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TRAUMATOLOGY Table of Contents   
Year : 2006  |  Volume : 40  |  Issue : 4  |  Page : 247-249
Partial resection of fibula in treatment of ununited tibial shaft fractures


Govt. Hospital for Bone & Joint Surgery, Srinagar, India

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   Abstract 

Background : In management of fracture of both tibia and fibula, intact fibula may delay union of tibial fractures.
Method : Twenty five cases of ununited fractures of tibia were managed between 1997 and 2004, by partial fibulectomy done after 20 weeks after fracture and a POP cast given for 4 weeks which was changed to a PTB cast and weight bearing encouraged at the earliest.
Result : All fractures united at an average time of 14 weeks (range 6 to 20 weeks) after partial fibulectomy with acceptable alignment in coronal and sagittal planes. There was no neurovascular complication, limitation of joint motion or problem at the osteotomy site.
Conclusion : Partial fibulectomy is a viable option in the management of tibial delayed and non-union.

Keywords: Fibulectomy, non-union, closed fractures.

How to cite this article:
Butt M, Mir B A, Halwai M A, Farooq M, Dhar S A. Partial resection of fibula in treatment of ununited tibial shaft fractures. Indian J Orthop 2006;40:247-9

How to cite this URL:
Butt M, Mir B A, Halwai M A, Farooq M, Dhar S A. Partial resection of fibula in treatment of ununited tibial shaft fractures. Indian J Orthop [serial online] 2006 [cited 2017 Aug 20];40:247-9. Available from: http://www.ijoonline.com/text.asp?2006/40/4/247/34505

   Introduction Top


Early weight bearing in a cast or cast brace as treatment for a fracture of the tibia has resulted in an exceptionally low rate of delayed union (11%), and very few non-unions[1],[2]. In most of these cases of delayed union and non-union posterolateral bone grafting is needed, in certain cases combined with rigid internal fixation.

The removal of a portion of the intact healed fibula to increase compression forces across an ununited fractures of the tibia while weight bearing has been reported by several authors[3],[4]. It is simple technically, gives opportunity to correct any malposition, avoids opening the fracture site thereby the chances of infection and of reducing the vascular supply to the fracture fragments and retains the options of bone grafting with or without plating if union fails to occur[5].


   Material and methods Top


Between 1997 and 2003 twenty-five fractures of the tibial shaft in skeletally mature adults with intact fibula, who had not shown union of the fracture five months or more after injury, were studied. Of the 25 patients in this study, 15 had sustained the tibial fracture during a motor-vehicle accident, seven in fall from a height; and the other three had miscellaneous mechanisms of injury. The average age of the patients was 28 years (range 21 to 52 years). There were 19 males and six females. All fractures were close and 16 were initially displaced. Twenty-one of the fractures were in the middle third, three in the proximal third and one in the distal third. There were no associated injuries. All patients were given long leg cast, with closed reduction of fractures in the displaced ones. The cast was changed to patellar tendon bearing cast at eight weeks and patient encouraged full weight bearing.

An ununited fracture was diagnosed on the basis of following two criteria, at least five months after fracture. First, there was no radiological evidence of normal progression to union between serial monthly examinations. Second, there was pain, tenderness, and warmth at the fracture site with or without clinical motion.

These patients had a partial fibulectomy with weight bearing as the sole treatment for an ununited fractures of the tibia. The operation was usually done twenty to twenty four weeks after the fracture.

The partial fibulectomy consisted of subperiosteal resection of upto 2cms of fibula, at a site remote from the level of the tibial fracture. After fibulectomy, a long leg cast was applied and weight bearing was begun. A patellar tendon bearing cast was applied at four weeks after operation. The patient continued to walk with the PTB cast until union was evident [Figure - 1].


   Results Top


All the 25 tibial fractures healed with the average time of union being fourteen weeks (range, six to twenty weeks) following fibulectomy. In the entire group, there were no operative wound infections or operative injuries to the peroneal artery or nerve. No patient complained of any symptom at the site of fibular resection.

All fractures united within an acceptable alignment in the coronal (average 8°) and sagittal plane (average 10°). One patient with fracture in the distal third complained of mild pain in the ankle with no radiological evidence of osteoarthrosis. there was no limitation of range of motion of ankle or knee joint.


