(Fig. The surroundings of the ossicle have isointense signal images, and it appears that the fibers of the anterior talofibular ligament were not attached to the ossicle directly. Zhang C., Wang X., Ma X., Huang J., Jiang J. National Library of Medicine 2017 Nov 26;9(11):e1881. The patient is in supine position. Be vigilant with casting. 6 Os subfibulare is sometimes a cause of ankle pain, in which case it is called symptomatic os subfibulare. They usually are asymptomatic. os acetabuli. Avoid ankle contracture by casting at 90 of dorsiflexion. Griffiths JD, Menelaus MB: Symptomatic ossicles of lateral malleolus in children. Knee Surg Sports Traumatol Arthrosc. (A) Ankle in neutral position. Optimal Visualization of Os Subfibulare Using 3D Water Selective Cartilage Scan (3D_WATSc) MRI Sequencing: A Case Report. The anteromedial portal is the viewing portal, and the anterolateral portal is the working portal. CS, cannulated screw; GP, guide pin; KW, Kirschner wire; OS, os subfibulare. Clin Anat May 2005 18(4): 239-244. Os subfibulare was originally described by Leimbach [] in 1937 and is defined as an ossicle around the tip of the lateral malleolus of the ankle joint.Two main etiologies of the os subfibulare are discussed in the literature, including (1) accessory ossification center [22, 31, 34, 51, 52] and (2) posttraumatic sequelae of an avulsion fracture of the distal fibula following an ankle injury [38 . Clarkson JH, Homfray T, Heron CW, Moss AL. However, the structure between the os subfibulare and the fibula is a mechanical weak point against inversion stress. 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. 2. Careers, Unable to load your collection due to an error. A patient with os subfibulare that may have been caused by accessory ossification rather than an avulsion fracture was treated by the current authors. At the time the article was created Craig Hacking had no recorded disclosures. Separated ossicles of the lateral malleolus, the condition known as os subfibulare, usually are found in 1% of the human population. The knee is flexed and supported by a triangular supporting frame (Innomed, Savannah, GA) during the arthroscopic procedure. Screening of the subtalar stability under fluoroscopy after fixation of the os subfibulare is essential. However, there is only one report 2 of os subfibulare being caused by accessory ossification. In each patient the ossicle was a nonunion of an avulsion fracture of the anterior talofibular ligament. Accessory ossicles of the lower limb. The os subfibulare is usually round, oval, or comma-shaped. The anteromedial portal is placed lateral to the tibialis anterior tendon to enhance visualization of the lateral ankle gutter. Bethesda, MD 20894, Web Policies The anterior talofibular ligament should be pulled to the anterior aspect of the fibula, and the calcaneofibular ligament should be pulled to the inferior tip of the fibula. Published: August, 2010, ISSN 1941-6806 LM, lateral malleolus; S, inflamed synovium; T, talus. Ahn H.W., Lee K.B. The ossicle could not be seen directly. treated all of the patients at one institution12. Please enable it to take advantage of the complete set of features! 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. Our patients wore the same cast for six weeks, but the cast can be changed if desired or necessary. 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. Arthroscopic stabilization of unstable os subfibulare of the right ankle. Protect ligament repair by everting and laterally rotating the subtalar joint. All symptoms were relieved by excision of the ossicle and reconstitution of the collateral ligament. (Fig. Up to 40 accessory ossicles and multiple sesamoids have been described in the foot and ankle, secondary ossification centersthat remain separated from the normal bon, accessory navicular (os tibiale externum), located in the flexor hallucis brevis tendon at the base of the 1st metatarsal head, Accessory Ossicles and Sesamoids of the Foot and Ankle, Posterior ankle impingement, FHL entrapment, Navicular tuberosity avulsion fx, type I accessory navicular, Painful os vesalianum, bipartite os peroneum, accessory ossicle representing the separated, usually asymptomatic, but can become symptomatic and cause, 10-25% of the population have os trigonum, ballet dancers due to extreme plantar flexion (", repetitive microtrauma (ankle plantarflexion), the secondary ossification