Bookshelf This pain was associated with tenderness at the tip of the lateral malleolus observed at each examination. Davies MB, Dalal S. Gross anatomy of the interphalangeal joint of the great toe: implications for excision of plantar capsular accessory ossicles. The anterior talofibular ligament had an adequate tension with anterior drawer maneuver on arthroscopic findings. 2%. 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. 8600 Rockville Pike Bethesda, MD 20894, Web Policies Knee Surg Sports Traumatol Arthrosc. J Foot Surg Jan-Feb 1991 30(1): 52-55. Post-operatively, the ankle was placed in a posterior splint and held in neutral position for two weeks. In 3,460 radiographs of patients over 7 years of age, the os tibiale externum was the most common accessory bone. Position the ankle at 90 to the tibia and gently evert and laterally rotate the subtalar joint. The patient is in supine position. J Bone Joint Surg 69B:317319, 1987. Treatment is generally observation as most are completely asymptomatic. The anterior talofibular ligament had a low to isointense signal on T2-weighted images; however, the surroundings of the ossicle had an isointense signal on T2-weighted images. 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. Tie the most proximal stitch to one of the middle stitches. When drilling the bone tunnels, align them so that the sutures will pull the ligaments in a straight line toward the fibula. This site needs JavaScript to work properly. LM, lateral malleolus; S, inflamed synovium; T, talus; TP, tibial plafond. Powell H (1961) Extra centre of ossification for the medial malleolus in children: incidence and significance. Kim B.S., Choi W.J., Kim Y.S., Lee J.W. Arthroscopic stabilization of unstable os subfibulare of the right ankle. Incidence and Significance, Symptomatic ossicles of the lateral malleolus in children, The symptomatic os subfibulare. There were no other long-term complications from the procedure. It could be dissected easily because the anterior talofibular ligament fibers were not attached to the ossicle directly. A novel 9-region systematic assessment tool for separated ossicle at the fibular tip effects on lateral ankle ligament complex integrity: a cadaveric study. The https:// ensures that you are connecting to the 6. Diagnosis is made with plain radiographs of the ankle. Arthroscopic stabilization of unstable os subfibulare of the right ankle. Ankle arthroscopy is performed using anteromedial and anterolateral portals. Review June 2002 6(2):153-161. Relation of severity and disability. 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. The symptomatic os subfibulare. Clarkson JH, Homfray T, Heron CW, Moss AL. This is followed by os tibiale (20%), os trigonum (10%), os peroneum (9%), os subfibulare (2%), os supranaviculare (1%) and os supratalare (0.9%). 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. Debride the docking site on the distal part of the fibula down to healthy cancellous bone (Fig. Henry Gray, Susan Standring, B. K. B. Berkovitz. Liu C, Zhang HS, Pei BJ, Wang HL, Su H, Wang QH. Ankle fractures are very common injuries to the ankle which generally occur due to a twisting mechanism. All patients returned to normal age-appropriate activities and regular gym class within four months postoperatively. 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). Hypertrophied synovium of the lateral ankle gutter is resected to expose the os subfibulare. The stability of the os subfibulare after screw fixation is tested. Regardless of its etiology, the real concern for the clinician should be to not ignore the problem when symptoms persist despite conservative treatment. After confirmation of anatomic reduction of the os subfibulare, a guide pin is inserted percutaneously across the ossicle to the lateral malleolus (Fig 6). You may be trying to access this site from a secured browser on the server. Atypical Chronic Ankle Instability in a Pediatric Population Secondary to Distal Fibula Avulsion Fracture Nonunion. government site. Pediatr Orthop 10: 306-316 (PMID: 2113062), [4] The anteromedial portal is the viewing portal, and the anterolateral portal is the working portal. Wang J., Hua Y., Chen S., Li H., Zhang J., Li Y. Arthroscopic repair of lateral ankle ligament complex by suture anchor. Careers. As a library, NLM provides access to scientific literature. Os subfibulare is an ossicle at the tip of the lateral malleolus found in 1% of the human population. To minimize potential disruption to the ankle joint related to the removal of a large os subfibulare (>10mm), fusion of the unstable os subfibulare is indicated.5, Special consideration should be given to patients whose distal fibular growth plate has not yet closed. GP, guide pin; OS, os subfibulare. The anteromedial portal is the viewing portal, and the anterolateral portal is the working portal. 