   Discussion Top


Nicoll in his large series of 705 cases has shown that, contrary to common belief, an intact fibula associated with a fractured tibial shaft causes no increase in the incidence of delayed union[6]. However this view was challenged in a clinical study of over 100 tibial fractures with an intact fibula had revealed 26 percent delayed union and 26 percent varus malunion in patients over the age of 20.[7]

The rationale of partial fibulectomy is simple. A fracture of the fibular shaft associated with a fracture of the tibia usually heals in 6-8 weeks.[8] Thus the fibula usually is intact when delayed union of a tibial fracture is diagnosed. The healed or intact fibula may prevent effective compression at the tibial fracture. Jorgensen9 has shown that in the presence of an intact fibula, if a tibial fracture is to be compressed, a considerable fraction of the applied force is spent to deform the intact fibula, thereby decreasing the compression force on the tibial fracture fragments.

Studies by Dehne[1] and Sarmiento[2] have shown that weight-bearing, if it is begun early, will lead to union if one waits long enough. The early fibulectomy in a delayed union is an effort to decrease the period of immobilization. In our patient if the fracture had not shown continuing clinical and radiological signs of progress in healing by twenty weeks, we implemented the fibulectomy regimen. We acknowledge that with further weight bearing, some of the 25 fractures might have healed without fibulectomy, but surely the procedure accelerated the healing.

Delee[10] et al analysed this technique in 40 patients and showed a 77% success rate, with failure being due to the presence of tibial pseudoarthrosis rather than a fibrous non­union[10]. Sorenson[5] reported 30 cases (18 delayed unions and 12 non-unions) in which partial fibular ostectomy was successful in all but one case. Fernandez-Palazzi[3] described fourteen cases of so-called delayed union of tibia in which union of the fracture occurred within seven to eighteen weeks after fibulectomy.

Rankin and Metz[4] reported the cases of four patients who had a fibular ostetomy and had union of the tibial fracture site at an average of 4.1 months after the fibulectomy. Moed and Watson[11] and Seldge et al[12] used partial fibulectomy together with exchange-reamed intramedullary nailing in management of non-union of tibia.

Even now not all centre of trauma management in the developing nations can afford to interlock all tibial fractures and initial treatment for almost all undisplaced and most displaced closed fractures is a POP cast after reduction. In cases presenting with delayed union or non-union partial fibutectomy is still a viable option against internal fixation or external fixation with bone grafting.

 
   References Top

1.Dehne E. Treatment of fracture of the tibial shaft. Clin Orthop. 1969; 66: 159-173.  Back to cited text no. 1    
2. Sarminto A. Functional bracing of tibial fractures. Clin Orthop. 1974; 105: 202-219.  Back to cited text no. 2    
3. Fernandez - Palazzi F. Fibular resection in Delayed union of tibial fractures. Acta Orthop Scand. 1969; 40: 105-118.  Back to cited text no. 3    
4.Rankin EA, Metz. CW. Management of delayed union in early weight bearing treatment of fractured tibia. J Trauma. 1970;10: 751-759.  Back to cited text no. 4    
5.Sorensen KH. Treatment of delayed union and non-union of the tibia by fibular resection. Acta Orthop Scand. 1969; 40: 92-104.  Back to cited text no. 5    
6.Nicoll EA. Fractures of the tibial shaft and survey of 705 cases. J Bone Joint Surg (Br). 1064; 46; 373-87.  Back to cited text no. 6    
7.Teitz CC, Carter DR, Frankel VH. Problems associated with tibial fractures with intact fibula. J Bone Joint Surg (Am). 1980; 62: 770-776.  Back to cited text no. 7    
8.Court-Brown CM. Fractures of the tibia and fibula. In Fractures in adults. Ed. Rockwood and Green Vol.2. Philadelphia: JB Lippincott. 2003l1939-96.  Back to cited text no. 8    
9.Jorgensen TE. The influence of intact fibula on the compression of a tibial fracture or pseudoarthrosis. Acta Orthop Scand. 1974; 45: 119­129.  Back to cited text no. 9    
10.Delee JE, Heckman JD, Lewis AG. Partial fibulectomy for ununited fractures of the tibia. J Bone Joint Surg (Am). 1981; 63: 1390-95.  Back to cited text no. 10    
11.Moed BR, Watson JT. Intrameduallary nailing of aseptic tibial non­unions without the use of fracture table. J Orthop Trauma. 1995; 9 : 128­134.  Back to cited text no. 11    
12.Sledge SL, Johnson KD, Henley MB et al. Intramedullary nailing with reaming to treat non-union of the tibia. J Bone Joint Surg (Am). 1989; 71 : 1004-1019.  Back to cited text no. 12    

Top
Correspondence Address:
Mohd Farooq Butt
Govt. Hospital for Bone & Joint Surgery, Srinagar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.34505

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    Figures

  [Figure - 1]

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