Osteotomy of the Distal Fibula for Correction of Posttraumatic Malunion

Orthopedics and Traumatology Classical Procedure

273Orthop Traumatol 2001 · N0. 4 © Urban & Vogel

Osteotomy of the Distal Fibula for Correction of Posttraumatic MalunionDaniel Weber1, Daniel Fritschy2, Niklaus F. Friederich3, Werner Müller3

AbstractObjective

Restoration of anatomic alignment of the lateral malleo-lus to delay or prevent development of posttraumatic os-teoarthritis of the ankle joint.

IndicationsPosttraumatic malunion of the distal fibula with shorten-ing, often combined with external rotation and abductionof the lateral malleolus. Osteoarthritic changes may beabsent, mild or moderate.

ContraindicationsSevere, preexisting osteoarthritis of the ankle.Presence of a remote lateral pilon fracture with articulardepression.Poor soft tissue conditions after infection or sympatheticreflex dystrophy.

Surgical TechniqueLateral approach respecting former incisions or wounds, ifat all possible. Osteotomy of the fibula (horizontal,oblique or Z-shaped), resection of scar tissue, osteophytesand bony fragments in the fibular notch and freeing of thedistal part of the fibula. Correction of any obstacle aroundthe medial malleolus if indicated. Correction of length, ro-tation and abduction of the lateral malleolus, and fixationwith a reconstruction or LC-DC plate. Fixation of the fibulain the fibular notch with two Kirschner wires.

ResultsAfter a follow-up of 3.9 years, all eight patients were sat-isfied. In five of six patients, there was only a slight pro-gression of arthritic changes radiologically already pres-ent before osteotomy. Two patients without any arthriticchanges before the osteotomy did not develop suchchanges thereafter.Our results, confirmed by previous reports, indicate thatthe most important factor determining the final outcomeis the presence of degenerative changes at the time of os-teotomy. Lengthening of the fibula slowed down or evenstopped progression of arthritis.

Key Words Lateral malleolus · Posttraumatic malalignment ·Shortening · Corrective osteotomy

Operat Orthop Traumatol 2001;13:292–304Orthop Traumatol 2001;9:273–83

DOI 10.1007/s00065-001-1029-1

1 Department of Orthopedics, Bürgerspital, Solothurn, Switzerland,2 Department of Orthopedics and Musculoskeletal Surgery, Universi

ty Hospital, Geneva, Switzerland,3 Department of Orthopedic Surgery and Traumatology of the Loco

motor Apparatus, Canton Hospital Bruderholz, Basel, Switzerland.

Weber D, et al. Corrective Osteotomy of Distal Fibula

274 Orthop Traumatol 2001 · N0. 4 © Urban & Vogel

Introductory RemarksIn the 70s, the importance of the position and alignmentof the lateral malleolus not only in relation to the talus[7] but also in regard to the stability of the ankle jointhas been recognized. The key role of the lateral malleo-lus in the treatment of displaced fractures of the anklewas described by Yablon et al. [13]. Shortly after, publi-cations appeared describing corrective procedures formalunited fibulae [2, 3, 11]. Some years later, the clinicalexperience was supported by laboratory studies [1, 4, 9].

Since internal fixation methods have now been per-fected, reports of fibular lengthening after malunion of

the lateral malleolus are scarce and concern only a fewpatients [10, 12]. Older publications [3, 11] report re-sults of transverse osteotomies and autogenous bonegrafting to fill fibular defects caused by the correction.With the aim to reduce the local trauma and to obtain adirect bone healing, we have added two choices to thetransverse osteotomy: a Z-shaped and an oblique os-teotomy. The latter two osteotomies maintain a partialcontact after lengthening and facilitate bone consolida-tion as well as vascular ingrowth into the distal frag-ment. We are unaware of any publication describing thistechnique.

Advantages• In general, elimination or decrease of pain as well as

improvement of the walking ability can be expect-ed.

• Delay of osteoarthritis.• Considerably smaller intervention in comparison to

an alternate choice of an arthrodesis in instances ofmoderate osteoarthritis.