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. Lateral malleolus avulsion frx. There are two theories regarding the origin of os subfibulare. In the event of symptoms, treatment depends on location of Os and chronicity of symptoms. The most likely explanation is that anomalous ossification centers, not yet fused to the body of the epiphysis, have been subjected to trauma, causing disruption to the fibrous or cartilaginous attachment and results in a fibrous union or pseudo-arthrosis. 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 [].Difficulties in diagnosing os subfibulare result from difficulties in establishing the appropriate etiology, especially in children and adolescents [].In most instances, os subfibulare is found incidentally on ankle . Guillo S., Bauer T., Lee J.W. She denied any prior trauma. Powell HDW: Extra centre of ossification for the medial malleolus in children: Incidence and significance. Os peroneum. and transmitted securely. Corte-Real N.M., Moreira R.M. 2. 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 4-mm cannulated screw is then inserted along the guide pin. Separated ossicles of the lateral malleolus, the condition known as os subfibulare, usually are found in 1% of the human population. 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 PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). The patient is in supine position. Accessory bones that are rare in the foot include accessory interphalangeus, os peroneum, anamolous os calcaneum and talus, os trignum and os tibiale extenum. Pass one of the anterior talofibular ligament stitch ends through the proximal tunnel, and the other anterior talofibular ligament stitch end through the middle tunnel. Accessibility The anterior talofibular ligament had a low to isointense signal on T2-weighted images, which suggested there was no disruption in the anterior talofibular ligament. A 23-year-old soccer player with a history of multiple ankle sprains presents with posterolateral ankle pain that has been present for the past 3 months. Clinical Orthopaedics and Related Research, Get new journal Tables of Contents sent right to your email inbox, The Association of Bone and Joint Surgeons, Symptomatic Os Subfibulare Caused by Accessory Ossification: A Case Report, Articles in Google Scholar by Taisuke Kono, MD, Other articles in this journal by Taisuke Kono, MD, Privacy Policy (Updated December 15, 2022). The indications, radiographic findings, and surgical technique are described. In general, accessory ossicles commonly observed in order of frequency of the lower extremity include: tibiale externum, os trigonum and os peroneum. FOIA Miller TT. Pearls and Pitfalls of Arthroscopic Stabilization of Unstable Os Subfibulare. Her symptoms returned with ballet activity following a 1 month course of full rest, nonsteroidal anti-inflammatory medication, and physical therapy. HHS Vulnerability Disclosure, Help Coronal T1-weighted MR images showed an os subfibulare bearing a transverse fracture through its midportion (Fig. (2005) ISBN: 9780443071690 -. It is indicated for symptomatic mechanical lateral ankle instability resulting from an unstable os subfibulare. In a study of healthy children between 6 and 12 years of age, Powell 6 found a separate center of ossification for the lateral malleolus in 1% of the study subjects. On MRI, the ossicle had a high signal on T2-weighted images. The mean Foot and Ankle Outcome Score, which has been shown to be both valid and reliable for the evaluation of patient-relevant outcomes related to ankle reconstruction13, was 91.4 (range, 87 to 98) of 100, with all but one patient returning to the preinjury recreational level. the contents by NLM or the National Institutes of Health. In summary, symptomatic os fibulare is extremely rare. Federal government websites often end in .gov or .mil. Shands AR Jr. Accessory bones of foot: x-ray study of feet of 1,054 patients. National Library of Medicine Reprint requests to Taisuke Kono, MD, Department of Orthopaedics, Shimane Medical University 891, Enya-cho, Izumo, Shimane 69385101, Japan. Received 2019 Mar 31; Accepted 2019 May 9. The best surgical option for lateral ankle instability associated with an unstable os subfibulare is still undetermined. Careers, Unable to load your collection due to an error. Radiographs are shown in Figure B and a MRI is shown in Figures C-E. Arthroscopic repair of chronic lateral ankle instability. A T2-weighted MRI scan of the right ankle shows that the ossicle had high signal images. The anteromedial portal is the viewing portal, and the anterolateral portal is the working portal. As the subsequent six weeks progress, allow the patient to gradually advance activities as tolerated to normal. 