Search Results (30)

Mandibular reconstruction with the fibula free flap is the gold standard for large defects, with virtual surgical planning becoming integral to the process. The localization and dissection of critical vessels, such as the recipient vessels in the neck and the perforating vessels of the fibula flap, are demanding steps that directly impact surgical success. Augmented reality (AR) offers a solution by overlaying three-dimensional virtual models directly onto the surgeon’s view of the operative field. We report the first case in Latin America utilizing a low-cost, commercially available holographic navigation system for complex microsurgical mandibular reconstruction. A 26-year-old female presented with a large, destructive osteoblastoma of the left mandible, requiring wide resection and reconstruction. Preoperative surgical planning was conducted using DICOM data from the patient’s CT scans to generate 3D holographic models with the Medicalholodeck^® software. Intraoperatively, the primary surgeon used the AR system to superimpose the holographic models onto the patient. The system provided real-time, immersive guidance for identifying the facial artery, which was anatomically displaced by the tumor mass, as well as for localizing the peroneal artery perforators for donor flap harvest. A free fibula flap was harvested and transferred. During the early postoperative course and after 3-months of follow-up, the patient presented with an absence of any clinical complications. This case demonstrates the successful application and feasibility of using a low-cost, consumer-grade holographic navigation system. Full article

Background: Mandibular defects caused by trauma or tumor resection pose significant challenges in both functional and aesthetic reconstruction. Additive manufacturing (AM) technologies offer promising solutions for surgical planning and personalized treatment. Objectives: This review aims to evaluate current trends in the application of AM technologies for mandibular resection and reconstruction, with a particular focus on material selection, clinical integration, and technology-specific advantages. Methods: A structured literature review was performed using PubMed, Scopus, Web of Science, and Google Scholar. Studies published between January 2020 and May 2025 were screened using the following inclusion criteria: original peer-reviewed English-language research involving AM in mandibular surgery. The exclusion criteria included review articles, non-English sources, and non-mandibular studies. A total of 77 studies met the inclusion criteria and were analyzed in this review. Results: Based on the literature review conducted from 2020 to 2025, the most common restorative methods for the mandible using additively manufactured models include reconstruction with a titanium surgical plate bent to the curvature of the edges and angle of the mandible or a personalized titanium or PEEK surgical plate made directly based on the patient’s diagnosis. Implants made of Ti-6AL-4V ELI and bioceramic scaffolds are also used in the reconstruction process. They are developed based on patient diagnostic data and effectively replace the loss of mandibular bone structure. In addition, based on models and surgical guides created using additive manufacturing techniques, the performance of autogenous grafts from the fibula or iliac crest has improved significantly when used with a titanium implant plate. Conclusions: Additive manufacturing supports highly personalized and accurate mandibular reconstruction. The advantages of these methods include a reduced overall duration of procedures, a lower health risk for patients due to less reliance on general anesthesia, a near perfect match between the implant and the remaining hard tissues, and satisfactory aesthetic outcomes. However, success depends on the appropriate selection AM technology and material, particularly in load-bearing applications. Full article

Background and Clinical Significance: Neurofibromatosis type 1 (NF1) predisposes individuals to various peripheral nerve sheath tumors (PNSTs), including benign neurofibromas, malignant peripheral nerve sheath tumors (MPNSTs), and intermediate lesions known as atypical neurofibromatous neoplasms of uncertain biologic potential (ANNUBP), previously often termed atypical neurofibroma. These atypical lesions are considered premalignant precursors to MPNST. Case Presentation: We present the case of a 33-year-old male with NF1 who developed a rapidly growing, painful mass in his right calf. Clinical examination revealed signs consistent with NF1. Magnetic resonance imaging showed a large, heterogeneous mass in the lateral compartment. Biopsy revealed a neurofibroma with hypercellularity, moderate atypia, scarce S100 positivity, focal CD34 positivity, and an elevated Ki-67 proliferation index of 10–12%, consistent with ANNUBP. The patient underwent wide surgical resection, including the fibula and peroneal muscles. At the 30-month follow-up, there was no local recurrence, though the patient had a mild residual limp. Discussion: This case highlights the clinical presentation, diagnostic features, and management considerations for ANNUBP in NF1, emphasizing the importance of recognizing warning signs and the role of pathology in guiding treatment for these high-risk precursor lesions. Full article

