Use nonabsorbable sutures to place a Krackow locking stitch in each of the ligaments. HHS Vulnerability Disclosure, Help Accessory bones of the foot are often misdiagnosed as fractures by trauma surgeons. Symptomatic os subfibularis-MRI. sharing sensitive information, make sure youre on a federal There are two theories regarding the origin of os subfibulare. To find out more about what to expect after surgery click here. Thats why we offer the areas best fracture care to patients of all ages. Consensus in chronic ankle instability: Aetiology, assessment, surgical indications and place for arthroscopy. Os Subfibulare Definition small piece of bone adjacent to inferior fibula Epidemiology incidence 1-2% of population Pathoanatomy may represent avulsion fx of ATFL that secondarily ossifies or accessory ossification center Presentation symptoms may be asymptomatic may have ankle pain (symptomatic os subfibulare) Anovel 9-region systematic assessment tool for separated ossicle at the fibular tip effects on lateral ankle ligament complex integrity: A cadaveric study. There are many different types and patternsof fractures and each requires a different technique and procedure to repair it. Kim E.S., Lee K.T., Park J.S., Lee Y.K. Sprinting. PMID: 11416796 Abstract Purpose: The understanding of the os subfibulare in childhood. However, recent studies have suggested that the ossicle is a non-union of avulsion fracture of the ATFL or the CFL [, , ]. Arch Trauma Res. The stability of the os subfibulare after screw fixation is tested. The subcutaneous tissue at the anteromedial portal is bluntly dissected down to the joint capsule, to minimize the risk of injury to the deep peroneal nerve. The patient is in supine position. If youre serious about optimizing your athletic performance. Cottom J.M., Rigby R.B. Bethesda, MD 20894, Web Policies Please try after some time. Pill SG, Hatch M, Linton JM, Davidson RS. Federal government websites often end in .gov or .mil. National Library of Medicine No ankle distractor is used. The anteromedial portal is placed lateral to the tibialis anterior tendon to enhance visualization of the lateral ankle gutter. The purpose of this Technical Note is to describe the details of arthroscopic stabilization of the os subfibulare. Get new journal Tables of Contents sent right to your email inbox, September 1991 - Volume 73 - Issue 8 - p 1251-1254. Arthroscopic repair of chronic lateral ankle instability. We prefer an absorbable subcuticular running closure for the skin. 1, 2 avulsion fracture may fail to unite because it is intra-articular and bathed in synovial fluid or because the tension The articular surface of the lateral malleolus is examined to confirm anatomic reduction of the ossicle. It is indicated for symptomatic mechanical lateral ankle instability resulting from an unstable os subfibulare. Other articles in this journal by E E Berg, The Journal of Bone and Joint Surgery, Inc. All rights reserved. Patients then can advance to a CAM (controlled ankle motion) boot with full weight-bearing. Fluoroscopy may also be used to examine for loose bodies. Avulsion fractures are frequently missed on standard anteroposterior and lateral radiographs of the ankle [ 13, 18 ]. Avulsion fractures of the distal fibula, where the anterior tibiofibular liga. Avulsion fracture of the fibula associated with recurrent instability of the ankle. Incidence and Significance, Symptomatic ossicles of the lateral malleolus in children, The symptomatic os subfibulare. All patients returned to normal age-appropriate activities and regular gym class within four months postoperatively. to maintaining your privacy and will not share your personal information without Before The injury of the calcaneocuboid ligaments. The anteromedial portal is the viewing portal, and the anterolateral portal is the working portal. Federal government websites often end in .gov or .mil. An official website of the United States government. os subfibulare: historically, this has been considered to be an accessory ossicle located just below the ditsal fibular epiphysis; it is distinguished from a fracture by its smooth borders, and by the fact that a fracture will preferentially involve the physis; The ossicle itself may fracture. Operative exploration revealed the ossicle to represent a non-union of an avulsion fracture of the anterior talofibular ligament. The knee is flexed and supported by a triangular supporting frame (Innomed, Savannah, GA) during the arthroscopic procedure. However, the structure between the os subfibulare and the fibula is a mechanical weak point against inversion stress. Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. Step 1: Indications and Preoperative Planning Arthroscopic synovectomy of the lateral gutter of the ankle joint is performed with an arthroscopic shaver (Dyonics; Smith & Nephew, Andover, MA) (Fig 3). Some error has occurred while processing your request. os subfibulare is an ossicle at the tip of the lateral malleolus found in 1% of the human population. For information on cookies and how you can disable them visit our Privacy and Cookie Policy. 2 Berg 1stated that separated ossicles of the lateral malleolus are an avulsion fracture rather than a normal variant. A patient with os subfibulare that may have been caused by accessory ossification rather than an avulsion fracture was treated by the current authors. It may be that os fibulare is a normal variant, but as it is attached to the anterior talofibular ligament and calcaneofibular ligament it can be avulsed, becoming an ununited ossicle. 2014 Apr;36(3):281-8. doi: 10.1007/s00276-013-1165-6. The anteromedial portal locates lateral to the tibialis anterior tendon, and the anterolateral portal locates lateral to the peroneus tertius tendon (Fig 2). Have other surgeons had experiences with attempted screw fixation? Wolters Kluwer Health eCollection 2022 Jul. The stability of the os subfibulare and ankle joint is confirmed arthroscopically (Fig 8, Table2, Video). PMC Accessory ossicles and avulsion fractures of the malleoli or talus may represent a predisposition or marker for ligamentous damage that may lead to the need for lateral ankle ligament repair or reconstruction in the future. The all inside arthroscopic Brostrom procedure: A prospective study of 40 consecutive patients. Presenting symptoms include lateral ankle swelling, recurrent lateral ankle sprains, and feelings of instability during athletic activity, most notably lateral cutting activities. Subtalar instability, if present, cannot be detected during ankle arthroscopy. Arthroscopic stabilization of unstable os subfibulare of the right ankle. Excision of the ossicle has been proposed; however, the anterior talofibular ligament connected to the ossicle will be damaged during dissection of the ossicle.1, 2 Resection of large ossicles may raise additional risks of ligament defects that can affect joint stability, and ligament repair or reconstruction should also be performed.3 However, when the ossicle is large, excision and a modified Brostrm technique can achieve varus stability but not sagittal stability of the ankle.5 Moreover, removal of a large articular fragment will markedly reduce the articular surface of the lateral malleolus. Arthroscopic stabilization of unstable os subfibulare of the right ankle. MY 0 0 PICK UP 2022 HOME > Epub 2007 Jan 20. The anteromedial portal is the viewing portal, and the anterolateral portal is the working portal. The ossicle is located under the tip of the lateral malleolus [2]. Four adults who had symptomatic instability of the ankle had an associated os subfibulare. For those ossicles located anteromedially to the lateral malleolus and not at its tip, the interface between the ossicle and lateral malleolus is oblique. Open the capsule to directly visualize the articular surface. Patients with lateral ankle pain and an os fibulare noted on radiographs who have not yet been treated with conservative measures including rest, immobilization, and a course of physical therapy. Monden S, Hasegawa A, Hio N, Taki M, Noguchi H. J Orthop Sci. Full ICMJE author disclosure forms are available for this article online, as supplementary material. A patient with os subfibulare that may have been caused by accessory ossification rather than an avulsion fracture was treated by the current authors. Operative indications are chronic pain at the distal part of the fibula, symptoms of instability at the anterior talofibular ligament and/or calcaneofibular ligament, and a radiographic finding of an os fibulare. Publication types Case Reports MeSH terms PMC legacy view sharing sensitive information, make sure youre on a federal A thigh tourniquet is applied to provide a bloodless operative field. Monden S., Hasegawa A., Hio N., Taki M., Noguchi H. Arthroscopic excision of separated ossicles of the lateral malleolus. Some previous studies have described the ossicle as a normal anatomic variant of accessory bone [19,20]. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article. Arthroscopic excision of separated ossicles of the lateral malleolus. Look for the radiographic findings of an os fibulare (Figs. The opposing surfaces of lateral malleolus and os subfibulare are debrided with an arthroscopic shaver, arthroscopic burr (Dyonics; Smith & Nephew), and arthroscopic curette (Acufex; Smith & Nephew) (Fig 5). A technique for arthroscopic resection of the os subfibulare has been reported.1 Arthroscopy has the advantages of minimally invasive surgery and allows evaluation and treatment of concomitant intra-articular pathology of the ankle.1, 2 This is important, as the prevalence of osteochondral lesions of the talus is significantly higher in cases of lateral ankle instability with the presence of os subfibulare than those without the ossicle,5 and poor clinical outcome will result if they are not addressed.8, 9, 10 An arthroscopic Brostrm procedure11, 12, 13, 14, 15, 16, 17 can also be done in the same setting of arthroscopic resection of the os subfibulare. The patient is in supine position. 