Disadvantages• Freeing of extensive scar formation may lead post-

operatively to trophic disturbances of the anteriorskin flap.

• The approach lies close to the superficial peronealand sural nerves, therefore risk of nerve damageduring exposure of the fibula.

• Removal of implant material is usually necessary.

Indications• Malalignment of the fibula through shortening, ro-

tation, and abduction after fracture of the lateralmalleolus independent of the initial treatment: for amalrotation exceeding 10° the classic horizontal os-teotomy of Weber & Simpson [11] is indicated, butif the rotation is less than 10°, an oblique or Z-shaped osteotomy should be done.

• Absence or presence of mild or moderate changesof the ankle joint, even in the presence of partialnarrowing of the cartilage space.

• Active patient, even of advanced age.

Contraindications• Severe osteoarthritis of the ankle joint, marked nar-

rowing of the medial or lateral cartilage space withosteophyte formation.

Surgical Principles and ObjectiveApproach to the lateral malleolus respecting existingscars.

Osteotomy of the distal fibula, removal of scar tis-sue and displaced bone fragments.

Revision of the medial side of the ankle through aseparate medial approach.

Correction of length, rotation and abduction ofthe lateral malleolus and internal fixation of the frag-

ments; reduction of the subluxed talus and restora-tion of the congruence of the ankle joint.

Prevention or slowing down of an already exist-ing osteoarthritis of the ankle joint; elimination ofpain and functional disturbances.



• State after an unreduced tibial pilon fracture withlateral impaction of the tibial articular surface.

• Extensive scarring after previous infections.• Trophic disturbances and limitation of motion after

reflex sympathetic dystrophy.• Severe osteoporosis.

Patient Information• Usual surgical risks.• Explanation of the expected improvement of ankle

function.• Risk of increase in degenerative changes in the ab-

sence of corrective surgery.• Harvesting of bone rarely necessary as the callus

can be used if needed.• Reflex sympathetic dystrophy (higher incidence in

revision surgery).• Discussion of postoperative measures including re-

habilitation (see Postoperative Management).• Nonunion.• Avascular necrosis of the lateral malleolus necessi-

tating arthrodesis.• Need for implant removal; at the same sitting osteo-

phytes can be removed.• Possible need for change of arch supports.

• Return to work depending on occupation: seden-tary work after 2 months, physical labor or work in astanding position: 5–6 months.

• Change of occupation may become necessary.

Preoperative Work Up• Weight bearing radiographs of both ankles to detect

any tibiotalar cartilage defect as well as any short-ening and malunion in abduction [8].

• CT of both ankles to determine the degree of exter-nal rotation (Figures 1a and 1b).

• MRI will be helpful to assess cartilage lesions of tib-ia and talus.

• Preoperative partial weight bearing to reduce ankleswelling.

• Preoperative drawing (Figures 1b and 2).• Antibiotic coverage: Zinacef® 1.5 g i.v. at induction.• Shaving only of the site of incision immediately pri-

or to surgery.

Preoperative PlanningThe preoperative planning must consider the extent ofthe malposition and the type of osteotomy. The amountof lengthening is determined through a comparison withthe opposite side. In our experience the difference

TF

F T

T

TFF

Figure 1aCT at the level of the tibiofibular syndesmo-sis of both ankles (patient 8). The degenerati-ve changes and formation of osteophytes,the presence of bony fragments, and thehealed fracture line of the “posterior malleo-lus” (Volkmann’s triangle) are present on theright. In comparison with the left side, themalrotation of the lateral malleolus is negli-gible.