6.Ogden JA. to maintaining your privacy and will not share your personal information without Clinical Orthopaedics and Related Research399:197-200, June 2002. 6: L164-177. doi: 10.3827/faoj.2010.0308.0003, Os subfibulare is a rarely reported ossicle involving the inferior portion of the fibular tuberosity of the ankle. This technique is not technically demanding and can be attempted by the average foot and ankle arthroscopist. Accessibility JBJS March 1987 69B (2):317-9. The patient is in supine position. 2. Have other surgeons had experiences with attempted screw fixation? (B) The lateral ankle is opened up upon inversion stress. As a library, NLM provides access to scientific literature. 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. Arthroscopic stabilization of unstable os subfibulare of the right ankle. Optimal Visualization of Os Subfibulare Using 3D Water Selective Cartilage Scan (3D_WATSc) MRI Sequencing: A Case Report. Currently, fusion of os subfibulare is performed as an open procedure. 2007 Apr;15(4):465-71. doi: 10.1007/s00167-006-0275-7. National Library of Medicine Published: August, 2010, ISSN 1941-6806 Arthroscopic stabilization of unstable os subfibulare of the right ankle. 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. 2017 Jan-Feb;56(1):148-152. doi: 10.1053/j.jfas.2016.04.018. The superior fragment of the ossicle was of low signal intensity, indicating bone marrow oedema associated with the preceding sprain injury. eCollection 2022 Jul. Part of the anterior talar fibular ligament was sutured to the lateral malleolus. None of the patients had tenderness or symptoms of instability in the follow-up period. The .gov means its official. After that, a guide pin is inserted, and correct positioning is confirmed fluoroscopically. The pain levels improved from a preoperative mean of 7.8 on a visual analog scale to 2.1 at the latest follow-up evaluation. Mechanical irritation or joint instability may produce local pain and tenderness and contribute to recurrent ankle sprains. A telephone survey was conducted at a mean of 4.5 years (range, 2.1 to 13.2 years) postoperatively. Drill three tunnels using a 0.62-in (1.575-cm) Kirschner wire from proximal posterior (anterior to the peroneal tendon sheath) to the distal anterior area from which the ossicle was avulsed. [9], The majority of os subfibulare are small. The precise cause of symptoms in patients is conjectural. Catel-Manzke syndrome: a case report of a female with severely malformed hands and feet. However, the structure between the os subfibulare and the fibula is a mechanical weak point against inversion stress. However, sometimes it may cause subfibular pain and may be associated with chronic lateral ankle instability (CLAI). The ossicle appears divided in two parts. OS, os subfibulare. 1 There are two theories regarding the origin of os subfibulare. Inclusion in an NLM database does not imply endorsement of, or agreement with, Clin Orthop 330:157165, 1996. After suture removal, the ankle was protected in range-of-motion brace for six weeks. An official website of the United States government. Lower Extremity Os are secondary ossification centersthat remain separated from the normal bone and may be confused with a fracture. The first is that it is an avulsion fracture of the anterior talofibular ligament, 1,5 and the second is that it is an accessory ossification. Ahn H.W., Lee K.B. Inclusion in an NLM database does not imply endorsement of, or agreement with, Check for errors and try again. Clin Orthop 330:157-165 (PMID: 8804286), [7] Eur Radiol 13: 164-177 (PMID: 16440220), [6] [10]. While three patients returned within the first three days for splitting of a tight cast, there were no wound complications, compartment syndromes, or infections. A 2.7-mm 30 arthroscope (Henke Sass Wolf, Tuttlingen, Germany) is used for this procedure. 4. Key words: Os subfibulare, accessory ossicle, pseudo-arthrosis. Figure 2 Computed tomography images show a fibular ossicle or os subfibulare at the distal end of the fibular with pseudo-arthrosis. Tie the most distal stitch to the other middle stitch. Technique is not technically demanding and can be attempted by the average foot and arthroscopist... 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