1991 Sep;73(8):1251-4. Hypertrophied synovium of the lateral ankle gutter is resected to expose the os subfibulare. The articular surfaces of the lateral malleolus and os subfibulare are examined to confirm anatomic reduction of the ossicle. Disclaimer, National Library of Medicine Arthroscopic stabilization of unstable os subfibulare of the right ankle. After application of general or spinal anesthesia, the ankle joint is examined under fluoroscopy. 1 The ossicle is reduced and temporarily fixed with a Kirschner wire. MeSH Pearls and Pitfalls of Arthroscopic Stabilization of Unstable Os Subfibulare. FOIA The indications, radiographic findings, and surgical technique are described. It is also contraindicated if the ossicle is too small or the bone quality is too poor to achieve stable internal fixation (Table1). 1400 East Side Road, Platteville, WI 53818. Knee Surg Sports Traumatol Arthrosc. Please enable it to take advantage of the complete set of features! Accessory bones may be stable or may sustain injuries and become avulsed. Zhang C., Wang X., Ma X., Huang J., Jiang J. The latest information about the 2019 Novel Coronavirus, including vaccine clinics for children ages 6 months and older.. La informacin ms reciente sobre el nuevo Coronavirus de 2019, incluidas las clnicas de vacunacin para nios de 6 meses en adelante. The os subtibiale is a rare accessory bone and a variant related to the posterior colliculus of the medial malleolus. The patient is in supine position. While three patients returned within the first three days for splitting of a tight cast, there were no wound complications, compartment syndromes, or infections. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The authors report that they have no conflicts of interest in the authorship and publication of this article. After synovectomy, the mobility of the os subfibulare can be assessed. You may be trying to access this site from a secured browser on the server. Please enable scripts and reload this page. The senior author (R.S.D.) Pain on plantar varus stress testing and point tenderness at the distal anterior aspect of the lateral malleolus that does not respond to nonoperative treatment. Lentell G, Baas B, Lopez D, McGuire L, Sarrels M, Snyder P. The contributions of proprioceptive deficits, muscle function, and anatomic laxity to functional instability of the ankle, Congenital anomalies, accessory bones, and osteochondritis in the feet of 850 children, Extra Centre of Ossification for the Medial Malleolus in Children. A 4-mm cannulated screw is then inserted along the guide pin. Securely suture the prepared crural ligament (superior extensor retinaculum) for the Brostrm lateral ankle reconstruction to the fibula. The working space of the reported technique is at the interface, and the anterior talofibular ligament would not be disrupted. Optimal Visualization of Os Subfibulare Using 3D Water Selective Cartilage Scan (3D_WATSc) MRI Sequencing: A Case Report. The ankle joint is examined for any concomitant pathology (e.g., osteochondral lesion) and treated accordingly. Tighten and tie down the sutures from the anterior talofibular ligament and the calcaneofibular ligament. and transmitted securely. The stability of the ossicle and lateral ankle is evaluated. Drilling of the mobile os subfibulare is easier than microfracture of the ossicle with an arthroscopic awl. 2 The ossicle is sometimes symptomatic and presents with local pain or lateral ankle instability. Relation of severity and disability. Methods A systematic literature search across two major sources (PubMed and Scopus) was performed. 