Figure 1bTo assess the fibular malrotation, the following axes are drawn: posteriorborder of tibia (T), tibiofibular notch (FT), maximal diameter of fibula (F).The angle F/FT indicates the rotational component in comparison to theopposite side. The angle T/TF serves for comparison (note the posttraumatic bony defor-mity of tibia).



amounts to 4–5 mm. A shortening with an external rota-tion of less than 10° will be corrected with an oblique orZ-shaped osteotomy. If the external rotation exceeds10°, a transverse osteotomy allows an easy derotation.In this instance, however, an intercalary bone graft mustbe used; it can be harvested from the iliac crest, the me-dial aspect of the tibia [11], or from the removed callus.The question has to be answered whether a revision ofthe medial structures of the ankle is necessary such as anosteotomy of the medial malleolus, removal of osteo-phytes and of free fragments, and revision of scars.

Instruments and Implants• AO small-fragment set (Synthes).• Thin saw blade, 10 mm wide.• Kirschner wires, 1.6 mm in diameter.• Image intensifier.• Sterile plastic bags for X-ray cassettes.

Anesthesia and Positioning • Regional or general anesthesia.• Supine, cushion under ipsilateral hip.• Tourniquet at thigh.• Prepping from toes to above the knee, free draping.

Figures 2a to 2ePreoperative drawing of an oblique osteotomy. For didactic purposes, the interventions on the medial and lateral side are shown se-parately.a, b, d) Malpositions to be corrected.c, e) State after correction corresponding to the normal opposite side.X: level of tip of lateral malleolus; Y: longitudinal axis of fibula; P: level of tibial joint line; angle α: deviation of the longitudinal axis ofthe fibula by 6° (a); angle β: deviation of the axis of the medial malleolus by 25° (d). Removal of the bony callus (b). Oblique osteotomyof the lateral malleolus over a distance of 2.5–3 cm and lengthening of the distal fibula by 5 mm and internal fixation with LC-DCplate (Synthes; c). Osteotomy at the level of pseudarthrosis of the medial malleolus, reduction after derotation of 25° and screw fixati-on.

�

P

Y

ba c d e

Y Y

X

� �



Surgical TechniqueFigures 3 to 9

Figure 3Longitudinal skin incision following the posterior side of the star-like scar. In general, the incision lies directly over the distal fibulaand is 10 cm in length. At the tip of the malleolus, the incision runs slightly anterior.

Figure 4Freeing of scars between subcutaneous tissue and fascia. The anterior and posterior tissue flaps are lifted after freeing of scars fromthe periosteum. Freeing of the scarred tibiofibular ligament. Exposure of the fracture site, the tip of the lateral malleolus and thefibular shaft up to 3 cm proximal to the fracture site.

V. saphena parva

Tibia

N. peroneus superfic.Malleolus lateralis

N. suralisScar

M. peroneus long.

Fibula

M. peroneus long.

Fibula

Callus

Membrana interossea

Lig. tibiofibulare ant.(syndesmosis)

Retinaculum peroneorum sup.

M. peroneus brev.



Figure 5Osteotomy: removal of callus from the lateral surface of thefibula. 3 cm long oblique osteotomy in the sagittal plane.Removal of a thin bony wedge from the proximal fragment withan anterior base of 1–2 mm to correct a rotational malpositionbetween 5 and 10°.If indicated: medial approach and removal of interposed bonefragments and osteotomy of medial malleolus (not shown).

Figure 6Mobilization of the distal fibular frag-ment: stepwise removal of blockingscar tissue and gradual distal displace-ment of the distal fragment with thehelp of a hook. It may be sufficient tofree the scars attached to the interos-seous membrane and to the anterioror posterior syndesmosis with a smallperiosteal elevator to obtain the distaldisplacement which should amount to4–5 mm. Blocking osteophytes, bonefragments, and scars in the fibularnotch of the tibia must be removed aswell as osteophytes of the anteriordistal tibial edge and adhesions of thejoint capsule.

Callus

Wedge to be removed

Wedge to be removed

Dorsal

Anterior

Proximal surface of osteotomy

Membrana interossea

Incisura fibularis tib.

Lig. tibiofibulare ant.