Background: Primary malignant bone tumors among adolescent patients are most commonly associated with burdensome surgeries that can severely affect young patients’ early life. To this day, despite available autologous tissue donor sites, cement spacers or endoprostheses are still most commonly used as a form of reconstruction of post-resection defects. Methods: The study group includes 20 adolescent patients diagnosed with Osteosarcoma or Ewing Sarcoma involving the upper limbs. The inclusion criteria were as follows: primary malignant bone tumors sensitive to neoadjuvant chemotherapy, tumors not infiltrating major blood vessels and nerves, and the appliance of the microsurgical free flap as a reconstructive method. Poor tumor response to neodajuvant chemotherapy or patients with incomplete follow-up were excluded from this study. To achieve the functional reconstruction of post-resection defects, fibula free flaps were applied. In cases of resection, including the metaphysis of a long bone, a modification of the flap harvest was applied in order to prevent arthrodesis. The MSTS (Musculoskeletal Tumor Society Scoring System) scale was used as a functional outcome measurement tool. Results: The reported outcomes of this study prove the efficiency of the treatment’s approach of combining the resection of the tumor with subsequent microsurgical restoration with the use of autologous tissues. The average score on the MSTS scale, which assesses the functional outcome, was 26.8/30 points, which indicates great motor outcomes. There were no reports of local recurrence during follow-up. Conclusions: Patients with primary malignant bone tumors in the upper limbs can benefit from microsurgical techniques, which are highly customized; effective; and give sufficient functionality following extensive resection. Full article

Background: Evidence supporting the validity of photogrammetry for assessing body segment alignment remains limited, with most studies focusing on spinal evaluation. Thus, there is a lack of robust research examining its use for other body segments such as the lower limbs. Objective: This study aimed to evaluate the concurrent validity of three photogrammetric methods for measuring knee alignment in the sagittal plane with and without corrections for potential rotational deviations in the participant’s thigh and leg. Methods: A total of 21 adults underwent sequential evaluations involving panoramic radiography of the lower limbs and photogrammetry at a private radiology clinic. Photogrammetric analysis involved identifying the following anatomical landmarks: the greater trochanter of the femur (GTF), the lateral condyle of the femur (LCF), the head of the fibula (HF), and lateral malleolus (LM). Three photogrammetric methods were employed: (1) the condylar angle (CA) defined by the GTF, LCF, and LM points; (2) the fibula head angle (FHA) defined by the GTF, HF, and LM points; and (3) the four-point angle (4PA) incorporating the GTF, LCF, HF, and LM. Concurrent validity was assessed using correlation analysis, agreement with radiographic measurements, and the root mean square error (RMSE). Each photogrammetric method was tested using raw (CA, FHA, and 4PA) and corrected (CAcorr, FHAcorr, and 4PAcorr) values, accounting for thigh and/or leg rotational deviations. Results: Correcting for thigh and leg rotations significantly improved the validity metrics for all methods. The best performance was observed with the corrected condylar angle (CAcorr: r = 0.746; adjusted r² = 0.533; RMSE = 2.9°) and the corrected four-point angle (4PAcorr: r = 0.733; adjusted r² = 0.513; RMSE = 3.0°); however, the measurements presented proportional errors, possible due the method of assessment of rotations. Conclusions: The findings validate the evaluated photogrammetric methods for assessing sagittal knee alignment. Accounting for thigh and leg rotational deviations is critical for achieving accurate measurements, raising the need of accurate tools for measuring rotational changes in the lower limbs to avoid errors. Full article