2022 SouthWest Health Inc. All Rights Reserved. Our patients wore the same cast for six weeks, but the cast can be changed if desired or necessary. | MBC WEB 1! This case report with a review of literature . Debride the docking site on the distal part of the fibula down to healthy cancellous bone (Fig. Ahn H.W., Lee K.B. Protect ligament repair by everting and laterally rotating the subtalar joint. For more information, please refer to our Privacy Policy. Arthroscopic stabilization of unstable os subfibulare of the right ankle. Cureus. Arthroscopic anterior talofibular ligament repair for chronic ankle instability with a suture anchor technique. GUID:9EEEEAF2-2E84-4F38-949C-3690B90271F4, GUID:27F84E91-14FE-4E12-BDBA-AE0350D8C908. Ankle arthroscopy is performed using the anteromedial and anterolateral portals. Modified arthroscopic Brostrom procedure. Make a longitudinal or curved posterior hockey stick incision over the posterior border of the lateral malleolus. After removal of the os subfibulare, the fibular bed is debrided to healthy cancellous bone. The ossicle is reduced and temporarily fixed with a Kirschner wire. Kim B.S., Choi W.J., Kim Y.S., Lee J.W. doi: 10.7759/cureus.1881. Separated ossicles at the tip of the lateral malleolus, the condition known as os subfibulare, are sometimes a cause of ankle pain. Os Subfibulare Definition small piece of bone adjacent to inferior fibula Epidemiology incidence 1-2% of population Pathoanatomy may represent avulsion fx of ATFL that secondarily ossifies or accessory ossification center Presentation symptoms may be asymptomatic may have ankle pain (symptomatic os subfibulare) J Bone Joint Surg Am. Lateral placement of the anteromedial portal enhances arthroscopic visualization of the lateral ankle gutter. Four adults who had symptomatic instability of the ankle had an associated os subfibulare. 2017 Nov 26;9(11):e1881. One theory proposes that it is caused by an avulsion fracture attributable to pull of the anterior talofibular ligament, whereas the other theory proposes that it is the result of an accessory ossification center. (A) Ankle in neutral position. Os subfibulare is a supernumerary bone of the lateral malleolus at the distal end of the fibula found in 1% of the general human population, usually in adolescents [1]. Epub 2013 Jul 31. Buckled Fracture: (or impacted fracture), ends are driven into each other; commonly seen in arm fractures in children. Avulsion fracture of the fibula associated with recurrent instability of the ankle. This website uses cookies. Guillo S., Bauer T., Lee J.W. There were no other long-term complications from the procedure. Received 2019 Mar 31; Accepted 2019 May 9. A 2.7-mm 30 arthroscope (Henke Sass Wolf, Tuttlingen, Germany) is used for this procedure. Look for loose bodies and damage to the lateral aspect of the talus, which may require debridement. The anteromedial portal is the viewing portal, and the anterolateral portal is the working portal. The site is secure. The patients included eight boys and fifteen girls ranging in age from eight to seventeen years at the time of surgery. The .gov means its official. (B) Postoperative anteroposterior and lateral radiographs of the ankle showed screw fixation of the os subfibulare. Imbricate the lateral capsule to secondarily reconstruct and reinforce the ligaments, adding to the strength of the repair. Separated ossicles at the tip of the lateral malleolus, the condition known as os subfibulare, are sometimes a cause of ankle pain. sharing sensitive information, make sure youre on a federal Accessibility The https:// ensures that you are connecting to the An ossicle that is >10mm or located at the anterior distal end of the lateral malleolus is more likely to be associated with disruption of the lateral ankle ligament complex.3, In general, nonoperative treatment (a period of rest with restricted weightbearing or immobilization) should be the first line of treatment.1 Surgical treatment is indicated if conservative treatment fails to relieve symptoms. Kicking. criminate a real os subbulare (formed by accessory ossication center) from an ATFL avulsion fracture in chronic cases. Radiographic findings of a typically displaced os fibulare. Accessibility This technique is not technically demanding and can be attempted by the average foot and ankle arthroscopist. Os subfibulare is an ossicle at the tip of the lateral malleolus found in 1% of the human population.1 It is a result of an unfused accessory ossification center or an avulsion fracture of the anterior talofibular ligament.1, 2 Avulsion fracture may fail to unite because it is intra-articular and bathed in synovial fluid or because the tension on the anterior talofibular ligament attached to the ossicle causes a separation of the fragment from the bone.2, The ossicle is sometimes symptomatic and presents with local pain or lateral ankle instability.1 The pain can be a result of traction stress of the ossicle from the attached ligament, surrounding synovitis, hypertrophic soft tissue impingement, or impingement of the ossicle on the tip of the lateral malleolus during ankle dorsiflexion.1, 3, 4 In the presence of os subfibulare, the ankle is normally stable because of the tight binding between the talus and the fibular tip by the superficial fibers of the anterior talofibular ligament. Hasegawa A., Kimura M., Tomizawa S., Shirakura