center forms posterior to the talus between 8-13yrs, if the ossicle fails to fuse, it articulates with the talus through a, the os lies lateral to FHL, tibial nerve, PTT, and posterior tibial artery, differentiate from FHL tendinitis where ankle pain is, posteromedial and there may be triggering, may have swelling and tenderness over FHL if associated with FHL tendinitis, lateral radiograph with foot in plantar flexion, shows os trigonum impinged between posterior tibial malleolus and calcaneal tuberosity, os trigonum can be round, oval or triangular and of variable size, shows os trigonum and associated inflammation and edema in FHL tendon, fracture of the posterior process of the talus (Shepherd's fracture), produce posterior medial ankle pain and tenderness, NSAIDS, rest, immobilization, restricted weightbearing, through open lateral approach or posterior ankle arthroscopy, Os Tibiale Externum (Accessory navicular), small piece of bone adjacent to inferior fibula, avulsion fx of ATFL that secondarily ossifies, may have ankle pain (symptomatic os subfibulare), chronic ankle instability and present with recurrent ankle sprains, standard ankle series (weightbearing AP, lateral, mortise), increased separation of os fragment from fibula tip, acute lateral malleolus avulsion fracture (by the ATFL), initial treatment for symptomatic os subfibulare, may represent avulsion or rupture of peroneus longus, associated with peroneus longus tendon rupture, initial treatment for painful os peroneum syndrome, minimally displaced os peroneum fractures, painful os peroneum syndrome (with minimal tendon involvement) refractory to conservative treatment, os peroneum fracture with displaced fragments, surgical excision and repair of peroneus longus tendon or tenodesis to peroneus brevis, os peroneum associated with peroneus longus tendon rupture, Posterior Tibial Tendon Insufficiency (PTTI). These avulsions, if not adequately diagnosed and treated, may progress to delayed union, nonunion, or a chronically painful ankle. 1. Avoid making bone tunnels through the distal fibular physis in skeletally immature patients. Eur Radiol 13: 164-177 (PMID: 16440220), [6] Please try after some time. 5. The patient is in supine position. After suture removal, the ankle was protected in range-of-motion brace for six weeks. 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. Lower Extremity Os are secondary ossification centersthat remain separated from the normal bone and may be confused with a fracture. Lower portion of the os subfibulare appears of normal signal intensity. Modified arthroscopic Brostrom procedure. The purpose of this Technical Note is to describe the details of arthroscopic stabilization of the os subfibulare. Drilling of the mobile os subfibulare is easier than microfracture of the ossicle with an arthroscopic awl. The patient was treated with immobilization for 4 weeks and anti-inflammatory agents. Patients then can advance to a CAM (controlled ankle motion) boot with full weight-bearing. Epub 2016 Jun 14. Shands AR Jr. Accessory bones of foot: x-ray study of feet of 1,054 patients. He reported that an ossicle of the lateral malleolus may be an avulsion fracture from the fibular tip or talus or accessory bones developing from a secondary ossification center. Inclusion in an NLM database does not imply endorsement of, or agreement with, The varus stress radiograph of the right ankle shows a lateral opening of normal range (5). 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. 15 Expert Comments Topic Podcast Images SUMMARY 5th Metatarsal Base Fractures are among the most common fractures of the foot and are predisposed to poor healing due to the limited blood supply to the specific areas of the 5th metatarsal base. 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 site is secure. However, they may be injured, either acutely or chronically. Powell HDW: Extra centre of ossification for the medial malleolus in children: Incidence and significance. 