Osteosynthesis or non-operative treatment of the fibula for distal lower-leg fractures with tibial nailing: a systematic review and meta-analysis

Fibular fixation to treat distal lower-leg fractures is a controversial intervention. To ensure better stability itself, better rotational stability, and to prevent secondary valgus dislocation – all these are justifications for addressing the fibula via osteosynthesis. High surgical costs followed by increased risks are compelling reasons against it. The purpose of this study was to systematically review the literature for rates of malunion and malrotation, as well as infections and nonunions. We conducted a systematic review searching the Cochrane, PubMed, and Ovid databases. Inclusion criteria were modified Coleman Methodology Score (mCMS) > 60, a distal lower-leg fracture treated by nailing, and adult patients. Biomechanical and cadaver studies were excluded. Relevant articles were reviewed independently by referring to title and abstract. In a meta-analysis, we compared five studies and 741 patients. A significantly lower rate of valgus/varus deviation is associated with fixation of the fibula (OR = 0.49; 95% CI: 0.29–0.82; p = .006). A higher risk for pseudarthrosis was revealed when the fibula underwent surgical therapy, but not significantly (OR = 1.46; 95% CI: 0.76–2.79; p = .26). Nevertheless, we noted an increased risk of postoperative wound infection following fibular plating (OR = 1.90; 95% CI: 1.21–2.99; p = .005). There was no statistically significant difference in the rate of nonunions between the two groups. Overall, the stabilization of the fibula may reduce secondary valgus/varus dislocation in distal lower-leg fractures but is associated with an increased risk of postoperative wound infections. The indication for fibula plating should be made individually. Cite this article: EFORT Open Rev 2021;6:816-822. DOI: 10.1302/2058-5241.6.210003

Ischemic Monomelic Neuropathy: The Case for Reintroducing a Little-Known Term

ABSTRACT:Ischemic monomelic neuropathy (IMN) is a little-known, painful axonal neuropathy, secondary to vascular occlusion or steal phenomenon. It typically occurs after vascular bypass, hemodialysis fistulization, or diabetic microvascular disease in the absence of significant clinical features of ischemia. There is limited literature to assist in the characterization and diagnosis of this condition. We describe three patients with IMN with no surgical or peripheral vascular disease history who exhibited spontaneous, persistent foot pain, edema numbness, and weakness with denervation on needle electromyogram in a distal lower leg peripheral nerve distribution. Occlusive disease was found in all patients on angiogram, requiring vascular bypass surgery.

Venous Supercharging Reduces Complications and Improves Outcomes of Distally Based Sural Flaps

Background The use of distally based neurocutaneous sural flaps (DBNCSF) is one of the most common methods of reconstructing the distal lower leg. However, they have developed a bad reputation because of their propensity for venous engorgement. Venous congestion that can lead to distal necrosis can be prevented by venous supercharging. Using a prospective comparative study, we thus explored the effect of venous supercharging on the reliability of these useful workhorse flaps. Methods We prospectively included 38 patients who received a conventional DBNCSF and 38 patients who received a supercharged version of this flap (sDBNCSF) between January 2012 and July 2016. Results No significant difference was identified between the groups in terms of age, sex, comorbidity, or defect origin. The main reconstruction etiology was traumatic (open fracture, scar disunion, and chronic osteitis). The flap size was noticeably larger in the sDBNCSF group, albeit without significance. The length-width ratio was significantly greater in the sDBNCSF group (6.08 vs. 5.53, p = 0.022). Venous congestion was significantly more common in the non-supercharged group (28.6 vs. 2.6%, p = 0.01), as was coverage failure (23.7 vs. 2.6%, p = 0.035). Conclusion There are significant benefits to using venous supercharging of DBNCSF, when technically feasible. In our experience, venous supercharging increases reliability, allows the raise of larger skin paddles with much narrower pedicles limiting the morbidity of the procedure, and improves the functional and esthetic results.

Advantages and disadvantages of graduated and inverse graduated compression hosiery in patients with chronic venous insufficiency and healthy volunteers: A prospective, mono-centric, blinded, open randomised, controlled and cross-over trial

Background The therapeutic effectiveness of compression therapy depends on the selection of compression hosiery. Objectives To assess efficacy and tolerability of graduated elastic compression stockings (GECS) and inverse graduated elastic compression stockings (PECS). Methods Thirty-two healthy volunteers and thirty-two patients with chronic venous insufficiency were analysed; wear period: one week for each stocking type (randomised, blinded). Primary outcome: volume reduction of ‘Lower leg’ (Image3D®) and ‘Distal leg and foot’ (water plethysmography). Secondary outcomes: clinical symptoms of chronic venous insufficiency assessed by the Venous Clinical Severity Score, side effects and wear comfort in both groups. Results Volume of ‘Lower leg’: significant reduction in healthy volunteers (mean GECS: −37.5 mL, mean PECS: −37.2 mL) and in patients (mean GECS: −55.6 mL, mean PECS: −41.6 mL). Volume of ‘Distal lower leg and foot’: significant reduction in healthy volunteers (mean GECS: −27 mL, mean PECS: −16.7 mL), significant reduction in patients by GECS (mean: −43.4 mL), but non-significant reduction by PECS (mean: −22.6 mL). Clinical symptoms of chronic venous insufficiency were improved significantly better with GECS than with PECS, p < 0.001. GECS led to more painful constrictions, p = 0.047, PECS slipped down more often, p < 0.001. Conclusion GECS and PECS reduce volume of the segment ‘Lower leg’ in patients and healthy volunteers. Patients’ volume of the ‘Distal lower leg and foot’, however, were diminished significantly only by GECS ( p = 0.0001). Patients’ complaints were improved by both GECS and PECS, and GECS were superior to PECS.

Trophic application in CVI I with peripheral oedema compared with compression stockings

Summary Aim In the warm season of 2015, the efficacy of Allga Med® Antiswelling Foot Spray and Allga Med® Warm Feet Balsam in combination with a class 2 compression stocking was compared with the efficacy of a compression stocking of the same class applied alone. Method 40 women aged 23–78 years (mean 48 years) were included in the investigation. The women were all overweight (mean height: 166 cm, mean weight: 83 kg; mean BMI 30.1 kg/m2). For one month before their inclusion, they had not been permitted to take venous medication or wear compression stockings. Prior to the start of the study, class 2 compression stockings were prescribed. The compression stockings were worn consistently during the day for 14 days. In addition, the right leg was treated twice daily with foot spray and balsam. Before the start of the study and after 14 days, the foot and distal lower leg volume of both legs was measured by means of water plethysmography Result On the stockinged left leg, the volume decreased by 152 ml. On the right leg, which was trophically treated and stockinged, the volume decreased by up to 335 ml.