K. Separated ossicles of the lateral malleolus. The patient is in supine position. Prepare a 1-cm-wide band of the transverse crural ligament (superior extensor retinaculum). This information is not meant as a substitute for medical advice from your doctor. FOIA 1, 2 avulsion fracture may fail to unite because it is intra-articular and bathed in synovial fluid or because the tension Repair the anterior talofibular ligament and calcaneofibular ligament to the debrided distal part of the fibula. These findings suggest that an os subfibulare represents an avulsion fracture that may or may not be associated with laxity of the anterior talofibular ligament, rather than being a normal variant. One theory proposes that it is caused by an avulsion fracture attributable to pull of the anterior talofibular ligament, whereas the other theory proposes . Instead, the os subfibulare is drilled with a Kirschner wire (K wire) (Zimmer, Warsaw, IN). Perform an approach to the lateral malleolus and excise the fragment while preserving the anterior talofibular ligament and calcaneofibular ligament. Os subfibulare are usually asymptomatic although they may eventually cause painful syndromes or degenerative change in response to overuse and trauma. One patient reported continued lateral ankle swelling when playing pivoting sports but not persistent pain or instability. The anteromedial portal is the viewing portal, and the anterolateral portal is the working portal. The stability of the ossicle and lateral ankle is evaluated. will also be available for a limited time. may email you for journal alerts and information, but is committed Arthroscopic stabilization of unstable os subfibulare of the right ankle. It allows evaluation and treatment of concomitant ankle pathology. Os subfibulare is an accessory ossicle located at the distal tip of lateral malleolus. Avoid making bone tunnels through the distal fibular physis in skeletally immature patients. os subfibulare is an ossicle at the tip of the lateral malleolus found in 1% of the human population. This leads to two questions: Should patients who undergo this procedure limit their participation in high-impact activities? Unable to load your collection due to an error, Unable to load your delegates due to an error. Investigation of an accessory bone, Accessory ossification patterns and injuries of the malleoli. The 2007. Persistent disability associated with ankle sprains: a prospective examination of an athletic population, Ankle sprains in young athletes. OS, os subfibulare. Cha S.D., Kim H.S., Chung S.T. Fluid inflow is by gravity, and no pump is used. The anteromedial portal is the viewing portal, and the anterolateral portal is the working portal. PMC legacy view Ankle arthroscopy is performed using anteromedial and anterolateral portals. Screening of the subtalar stability under fluoroscopy after fixation of the os subfibulare is essential. Surg Radiol Anat. Modified arthroscopic Brostrom procedure with bone tunnels. Keles-Celik N, Kose O, Sekerci R, Aytac G, Turan A, Gler F. Cureus. Llanes ACD, Van Tassel D, Wirth A, Goncalves LF, Belthur MV. On examination, determine if the patient has pain with plantar varus stress testing and point tenderness at the distal anterior aspect of the lateral malleolus, both of which were present in all of the patients in our study. When drilling the bone tunnels, align them so that the sutures will pull the ligaments in a straight line toward the fibula. As the subsequent six weeks progress, allow the patient to gradually advance activities as tolerated to normal. One theory proposes that it is caused by an avulsion fracture attributable to pull of the anterior talofibular . Learn more will also be available for a limited time. The opposing surfaces of the ossicle and lateral malleolus are debrided and microfractured. Careful history-taking and clinical examination are usually sufficient to establish the diagnosis of chronic lateral ankle instability. 8600 Rockville Pike Intra-articular lesions in chronic lateral ankle instability: Comparison of arthroscopy with magnetic resonance imaging findings. Avulsion fracture of the fibula associated with recurrent instability of the ankle. about navigating our updated article layout. Hua Y., Chen S., Li Y., Chen J., Li H. Combination of modified brostrm procedure with ankle arthroscopy for chronic ankle instability accompanied by intra-articular symptoms. Wang J., Hua Y., Chen S., Li H., Zhang J., Li Y. Arthroscopic repair of lateral ankle ligament complex by suture anchor. The symptomatic os subfibulare. Arthroscopic stabilization of unstable os subfibulare of the right ankle. Comparison of the modified Brostrom procedure for chronic lateral ankle instability with and without subfibular ossicle. There are two theories regarding the origin of os subfibulare. Based on an original article: J Bone Joint Surg Am. Chun T.H., Park Y.S., Sung K.S. The articular surfaces of the lateral malleolus and os subfibulare are examined to confirm anatomic reduction of the ossicle. doi: 10.7759/cureus.27469. 