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). The opposing surfaces of the ossicle and lateral malleolus are debrided and microfractured. Using two large Keith needles, pass the sutures from the Krackow stitches in the anterior talofibular ligament and calcaneofibular ligament through the tunnels. We performed a retrospective case study of the first twenty-three patients treated with our procedure for symptomatic os subfibulare. (OBQ11.253) On physical examination she has no tenderness at the insertion of the achilles tendon at the calcaneus. Ogden J, Lee J (1990) Accessory ossification patterns and injuries of the malleoli. Keep bone tunnels away from the distal fibular physis. Figure 1 The anterior posterior (A) and Oblique (B) radiograph showing a large accessory ossicle or os subfibulare to the tip of the right lateral malleolus. Cureus. Tsuruta T, Shiokawa Y, Kato A, Matsumoto T, Yamazoe Y, Oike T, Sugiyama T, Saito M. [Radiological study of the accessory skeletal elements in the foot and ankle (authors transl)]Nippon Seikeigeka Gakkai Zasshi April 1981 55(4): 357-370. There was no ossicle visible on radiographs, and there was no laxity of the lateral ligament detected by manual maneuvering. Several of these patients did have ankle pain, and it was termed symptomatic os subfibulare. [9], The majority of os subfibulare are small. They are commonly separated from the tip of the lateral malleolus and are totally asymptomatic. Painful os subfibulare. Have other surgeons had experiences with attempted screw fixation? Intra-articular lesions in chronic lateral ankle instability: Comparison of arthroscopy with magnetic resonance imaging findings. Copyright 2023 Lineage Medical, Inc. All rights reserved. (B) Postoperative anteroposterior and lateral radiographs of the ankle showed screw fixation of the os subfibulare. Patients wear a cast and remain non-weight-bearing for six weeks postoperatively. In: Karantanas A (ed). official website and that any information you provide is encrypted [10]. government site. Which of the following options is the most appropriate next step in treatment? The ossicle which was separate from the fibular tip appeared divided in two parts (Figs 1a, b). Anteroposterior radiograph of the ankle joint demonstrates an ossicle (arrow) that is separate from the lateral malleolus. Corte-Real N.M., Moreira R.M. The patient is in supine position. OS, os subfibulare. HHS Vulnerability Disclosure, Help 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. Fluoroscopy may also be used to examine for loose bodies. Use nonabsorbable sutures to place a Krackow locking stitch in each of the ligaments. After that, the patient is allowed weightbearing walking in an Aircast Air-Stirrup ankle support brace (DJO, Dallas, TX) for another 4weeks (Fig 9). by Vasu Pai MS, D[Orth], National board [Orth], FICMR, FRACS, MCh[Orth]1, The Foot and Ankle Online Journal 3 (8): 3. Reports of accessory ossification are sparse. Ankle arthroscopy revealed that the anterior talofibular ligament fibers were not torn and were attached firmly at the fibula and talus. Clin Orthop 330:157165, 1996. The os subfibulare formed a painful pseudo-arthrosis and the accessory ossicle was excised. The stability of the ossicle and lateral ankle is evaluated. 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. Our surgical treatment consists of excision of the osseous fragment, ligament repair, and a modified Brostrm procedure (Video 1). Bookshelf 2015 Jun 20;4(2):e27046. (B) Lateral ankle joint space opening up and plantar displacement of os subfibulare upon inversion stress. An official website of the United States government. Referral to an orthopaedic oncologist for biopsy and staging, Arthroscopic Haglund deformity excision and debridement of achilles tendon, Type in at least one full word to see suggestions list, Posterior Ankle Endoscopy (Hindfoot Arthroscopy). Post-operatively, the ankle was placed in a posterior splint and held in neutral position for two weeks. However, a varus stress radiograph demonstrates gross instability and incompetence of the lateral ankle ligaments. It allows evaluation and treatment of concomitant ankle pathology. These include: ossicles of the hip. 6 Os subfibulare is sometimes a cause of ankle pain, in which case it is called symptomatic os subfibulare. Look for loose bodies and damage to the lateral aspect of the talus, which may require debridement. Clin Dysmorphol Oct 2004 13(4):237-240. 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 technique has the advantages of minimally invasive surgery, evaluation and treatment of concomitant ankle pathology, and preservation of integrity of the anterior talofibular ligament. After temporary fixation of the os subfibulare with a Kirschner wire, a guide pin is inserted. Normally, the secondary center of ossification of the lateral malleolus appears during the first year of life, and fuses with the shaft at 15 years. Os subfibulare, defined as a separated ossicle of the distal fibular, has been linked to various clinical problems such as subfibulare pain and chronic lateral ankle instability. 