258 THE JOURNAL OF BONE AND JOtNT SURGERY ANKLE INSTABILITY AFTER FIBULAR RESECTION S. S. BABHULKAR, KETAN C. PANDE, SUSHRUT From Sushrut Hospital, Nagpur, india We have reviewed 104 patients who had partial resection of the fibula for use as a graft. Only 44 were completely free from symptoms, and six had developed significant ankle instability which had required reconstruction by a sliding graft. This procedure successfully restored ankle stability in all six cases. J Bone Joint Surg [Br] l995:77-B:258-6l. Received 16 March 1994: Accepted after revision /5 July /994 In recent years the fibula has been used as a free graft and as a vascularised transplant to bridge large bony defects for such conditions as congenital pseudarthrosis of the tibia (Pho et al 1985), tumour resection (Pho 1981; Moore, Weiland and Daniel 1983), nonunion (Solonen 1982; Pho, Vajara and Satku 1983) and grafting operations for avas- cular necrosis of the femoral head (Hungerford 1979; Ficat 1983). In children, it is known that a valgus deformity of the ankle may develop after fibular resection (Paluska and Blount 1968; Wiltse 1972) but in adults it has been claimed that there is no significant disability. Recent studies (Lee et a! 1990; Goh et al 1992) have highlighted the load-bearing function of the fibula and indicated that morbidity may follow resection of the fibula. PATIENTS AND METHODS We have reviewed retrospectively 104 patients who had a fibular transplant, at a follow-up of 28 months to 5 years. In all cases the fibula was used as a free corticocancellous graft. We assessed the patients clinically and radiologically, comparing the findings with those in the opposite ankle. Clinical assessment. We recorded pain in the leg, limp, weakness, instability of the knee and ankle and any sensory changes in the foot. Examination included the range of motion and instability in the knee and ankle with assess- S. S. Babhulkar, MS Orth, D Orth, PhD Orth, FICS, FICA, FACS, Hon- orary Professor of Orthopaedics, Indira Gandhi Medical College and Director, Sushrut Hospital and Research Centre K. C. Pande, MS Orth, DNB, Junior Consultant in Orthopaedics S. Babhulkar, MS Orth, MCh Orth, Junior Consultant in Orthopaedics Sushrut Hospital and Research Centre, Randaspeth, Nagpur 440 010, India. Correspondence should be sent to Professor S. S. Babhulkar. ©1995 British Editorial Society of Bone and Joint Surgery 0301-620X/95/2939 $2.00 ment of any motor weakness or sensory deficit, especially on the lateral border of the foot. Ankle assessment included inversion and eversion, stress tests and an anteroposterior stress test. Varus, valgus and rotatory instability tests were performed at the knee in patients who had proximal fibular resection. Only significant differences between the sympto- matic and normal ankle were recorded. Stress radiographs were taken only when instability was suspected on clinical examination. Management. Patients with minor symptoms were treated by muscle-strengthening and mobility exercises. Six patients with disabling ankle instability had reconstruction of the fibula by a sliding graft from the intact upper part of the bone. Operative technique. The upper fibula is exposed sub- periosteally by a lateral incision, the length of the graft being assessed from preoperative tracings of radiographs (Fig. 1). The shaft of the fibula is cut into two halves by a pneumatic saw, using a cross cut in the anteroposterior plane at the upper end. A step-cut is made in the distal remnant to receive the graft, which is moved down and fixed by two 3.5 mm cortical screws at each end, attempt- ing to restore the normal length and position of the lateral malleolus (Fig. I). Cancellous grafts from the iliac crest are placed around the ends of the graft. An above-knee plaster is used for six to eight weeks. Depending on the progress of union, weight-bearing is resumed, but activities are restricted until there is solid consolidation of the graft. RESULTS The indications for the original fibular excision varied. The most common was grafting for avascular necrosis of the femoral head (69) followed by bone replacement after tumour resection (26), and nonunion of long bones (8). In one case part of the fibula had been excised for a chronic inflammatory reaction. No patients had postoperative infec- tion or lateral popliteal nerve palsy after the original resection. At review, only 44 of the 104 patients had no complaints or clinical abnormality. The commonest complaints were weakness of the foot and inability to walk quickly or run. Others were foot numbness, occasional cramps, and instab- ility of the ankle (Table I). Muscle weakness usually involved the extensor hallucis longus but a few patients also had poor function of flexor hallucis longus or of flexor or extensor digitorum longus. None of the 26 patients who