progressive increase of the LLD. The L-IPA showed a more predictable behaviour while the AP-IPA showed a scattered correction, with a wider variation of the estimated final angle. The final LDTA was 85.3° ± 4.2° and was correlated with the L-IPA (r = 0.5; p = 0.02). Among the 26 children who underwent surgical treatment, 23 cases had limb lengthening, 1 case had contralateral epiphysiodesis, 1 child underwent tibial osteotomy, 1 patient was treated by hemiepiphysiodesis of the distal tibia to correct ankle valgus deformity., Conclusions: our study described the largest case series of CPMBT. A combination of surgical treatments, in a staged surgical process, should be tailored to the developmental characteristics of this abnormality. An experience-based algorithm of treatment is also proposed. Further studies are needed to understand which is the best strategy to correct this deformity during childhood., Level of Evidence: level IV prognostic study.

Defects occurring in the femoral-fibular-ulnar developmental field are believed to cause the cluster of anomalies seen with femoral, fibular and ulnar limb deficiencies. Upper limb function must be considered in the management of lower limb deficiencies. The purpose of this study is to determine the frequency and type of upper extremity anomalies found in children with femoral and/or fibular deficiency. A retrospective review of 327 consecutive patients with the diagnosis of femoral and/or fibular deficiency was performed using existing records and radiographs. Characteristics of those with and without upper extremity anomalies were compared. Upper extremity anomalies were identified in 56 patients. They were more common among those with bilateral, compared with unilateral, lower extremity deficiencies (P < 0.0001). Seventy-five upper limbs were involved with 50 ulnar deficiencies, nine congenital transhumeral deficiencies, four congenital shoulder disarticulations, seven cleft hands, two radial head dislocations and one each - radial deficiency, syndactyly and capitate-lunate coalition. Two patients with bilateral upper extremity anomalies had ulnar deficiency on one side and a transverse deficiency on the other. Upper extremity anomalies are found in 17% of children with femoral and/or fibular deficiency, especially with bilateral lower extremity involvement. Ulnar deficiency is the most common type but one-third had other anomalies. The frequent finding of congenital transverse upper extremity deficiencies suggests there may be common embryology.

Background: Deformity of the tibia, including shortening and angulation, may accompany severe forms of postaxial hypoplasia (fibular deficiency). The current literature reflects varying opinions on the appropriate management for tibial deformity in the setting of fibular deficiency., Methods: We performed a retrospective review to determine outcomes of tibial deformity correction in patients with a primary diagnosis of fibular deficiency. Clinical and radiographic outcomes of patients treated with foot ablation were reviewed to establish indications for tibial deformity correction, identify occurrence of additional surgical procedures related to limb alignment or deformity, and characterize difficulties with prosthetic wear potentially related to residual or recurrent tibial deformity., Results: From 1989 to 2016, 51 patients (57 extremities) with fibular deficiency were managed with a foot ablation procedure. Twenty-five (44%) had simultaneous correction of the tibial deformity. The initial tibial deformity measured 42.5 degrees, was corrected to 5.6 degrees intraoperatively, and measured 18.6 degrees at follow-up, suggesting recurrent deformity. In follow-up, approximately half of the patients complained of redness and one third complained of a continued prominence along the anterior tibia. Thirty-two extremities had an isolated foot ablation procedure without tibial osteotomy. Radiographic review demonstrated mild tibial bowing at the time of amputation with a mean angular deformity of 15.4 degrees and remained unchanged during the follow-up period (mean, 12.7 degrees). Similar to the osteotomy group, approximately half of the patients complained of redness and erythema over the anterior bow, with one fourth noting prominence, and only 2 reporting significant pain., Conclusions: Tibial osteotomies in patients with more significant degrees of angular deformity can be safely performed at the same setting as foot ablative procedures for fibular deficiency. Recurrent deformity with growth may occur. Patients and their caregivers should be aware that rebound deformity may occur, but typically can be managed with prosthetic adjustment and without significant disruption to the child's daily activities., Level of Evidence: Level IV (case series).

Background: The os subfibulare is usually asymptomatic and found incidentally on radiographs. However, sometimes it may cause subfibular pain and may be associated with chronic lateral ankle instability (CLAI). We hypothesized that os subfibulare could interrupt the talofibular space causing impingement, resulting in chronic pain and functional instability around the lateral malleolus. The purposes of this study were to analyze morphologic characteristics of os subfibulare, and to evaluate the clinical significance of the os subfibulare in patients with CLAI., Methods: Between November 2011 and April 2015, 70 patients who had both computed tomography (CT) and magnetic resonance imaging (MRI) among 252 patients who visited our hospital with the symptom of lateral ankle instability were included in this study. The location of the ossicle was classified into 3 zones in reference to the attachment site of the lateral ankle ligaments. The impingement was classified into 2 groups according to the presence of talofibular encroachment. Digital radiographs were used to measure the ossicle width and shape determined by the length and width on an magnetic resonance (MR) image., Results: The most common shape of ossicles was oval, and the most common location of ossicles was at the anterior talofibular ligament (ATFL) attachment site. Sixty-one percent of patients showed talofibular impingement on coronal MR images. In 48 cases, the dimension of fibula plus os subfibulare was larger than that of the contralateral normal fibula. The larger size and talofibular impingement of the ossicle were associated with greater need for operative treatment in patients with ankle instability., Conclusion: The morphologic analysis of the os subfibulare revealed that there might be impingement of the talofibular space by the ossicle in some patients. We suggest that morphologic characteristics of the os subfibulare should be considered when selecting treatment options in patients with CLAI and os subfibulare., Level of Evidence: Level III, retrospective comparative series.

Case: We report a case of a child with widely divergent congenital inferior tibiofibular diastasis with persistent sciatic artery (PSA). The dysplastic tibia and fibula were widely divergent, and the fibula was displaced proximally and medially with the foot alongside the thigh between the 2 legs, with PSA diagnosed on computed tomography angiogram. The child was treated with fibula-foot complex excision and below-knee prosthesis and was ambulating independently at 1-year follow-up., Conclusions: The combination of a major structural anomaly (tibiofibular diastasis with a separate soft-tissue cover) and an unusual vascular malformation (PSA) has not been reported previously and made surgical reconstruction challenging.

Most of the anatomic variations of the extensor hallucis longus (EHL) muscle are related to the tendon of insertion. We show a double origin of the EHL from the medial aspect of the fibula and the lateral aspect of the tibia. A 27-year-old male with a double closed fracture of tibia and fibula showed an involuntary extension of the big toe during foot plantar flexion after surgery. A tendon fibrosis by the fixation plates could be the cause of the foot functional alteration. Interestingly, the anatomic variation described could be related to the postsurgical foot dysfunction, since when the fibrotic tissue was removed the normal extension of big toe recovered. As illustrated in this case report, knowledge of anatomic variations is very useful, particularly in the context of foot surgery.