3. An official website of the United States government. Flexor hallucis longus (FHL) tendon debridement, EMG to evaluate for tarsal tunnel syndrome. Excision of the os subfibulare is indicated for a painful small ossicle without ankle instability.1 For symptomatic mechanical lateral ankle instability, surgical options include excision of the os subfibulare together with repair or reconstruction of the lateral ligament of the ankle or fusion of the ossicle.1, 5, 6, 7. Hallux sesamoids ~100%. Tie the most proximal stitch to one of the middle stitches. Clinical Orthopaedics and Related Research399:197-200, June 2002. The patients included eight boys and fifteen girls ranging in age from eight to seventeen years at the time of surgery. Ankle arthroscopy is performed using the anteromedial and anterolateral portals. Radiographs showed a separate round ossicle at the tip of the lateral malleolus and a similar ossicle, 5 mm in diameter, in the contralateral ankle (Fig 1). Epub 2013 Jul 31. After application of general or spinal anesthesia, the ankle joint is examined under fluoroscopy. Clinical examination revealed a visible swelling 2cm by 2cm over the lateral malleolus. South Med Surg 1931 93: 326-334. One patient reported continued lateral ankle swelling when playing pivoting sports but not persistent pain or instability. Superior fragment is of low signal intensity (thick arrow), whereas inferior fragment (arrowhead) maintains normal high signal. The pain was worse with weight-bearing. 8600 Rockville Pike 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 PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). It is also contraindicated if the ossicle is too small or the bone quality is too poor to achieve stable internal fixation (Table1). The anteromedial portal is the viewing portal, and the anterolateral portal is the working portal. On MRI, the ossicle had a high signal on T2-weighted images. Painful accessory bones of the foot. Using the radiographic imaging, the skin was cut approximately 1 cm at the location of the ossicle, the subcutaneous tissue was dissected bluntly, and the anterior talofibular ligament fibers were exposed. The best surgical option for lateral ankle instability associated with an unstable os subfibulare is still undetermined. A telephone survey was conducted at a mean of 4.5 years (range, 2.1 to 13.2 years) postoperatively. The injury of the calcaneocuboid ligaments. 9. Wolters Kluwer Health From the Department of Orthopaedics, Shimane Medical University, Shimane, Japan. 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. He said that an os subfibulare is an avulsion fracture that may be associated with laxity of the anterior talofibular ligament and that it is not a normal variant. A radiograph can confirm the presence of the os subfibulare and assess the size of the ossicle. There was no evidence of instability or locking of the ankle joint. Avulsion fracture of the fibula associated with recurrent instability of the ankle. METHODS: Twenty-three patients presented with chronic ankle pain and instability, tenderness anterior and distal to the lateral malleolus, and imaging studies (magnetic resonance imaging and/or stress radiographs) suspicious for avulsion injury of the anterior talofibular ligament and/or calcaneofibular ligament. Displacement of the os subfibulare can be shown during an inversion stress test (Fig 1). 2007 Apr;15(4):465-71. doi: 10.1007/s00167-006-0275-7. Liu C, Zhang HS, Pei BJ, Wang HL, Su H, Wang QH. We performed a retrospective case study of the first twenty-three patients treated with our procedure for symptomatic os subfibulare. 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. 1. 10.Griffith JD, Menelaus MB. A T2-weighted MRI scan of the right ankle shows that the ossicle had high signal images. There was no history of ankle sprain. The distal fascicle of the anterior inferior tibiofibular ligament as a cause of tibiotalar impingement syndrome: a current concepts review. 