8600 Rockville Pike The https:// ensures that you are connecting to the Be vigilant with casting. An official website of the United States government. Would you like email updates of new search results? 27 Radiograph-Negative Lateral Ankle Injuries in Children: Occult Growth Plate Fracture or Sprain? It's because contact sports involve movements that stress your limbs, such as: Suddenly changing direction. Champagne IM, Cook DL, Kestner SC, Pontisso JA, Siesel KJ. Video Arthroscopic stabilization of unstable os subfibulare of the right ankle. The potential risks of this technique include iatrogenic fracture of the ossicle and injury to the the branches of the deep or superficial portal nerve (Table3). You can read the full text of this article if you: Your message has been successfully sent to your colleague. Operative exploration revealed the ossicle to represent a non-union of an avulsion fracture of the anterior . Our surgical treatment consists of excision of the osseous fragment, ligament repair, and a modified Brostrm procedure (Video 1). CS, cannulated screw; GP, guide pin; KW, Kirschner wire; OS, os subfibulare. The size, length, and placement of the screw should be carefully planned to avoid damage to the growth plate, or an alternative fixation modality such as a K wire should be considered.1, 3. The A telephone survey was conducted at a mean of 4.5 years (range, 2.1 to 13.2 years) postoperatively. A normal anteroposterior radiograph of the ankle does not demonstrate any gross deformity. Clinical examination may show mobility of the os subfibulare if it is sizable: the ossicle will move distally or anteriorly during inversion stress test and anterior drawer test, respectively. After that, the patient is allowed weightbearing walking in an Aircast Air-Stirrup ankle support brace (DJO, Dallas, TX) for another 4weeks (Fig 9). Falling on an outstretched hand. J Bone Joint Surg Am. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. The correct positioning of the guide pin is confirmed fluoroscopically, and a 4-mm cannulated screw is inserted (Fig 7). Avulsion fracture may fail to unite because it is intra-articular and bathed in synovial fluid or because the tension on the anterior talofibular ligament attached to the ossicle causes a separation of the fragment from the bone. Before The patient is in supine position. Reduce the ankle joint and tie down the sutures. Patients advance to full weight-bearing in a CAM boot and start physical therapy at six weeks. Bookshelf 2007 Apr;15(4):465-71. doi: 10.1007/s00167-006-0275-7. Os Subfibulare Vs Lateral malleolus Avulsion A 20 yrs female with history of fall-Os -Subfibulare: Os Subfibulare is just inferior and medial to the tip of lateral malleolus and round/oval well corticated. ALP, anterolateral portal; AMP, anteromedial portal; LM, lateral malleolus; OS, os subfibulare; TA, tibialis anterior tendon. Berg, E E Author Information The Journal of Bone & Joint Surgery: September 1991 - Volume 73 - Issue 8 - p 1251-1254 Buy Abstract Copyright 1991 by The Journal of Bone and Joint Surgery, Incorporated The opposing surfaces of the ossicle and lateral malleolus are debrided and microfractured. Have the patient begin physical therapy at six weeks with low-impact range-of-motion and strengthening exercises. Nery C., Raduan F., Del Buono A., Asaumi I.D., Cohen M., Maffulli N. Arthroscopic-assisted Brostrom-Gould for chronic ankle instability: A long-term follow-up. Epub 2013 Jun 1. Here are several types of fracture patterns: As the patient, you play a very important role in your medication therapy. Avulsion fracture of the lateral ankle ligaments in cases of severe inversion injury is more common than previously believed and requires high level of suspicion in order to obtain an accurate diagnosis and achieve adequate stability. Symptomatic mechanical lateral ankle instability due to unstable os subfibulare that is recalcitrant to conservative treatment and an ossicle >10mm, Lateral ankle instability is anterior as a result of talofibular ligament insufficiency rather than the unstable ossicle, There is concomitant subtalar instability, The ossicle is too small or the bone quality is too poor to achieve stable internal fixation. Two patients in our group had a second lateral ankle ligament disruption nearly one year after their initial surgery and required a revision Brostrm lateral ankle reconstruction. (A) Anterior view of the ankle. At the six-week appointment, remove