Background: Mandibular reconstruction has evolved significantly since its inception in the early 1900s. Currently, the fibula free flap (FFF) is considered the gold standard for mandibular and maxillary reconstructions, particularly for extensive defects, and the introduction of Extended Reality (XR) and virtual surgical planning (VSP) is revolutionizing maxillofacial surgery. Methods: This study focuses on evaluating the accuracy of using in-house cutting guides for mandibular reconstruction with FFF supported by virtual surgical planning (VSP). Planned and intraoperative osteotomies obtained from postoperative CT scans were compared in 17 patients who met the inclusion criteria. The proposed analysis included measurements of deviation angles, thickness at the centre of gravity, and the maximum thickness of the deviation volume. Additionally, a mandibular resection coding including 12 configurations was defined to classify and analyze the precision of mandibular osteotomies and investigate systematic errors. Preoperative, planned, and postoperative models have been inserted in an interactive VR environment, VieweR, to enhance surgical planning and outcome analysis. Results: The results proved the efficiency of adopting customized cutting guides and highlighted the critical role of advanced technologies such as CAD/CAM and VR in modern maxillofacial surgery. A novel coding system including 12 possible configurations was developed to classify and analyze the precision of mandibular osteotomies. This system considers (1) the position of the cutting blade relative to the cutting plane of the mandibular guide; (2) the position of the intersection axis between the planned and intraoperative osteotomy relative to the mandible; (3) the direction of rotation of the intraoperative osteotomy plane around the intersection axis from the upper view of the model. Conclusions: This study demonstrates the accuracy and reliability of in-house cutting guides for mandibular reconstruction using fibula free flaps (FFF) supported by virtual surgical planning (VSP). The comparison between planned and intraoperative osteotomies confirmed the precision of this approach, with minimal deviations observed. These findings highlight the critical role of CAD/CAM and XR technologies in modern maxillofacial surgery, offering improved surgical precision and optimizing patient outcomes. Full article

Introduction: Generally, after an oral oncological therapeutic process in which, unfortunately, surgery plays a fundamental role, a reconstructive and rehabilitative procedure should be initiated, seeking as far as possible to recover the patient’s vital functions (mastication, aesthetics, and phonetics). Case report: We present the case of a patient who successfully underwent treatment for mandibular sarcoma. After a disease-free period of one year, following oncological treatment, an intervention was performed for the insertion of dental implants into the fibula to subsequently rehabilitate the patient prosthetically. There were several challenges, including free-end edentulous space in the lower jaw with a depth of 18 mm on peri-implant tissues consisting of osteoseptocutaneous skin graft, hypotonic perioral musculature, and high aesthetic expectations of the patient. An overdenture with a titanium milled bar substructure with retentive prosthetic components was chosen for treatment. This implant-supported removable prosthesis was selected to facilitate cleaning, since the patient did not maintain oral hygiene habits. The patient was educated on using and handling the prosthesis, and the treatment objectives were achieved (to restore aesthetics and masticatory function). Conclusions: Removable prostheses are a valid alternative for oncologic patients and patients with unfavorable conditions for more complex implant-supported rehabilitation. Full article

The paper presents a detailed gross anatomical description of the elements of the pelvic limb in the African green monkey and provides comparative and differential elements on pelvic limb monkey osteology. The osteometric investigation adds value to the gross morphological and radiological investigation, adjoining metric data to the gross descriptive data set. The main methodology used was the gross morphological investigation, doubled by regular osteometrical and radiographical assessments. For each of the elements, several morphological aspects are described, pointing to the specific and differential aspects that might serve as landmarks in the specific diagnosis of different adaptative changes, related to the type of locomotion. For the pelvis, the aspect of the symphysis, the overall shape of the pelvic inlet, the iliac wing aspect and the acetabular shape are listed as significant elements. The femur has a spherical head with an inferior position of the femoral fovea and a well-developed (tall) greater trochanter, lacking the third trochanter. The medial condyle of the femur is better developed than the lateral one and an evident extensor’s fossa is noted at the level of the distal shaft. The proximal lateral condyloid surface in the tibia is slightly larger than the medial one, with noticeable intercondilar eminences. The fibula is long and unfused with the tibia. Some specific anatomical features are listed only for the talus and calcaneus from tarsals. The study revealed the presence of the gastrocnemius sesamoid bones and the proximal sesamoidi bones as well. Investigation presents a series of osteometrical data with an attempt to show some basic metrical differences among the investigated specimens. Full article

The Komodo dragon (Varanus komodoensis) is the largest extant lizard and is classified as an endangered species. Despite its rarity, anatomical studies on this species remain limited, hindering a comprehensive understanding of its biology and evolutionary traits. This research presents a detailed anatomical and histological examination of the pelvic limb of a female Komodo dragon, providing valuable insights into the musculoskeletal system of this species. A series of measurements and observations were made on the bones of the pelvic limb, including the femur, tibia, fibula, and pes, all of which are essential for supporting the animal’s large body size and facilitating its predatory behavior. This study also highlights the diverse muscle architecture, where large muscle masses are associated with the femoral retractors and ankle plantarflexors. Histological analysis of the muscle fibers revealed significant variability in fiber diameters, supporting the functional adaptation of the Komodo dragon’s limbs for high-speed ambush predation. This research provides important morphological data that could inform clinical practices, including orthopedic procedures and physiotherapy for Komodo dragons in zoological settings. Additionally, these findings shed light on the evolutionary patterns inherited from the species’ ancestors, which contributed to the development of its distinctive biological adaptations. Full article