1 It is a result of an unfused accessory ossification center or an avulsion fracture of the anterior talofibular ligament. Examine the integrity of the remaining ankle ligaments. When used for strict surgical indications, operative management of chronic symptomatic os subfibulare in children involving fragment excision and ligament repair can significantly improve visual analog scale pain scores and result in high Foot and Ankle Outcome Scores. Berg EE: The symptomatic os subfibulare. JBJS March 1987 69B (2):317-9. The precise cause of symptoms in patients is conjectural. (SBQ18FA.2) Arch Orthop Trauma Surg 38:431448, 1937. Unusual foot pathologies mimicking common sports injuries.J Foot Ankle Surg Jan-Feb 1993 32(1): 53-59. (A) The os subfibulare can be displaced distally. Os subfibulare is the separated ossicle of the distal fibula. Tighten and tie down the sutures from the anterior talofibular ligament and the calcaneofibular ligament. On the MRI scans, the images showed that the fibers of the anterior talofibular ligament did not appear to be attached to the ossicle directly, but were attached firmly to the distal fibula. The lateral instability of the ankle joint can be confirmed arthroscopically by observing the lateral ankle opening up during inversion stress to the ankle (Figure4). After removal of the os subfibulare, the fibular bed is debrided to healthy cancellous bone. Theodorou D,DeptRadiol,GenHospIoannina,Greece. Please enable scripts and reload this page. The mean age was 10.4 years (range, eight to thirteen years) at the time of injury and 13.6 years (range, eight to seventeen years) at the time of surgery, representing an average delay in diagnosis and treatment of 3.2 years (range, six months to five years). The first is that the ossicles are caused by an avulsion fracture 1,5 and the second is . Subtalar instability, if present, cannot be detected during ankle arthroscopy. Your message has been successfully sent to your colleague. The os subfibulare is a normal anatomic variant that represents either an unfused accessory ossification centre or a supernumerary bone [1]. An ossicle may also be avulsed as a ligament failure analogue, similar to a sleeve fracture of the patella. The arrow points to the ossicle in the anterior talofibular ligament fibers. Os subfibulare is an ossicle at the tip of the lateral malleolus. 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. An extension of the phenotype or a new syndrome? 2007. The patient was a 17-year-old boy who was a competitive soccer player in high school. Clipboard, Search History, and several other advanced features are temporarily unavailable. Mosel LD, Kat E, Voyvodic F. Imaging of the symptomatic type II accessory navicular bone. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Definition accessory ossicles secondary ossification centers that remain separated from the normal bon sesamoids are bones that are incorporated into tendons and move with normal and abnormal tendon motion Most common ossicles os trigonum accessory navicular (os tibiale externum) os intermetatarseum Most common sesamoids os peroneum and transmitted securely. Hypertrophied synovium of the lateral ankle gutter is resected to expose the os subfibulare. Treatment is generally observation as most are completely asymptomatic. Space bone tunnels adequately to prevent suture cutout or bone avulsion. This leads to two questions: Should patients who undergo this procedure limit their participation in high-impact activities? Surgical excision resulted in complete, symptomatic relief. When symptomatic, it can be treated with anti-inflammatory drugs, physiotherapy and modified footwear. 8600 Rockville Pike Os peroneum. Avulsion fracture of the fibula associated with recurrent instability of the ankle. 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. As the subsequent six weeks progress, allow the patient to gradually advance activities as tolerated to normal. 