Patient has No Fibula

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I have a patient 51 year old male, involved in a motor cycle accident fracturing his shoulder in 2014.
The surgeon removed the fibula to repair the shoulder and sent the patient on his way.
Whilst the function of his shoulder has been restored his ankle is suffering. He has had poor post op care in regards to his foot. He has never seen a specialist/orthopedic surgeon in regards to his foot.

He presented with a primary symptom of a hypersensitive callus at the medial aspect of his right hallux.
As you can see on weight bearing X-ray his right foot is excessively pronated, and has developed a functional leg length discrepancy. He has poor muscle strength (despite physiotherapy) and has poor muscle control of his ankle.
His right foot, is continually painful with swelling.

Is the only solution for him to have a some sort of metal replacement for the fibula?
Thought the radio graphs may be of interest.

Any advice/experience/comments appreciated

Thanks
Mark

 

wow in a bad way how much of the Distal Fibula is left?

and yes off to the best surgeon you know

 

This set of images show the head of the fibula (12 months prior to last set of images- post surgery)

 

Thanks Mark

Not sure how much that sort of thing happens, by the old story of Robbing Peter to pay Paul comes to mind, except Peter was robbed at gun point and shot in this case.

But off to the best surgeon you know, would be a great follow up case I would love to see the post op X-rays

 

With Mike on this one. Off to a (different) surgeon. Never heard of anything like this. Hope that shoulder is pretty damn good now.

The only other thing would be to consider a brace of some kind (Richie or similar) to try and limit further damage before he can be assessed. Unless it's coming up above the ankle I think orthotic intervention will be a case of marginal improvement at best.

Footwear could also be helpful too- ankle boot, med flange, ff rocker etc

Hope this helps and would be interested to hear how it progresses.

 

He has consulted with his original surgeon, who requested CT scan attached.
The surgeon was keen to operate, next week !
From what my patient understands the surgery involves inserting a plate into the foot, he doesn't know where or what. The surgeon did not mention the the fibula.
He is off to have a 2nd opinion.

 

2nd Opinion are good in this case Very Good

Thanks for the update

 

Wow a surgeon can see him that quick is brilliant, l was thinking months before he could get surgery.

Otherwise a fairly quick outcome would be an Arizona brace and an ankle boot with lateral flare will stabilise the ankle and control some of the swelling and these results could be had in a week or two, this option may still be needed in part post surgery?

 

Just an update on this case.
He has had surgery (with the original surgeon) didn't seek a 2nd opinion.
After consulting with his GP, it was decided to go ahead with the surgery.
The patient is not sure what exactly was done, he just sent me this pic.

 

Patient doesn?t know what done and went to the same surgeon

cross your fingers and hope for the best then

 

If things don't quite go to plan would be interested to hear if this counts as informed consent!

 

Looks like an ankle distraction arthroplasty, usually done for Tibio Talar OA.
https://www.aofas.org/footcaremd/treatments/Pages/Distraction-Arthroplasty.aspx
Is he in the frame for 3 months?

Ben

 

Not really sure why 2/3's of the fibula would be used for shoulder reconstruction, when there are a multitude of bone banks available. What was the surgeon repairing/replacing...the clavicle? Taking a look at the post op CT scans and plain film radiographs, it appears that the patient could've benefitted from a STJ/AJ fusion using an IM nail through the plantar aspect of the calcaneus up into the tibia. Quite effective and doesn't require the post op recovery time of ex-fix procedures.

 

My patient has provided very little detail of his procedure (all by phone), he tells me the surgeon put a plate in his foot. That's it ! for such extensive and ongoing surgery.
He is keen for advice on orthotics/foot wear and will consult again then, I expect in a few months?