the cast and examine the wound. The https:// ensures that you are connecting to the The anteromedial portal is the viewing portal, and the anterolateral portal is the working portal. (B) The lateral ankle is opened up upon inversion stress. Careers. After that, a guide pin is inserted, and correct positioning is confirmed fluoroscopically. Based on the findings of our study, we carefully suggest that majority, if not all, of os subfibulare would be posttraumatic in pediatric period. After application of general or spinal anesthesia, the ankle joint is examined under fluoroscopy. While we were unable to resolve the debate over the etiology of os subfibulare, we were able to develop a successful surgical treatment protocol for chronic symptomatic os subfibulare and evaluate the long-term outcomes following this treatment. Hypertrophied synovium of the lateral ankle gutter is resected to expose the os subfibulare. Difficulties in diagnosing os subfibulare result from difficulties in establishing the appropriate etiology, especially in children and adolescents [2]. Careers. It is indicated for symptomatic mechanical lateral ankle instability resulting from unstable os subfibulare that is recalcitrant to conservative treatment and an ossicle >10mm.1, 3 This procedure is contraindicated if the lateral ankle instability results from anterior talofibular ligament insufficiency rather than the unstable ossicle or if there is concomitant subtalar instability. It is usually detected incidently, however, it may be misdiagnosed as lateral malleolar avulsion. It took over six months for these patients to obtain osseous union. The opposing surfaces of lateral malleolus and os subfibulare are debrided with an arthroscopic shaver. Os subfibulare is located beneath the lateral malleolus. There are three common accessory ossicles in the ankle: os trigunum (usually forms at 7-13 years old); os subtibiale (when the medial malleolus epiphysis fails to fuse with the tibia in the later teenage years); os subfibulare (can also be an unfused ossification centre or an avulsion fracture). 2015 Jun 20;4(2):e27046. government site. The integrity of the anterior talofibular ligament is also confirmed with an arthroscopic probe (Acufex; Smith & Nephew). Contact sports like lacrosse, boxing and football, for example, are the most common causes of avulsion fractures. The patient is in supine position. Some fractures may require surgery to align the bones and to promote better long term function, but most can be treated without surgery. Association between avulsion fracture of the distal fibula and recurrent sprain in children with ankle sprain - Satoshi Yamaguchi, Ryosuke Nakagawa, 2018 official website and that any information you provide is encrypted The new PMC design is here! and transmitted securely. Acute trauma or chronic inversion stress can lead to avulsion of the ossicle from the lateral malleolus, and the ankle may become symptomatic.2 Both size and location of the os subfibulare play a role in determining the clinical effect of the separated ossicle. official website and that any information you provide is encrypted 2013 Aug 21;95(16):e115. Chronic symptomatic os subfibulare in children, Validation of the foot and ankle outcome score for ankle ligament reconstruction, Step 1: Indications and Preoperative Planning, Step 5: Preparation for Modified Brostrm Procedure, Step 6: Repair, Reconstruction, and Closure. Common fractures and their management Avoid the distal fibular physisuse fluoroscopy. The .gov means its official. The new PMC design is here! Federal government websites often end in .gov or .mil. Pass one of the calcaneofibular ligament stitch ends through the middle tunnel (with the one anterior talofibular ligament stitch), and pass the other calcaneofibular ligament stitch end through the most distal hole (Fig. Accessibility Frontal Oblique Lateral X-ray Frontal Thin bony fragments adjacent to the lateral aspect of tip of the lateral malleolus and cortical irregularity at the lateral talus, likely representing avulsion fractures. We report a case of bilateral os subtibiale, which was mistakenly treated as an ankle fracture. Avoid ankle contracture by casting at 90 of dorsiflexion. Chronic symptomatic os subfibulare in children. One potential cause of residual disability is a chronic symptomatic os subfibulare, which, rather than being a benign unfused accessory ossification center, may instead result from an avulsion of the anterior talofibular ligament or calcaneofibular ligament5-11. 2022 Jul 29;14(7):e27469. A novel 9-region systematic assessment tool for separated ossicle at the fibular tip effects on lateral ankle ligament complex integrity: a cadaveric study. 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