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. Twenty two percent of normal children under the age of 16 have one or more accessory ossicles in the foot and ankle. Arthroscopic stabilization of unstable os subfibulare of the right ankle. The anteromedial portal is the viewing portal, and the lateral ankle gutter is examined. J Foot Ankle Surg. The accessory ossicle was separated easily. Theodorou D,DeptRadiol,GenHospIoannina,Greece, Theodorou D, DeptRadiol,GenHospIoannina,Greece. aDepartment of Orthopaedics and Traumatology, North District Hospital, Hong Kong SAR, China, bDepartment of Orthopaedics and Traumatology, Princess Margaret Hospital, Hong Kong SAR, China. Berg EE (1991) The symptomatic os subfibulare. In the event of symptoms, treatment depends on location of Os and chronicity of symptoms. In all patients, the ossicle was dissected, and the lateral ligaments were resutured. Hasegawa A, Kimura M, Tomizawa S, Shirakura K (1996) Separated ossicles of the lateral malleolus. Bethesda, MD 20894, Web Policies In general, accessory ossicles commonly observed in order of frequency of the lower extremity include: tibiale externum, os trigonum and os peroneum. An ossicle 5 mm in diameter in the anterior talofibular ligament fiber was found. (Fig. 4. The K wire and guide pin are then removed. There are two theories regarding the origin of os subfibulare. This site needs JavaScript to work properly. After application of general or spinal anesthesia, the ankle joint is examined under fluoroscopy. 2022 Jul 29;14(7):e27469. The ossicle is located under the tip of the lateral malleolus [2]. Case presentation includes radiographic and computed tomography findings with discussion of various accessory ossicles and their respective incidence in the lower extremity. Os subfibulare is an ossicle at the tip of the lateral malleolus. A normal anteroposterior radiograph of the ankle does not demonstrate any gross deformity. The anterior talofibular ligament, which is the main lateral stabilizer of the ankle joint, appeared intact with low signal intensity. No ankle distractor is used. It is indicated for symptomatic mechanical lateral ankle instability resulting from an unstable os subfibulare. J Bone Joint Surg 43B: 107-113, [5] (A) Anterior view of the ankle. The articular surfaces of the lateral malleolus and os subfibulare are examined to confirm anatomic reduction of the ossicle. Andermahr J, Helling HJ, Maintz D, Mnig S, Koebke J, Rehm KE. 2 In the current report, a patient with os subfibulare that was thought to have been caused by accessory ossification is reported. The stability of the os subfibulare after screw fixation is tested. 6. Henry Gray, Susan Standring, B. K. B. Berkovitz. Arthroscopic stabilization of unstable os subfibulare of the right ankle. Background: The os subfibulare is usually asymptomatic and found incidentally on radiographs. ossicles of the knee. Os subfibulare is a separated ossicle at the tip of the lateral malleolus and inferior portion of the fibular tuberosity of the ankle which is rarely reported. Treatment can be nonoperative or operative depending on fracture displacement, ankle stability, presence of syndesmotic injury, and patient activity demands. Clinical presentation Os subfibulare are usually asymptomatic although they may eventually cause painful syndromes or degenerative change in response to overuse and trauma. 3. Davies MB, Dalal S. Gross anatomy of the interphalangeal joint of the great toe: implications for excision of plantar capsular accessory ossicles. 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. Careers, Unable to load your collection due to an error. The patient is in supine position. Iatrogenic fracture of the os subfibulare, Injury to the the branches of the deep or superficial portal nerve, Allows evaluation and treatment of concomitant ankle pathology, The anterior talofibular ligament is not disrupted. A 16 year-old female presented with pain of the right lateral ankle for six months duration. Please try again soon. and transmitted securely. Figure 3 Three-dimensional computed tomography reveals a large accessory ossicle or os subfibulare to the tip of the lateral malleolus with pseudo-arthrosis of the fragment. Since symptoms were recalcitrant, exploration and removal of the ossicle was performed. 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). 2). Unable to process the form. Hypertrophied synovium of the lateral ankle gutter is resected to expose the os subfibulare. The indications, radiographic findings, and surgical technique are described. During surgery, the fibers of the anterior talofibular ligament were found not to be attached to the ossicle directly, so the ossicle could be resected easily. You may be trying to access this site from a secured browser on the server. The ossicle showed a high signal on T2-weighted magnetic resonance imaging (MRI) scans (Fig 3). True submalleolar accessory ossicles causing impingement of the ankle. The purpose of this Technical Note is to describe the details of arthroscopic stabilization of the os subfibulare. 