The Lateral Collateral Ligament (LCL), one of the four major ligaments in the knee joint, resides on the outer aspect of the knee. It forms a vital connection between the femur and the fibula. The LCL’s primary role is to provide stability against Varus forces, safeguarding the knee from undue rotation and tibial displacement. Uniaxial mechanical testing was conducted on the dog bone (DB) samples in this study. The porcine of different ages, from 3 months to 48 months (4 years) old, were used to analyse the effect of age. A constant head speed of 200 mm/s was applied throughout the tests to mimic strain–stress and damage responses at an initial strain rate of 13.3/s. The mechanical properties of LCL were evaluated, with a specific focus on the effect of age. The LMM (Linear Mixed Model) analysis revealed a marginally significant positive slope for Young’s modulus (p = 0.0512) and a significant intercept (p = 0.0016); for Maximum Stress, a negative slope (p = 0.0346) and significant intercept (p < 0.0001); while Maximum Stretch showed a significant negative slope (p = 0.0007) and intercept (p < 0.0001), indicating the muscle reduces compliance and load-bearing capacity with age. Full article

Objectives: The COVID-19 pandemic has had a profound effect on the pediatric population worldwide. The consequences of the lockdown and the reallocation of hospital resources have caused notable changes in the presentation of pediatric orthopedic injuries. Through our use of patient records, we were able to display the epidemiological trends, as well as analyze the changes in the type and mechanism of various injuries. Our purpose is to further understand the considerable effects of the COVID-19 pandemic on pediatric orthopedic trauma and help guide the allocation of future healthcare resources. Methods: We conducted a retrospective cohort study on pediatric patients admitted for any orthopedic injury over a 3-year period (September 2018 to August 2021) at a Midwest level 1 trauma center. Cases were stratified into two groups based on the United States’ COVID-19 lockdown (19 March 2020): Pre-COVID-19 cases were any cases prior to the lockdown and Intra-COVID-19 which are cases following the lockdown. Numerical data and categorical variables were summarized and differences between the case groups were examined using either two-Proportion Z-Test, Independent Two-Sample t-test, Pearson’s chi-squared, or Fisher’s exact tests. Results: A total of 3179 pediatric orthopedic referrals occurred between the Pre-COVID-19 and Intra-COVID-19 study periods. We observed a general decrease in orthopedic injuries following the COVID-19 lockdowns with 1235 injuries compared to 1606 Pre-COVID-19. Patterns in the locations of injuries changed; notably, fractures of the humerus, tibia, and fibula decreased significantly (p < 0.05). Several mechanisms of injuries decreased significantly following the onset of COVID-19 including injuries caused by monkey bars, basketball, and automobiles (p < 0.01). There was a significant increase in the overall injury severity during the Intra-COVID-19 period (p < 0.05). Conclusions: Although there was a reduction in acute orthopedic trauma referrals, many injury mechanisms displayed similar trends regardless of restrictions. We clinically observed an overall increase in the severity of pediatric orthopedic injuries during the COVID-19 pandemic. Full article

Introduction: We investigated the biomechanical behaviour of different fixations of the tibial posterior malleolus (TPM), simulating distinct situations of involvement of the tibiotalar articular surface (TTAS) through a finite element model (FEM). Material and methods: A 3D computer-aided design model of the left ankle was obtained. The materials used were divided according to their characteristics into ductile and non-ductile, and all materials were assumed to be linear elastic, isotropic, and homogenous. Three different fracture lines of the TPM were defined, with sagittal angles of 10°, 25°, and 45°. For biomechanical comparison, different constructions using a trans-syndesmotic screw (TSS) only (Group T), a one-third tubular plate only with (Group PT) and without (Group PS) a TSS, and a locked compression plate with (Group LCPT) and without (Group LCPS) a TSS were tested. FEM was used to simulate the boundary conditions of vertical loading. Load application regions were selected in the direction of the 700 N Z-axis, 90% on the tibia and 10% on the fibula. Data on the displacement and stress in the FEM were collected, including the total principal maximum (MaxT) and total principal minimum (MinT) for non-ductile materials, total displacement (desT), localized displacement at the fragment (desL), localized displacement at syndesmosis (desS), and Von Mises equivalent stress for ductile materials. The data were analysed using ANOVA and multiple comparison LSD tests were used. Results: For TPM fractures with sagittal angles 10° and 25°, desL in the PT and LCP groups was significantly lower, as well as Von Mises stress in Group LCPT in 10°, and PT and LCPT groups in 25°. For TPM fractures with a sagittal angle of 45°, desL in the LCP group and Von Mises stress in Group LCPS and LCPT were significantly lower. We found that any TPM fracture may indicate instability of the distal tibiofibular syndesmosis, even when the fragment is small. Conclusion: Our study showed that in fragments involving 10% of the TTAS, the use of a TSS is sufficient, but when the involvement is greater than 25% of the TTAS, either a non-locked or locked plate must be used to buttress the TPM. In posterior fragments affecting 45% or more of the TTAS, the use of a locking plate is recommended. Full article