6.Ogden JA. Before The ossicle is enlarged and has a bifid appearance. Accessibility Pill SG, Hatch M, Linton JM, Davidson RS. The patient presented with lateral ankle pain associated with tenderness at the tip of the lateral malleolus. Vanhoenacker F, de Cuyper K, Williams H (2011) Normal anatomy and variants that simulate injury. Very rarely do they enlarge and become symptomatic. Arch Trauma Res. 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. One day after surgery, the patient was allowed to walk using crutches, but he was not allowed to bear weight for 3 weeks. Gray's Anatomy. 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. Lui T.H. doi: 10.2106/JBJS.L.00847. doi: 10.7759/cureus.1881. J Bone Joint Surg 73A: 1251-1254 (PMID: 1890128), [3] The surroundings of the ossicle had an isointense signal on T2-weighted images. The correct positioning of the guide pin is confirmed fluoroscopically, and a 4-mm cannulated screw is inserted (Fig 7). cyamella. There are numerous named and unnamed accessory ossicles of the lower limb. Open the capsule to directly visualize the articular surface. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Close the incision in layers. Arthroscopic stabilization of unstable os subfibulare of the right ankle. 4. Careers. 7. meniscal ossicle. Step 1: Indications and Preoperative Planning 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. 2013 Aug 21;95(16):e115. 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. J Foot Surg Jan-Feb 1991 30(1): 52-55. She attempted various shoe gear and multiple courses of anti-inflammatory medication with no benefit or symptomatic relief. It seemed that the fibers of the anterior talofibular ligament were not attached to the ossicle directly. Hasegawa A., Kimura M., Tomizawa S., Shirakura K. Separated ossicles of the lateral malleolus. Federal government websites often end in .gov or .mil. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. 8. Identify and sharply dissect the fragment from the anterior talofibular ligament and calcaneofibular ligament as it is removed (Fig. For more information, please refer to our Privacy Policy. 1991 Sep;73(8):1251-4. Os vesalianum. National Library of Medicine Wang J., Hua Y., Chen S., Li H., Zhang J., Li Y. Arthroscopic repair of lateral ankle ligament complex by suture anchor. (Untersuchungen an 500 Rontgenbildern der Chir Universitatsklinik zu Jena.) The site is secure. The patient is in supine position. Champagne IM, Cook DL, Kestner SC, Pontisso JA, Siesel KJ. Unauthorized use of these marks is strictly prohibited. Avulsion fracture of the lateral malleolus, Brought to you by the European Society of Radiology (ESR) -. Patients advance to full weight-bearing in a CAM boot and start physical therapy at six weeks. Disclaimer. In 3,460 radiographs of patients over 7 years of age, the os tibiale externum was the most common accessory bone. All patients returned to normal age-appropriate activities and regular gym class within four months postoperatively. An incision was centered over the area of edema and a pseudo-arthrosis was demonstrated. Chun T.H., Park Y.S., Sung K.S. A 17-year-old ballet dancer presents with 5 months of pain in the posterior aspect of the right lower extremity that is exacerbated with the ballet position shown in Figure A. After synovectomy, the mobility of the os subfibulare can be assessed. Guillo S., Bauer T., Lee J.W. 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. government site. If fractured, the injury can extend through a segment of the malleolus. Anomalous multifocal ossification of the os calcis. Full ICMJE author disclosure forms are available for this article online, as supplementary material. A plain mortise radiograph of the right ankle shows a separate round ossicle at the tip of the lateral malleolus (arrow). FOIA The https:// ensures that you are connecting to the Currently, fusion of os subfibulare is performed as an open procedure. 3). Painful os vesalianum. Before Some error has occurred while processing your request. LM, lateral malleolus; S, inflamed synovium; T, talus; TP, tibial plafond. The most common accessory ossicles in the ankle and foot are the os trigonum, the accessory navicular (among the different three types, type II is the most common) and the os intermetatarseum, in this order.
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