Proximal fibular osteotomy (PFO) was found to relieve pain and improve knee function in patients with medial compartment knee osteoarthritis (OA). Therapy redistributes the load applied from the inside to the outside and alleviates the load applied on the inside through fibula osteotomy. Therefore, the clinical effect of fibular osteotomy using the finite element (FE) method was evaluated to calculate the exact change in stress inside a knee joint with varus deformity. Using CT and MRI images of a patient’s lower extremities, 3D models of the bone, cartilage, meniscus, and ligaments were constructed. The varus angle, representing the inward angulation of the knee, was increased by applying a force ratio in the medial and lateral directions. The results showed that performing proximal fibular osteotomy led to a significant reduction in stress in the medial direction of the meniscus and cartilage. The stress reduction in the lateral direction was relatively minor. In conclusion, the study demonstrated that proximal fibular osteotomy effectively relieves stress and redistributes the load in the knee joints of patients with medial compartment knee osteoarthritis. The findings emphasize the importance of considering force distribution and the position of fibular osteotomy to achieve optimal clinical outcomes. Full article

In March 2020, Germany imposed a nationwide lockdown to curb the spread of COVID-19, prompting questions about the impact on the incidence of common fractures. This study examined 15 fracture types in pre-outbreak (2010–2019) and post-outbreak (2020–2021) periods, using data categorized by age (18–64 years, >65 years) and sex (male, female). Linear regression assessed annual growth rates, and mean fracture numbers were compared across periods for significant differences. Results indicated a positive correlation between fracture incidence rates and time for various types, such as cervical, thoracic, lumbar, and pelvic spine fractures, rib fractures, femoral neck, pertrochanteric femur, femoral shaft, and ankle fractures. Frequencies of proximal humerus, distal radius, femoral neck, pertrochanteric femur, femoral shaft, and ankle fractures in 2020 and 2021 were within predicted ranges from previous years. However, rib fractures and spinal fractures (cervical, thoracic, lumbar, and pelvic spine) occurred less frequently during this time. Notably, this study found a consistent decline in most fracture types for individuals aged 18–64 after the pandemic’s onset, while the fracture incidence of hip fractures, often referred to as fragility fractures, for those over 65 remained unchanged. Fibula fractures showed the most considerable decrease in both age groups. In conclusion, the COVID-19 pandemic substantially impacted fracture incidence, with lower rates among individuals under 65 and unchanged fragility fractures in the elderly population. Full article

This case report focuses on a 17-year-old polytrauma patient who suffered a septic wound infection after an open reduction and internal fixation (ORIF) and soft tissue reconstruction with a pedicled flap, which led to a substantial bone and soft tissue defect of the lower leg. After thorough antibiotic treatment and after ensuring a non-septic wound, the defect was reconstructed using a contralateral free fibula flap designed as a flow through flap in a double loop manner to accommodate two fibular fragments and an ipsilateral ALT flap. Early weight bearing was initiated 11 days after the free flap transfer under external fixation, with full weight bearing achieved in 36 days with external fixation. After the removal of external fixation, full weight bearing was able to be reinitiated after 13 days, leading to the patient’s return to normal activity 6 months after the bony reconstruction. This case presents an innovative approach to treating a complex defect, with the final decision on using two separate free flaps instead of a single osteofasciocutaneous free flap resulting in a good bony reconstruction and soft tissue coverage, and with the use of external fixation enabling early rehabilitation. Full article