Retinaculum peroneorum sup.Distal fibula

M. peroneus long.M. peroneus brev.



Figure 8aDefinite reduction and internal fixation. The first screw is inserted into the distal fragment. Following visual control of lengtheningand reduction, the second screw is inserted into the proximal fibular fragment. An eccentric drill hole allows to vary the lengtheningby 1–2 mm. Removal of the Kirschner wire. Placement of a lag screw through the oblique osteotomy.

Figure 7Trial reduction: distal displacement of the lateral malleolus by 4–5 mm and fixation with a 1.6-mm Kirschner wire. Positioning of aslightly contoured 3.5-mm AO reconstruction plate (in general 7- or 8-hole plate) [5]. Control of reduction with image intensifier; if theinterpretation of the result is uncertain, take anteroposterior radiographs of both ankles on the same cassette with the feet in identi-cal rotation.

Surface of osteotomy

Remnants of syndesmosis

K’wire 8-hole AO reconstruction plate

Surface of osteotomy

Lag screw

K’wire



Special ConsiderationsAlternative Osteotomies

If the malrotation exceeds 10°, a classic transverse os-teotomy should be used. It allows complete derotation.The disadvantage lies in the fact that the bone defectmust be filled with autogenous bone. This bone graft canbe harvested from the callus, or from the medial aspectof the distal tibia.

If the shortening of the lateral malleolus is accom-panied by a small malrotation and axial deviation ornone, the Z-osteotomy offers an elegant means of cor-rection. It results in a stable internal fixation with con-tacts between the fragments.

Figure 8bThe internal fixation is completed with one to two screws proxi-mal and another screw distal to the osteotomy. Reduction of thefibula in the fibular notch keeping the ankle in neutral position.Fixation with two 1.6-mm Kirschner wires. The wires are insert-ed at an angle of 45–50° in the frontal and of 30° in the sagittalplane. They are advanced through the medial tibial cortex untilthey exceed the cortex by 2 mm. Their position is then checkedwith the image intensifier. The lateral ends of the Kirschnerwires are shortened so that they exceed only 1 cm. Then thewires are slightly pulled back, their ends are bent and the wiresdriven into the fibula.Note: the fibula can also be fixed in the notch with a screw. Thisscrew, however, must be removed after 8 weeks, an interventionnot necessary when Kirschner wires are used [6].

Lengthening

K’wires

Lag screw

Remnants of syndesmosis

Figures 9a and 9ba) Example of a transverse osteotomy. The fibula is osteotomiz-ed 3 cm proximal to the syndesmosis. All other steps are as de-scribed above.b) Example of a Z-shaped osteotomy. The fibula is osteotomized4 cm proximal to the syndesmosis in the frontal plane. The Z-shape extends over 2 cm. Lengthening. A correction of a smallmalrotation is possible (analogous to Figure 5); the bony wedgemust have a posterior base, a technique difficult to execute.

Figure 9a Figure 9b



Postoperative Management• Posterior below-knee slab of plaster of Paris with

ankle in neutral position. Elevation of leg until dis-charge from hospital.

• Daily inspection of wound. Local ice application.The stitches are pulled on day 12.

• Physiotherapy to mobilize ankle, strengthening ofmuscles, training of proprioception and of gait. Onday 1 the patient is allowed to walk without puttingany weight on the leg and while wearing the posteri-or slab. During the 2nd week active assisted exercis-es are started. The patient is instructed on a heelstrike to toe-off gait; for this, the slab is temporarilyremoved. Between the exercises the slab is worn for6 weeks. Partial weight bearing (20 kg) from week7–12. After the 12th week mobilization of the anklethrough the entire range of motion. Increasingweight bearing as tolerated.

• Discharge from hospital after 5–7 days as soon as thepostoperative pain and the swelling have decreasedand no signs of trophic disturbances are present.Since the patient cannot put full weight on the leg,low molecular heparin is given during this period.

• The first visit to the outpatient department is sched-uled for day 12 when the stitches are removed. Sub-sequent clinical and radiologic controls after 6, 12,16, and 26 weeks.

• Removal of implants used for internal fixation aftercomplete bony consolidation but not before 1 year.

Errors, Hazards, Complications• Omission to consider preexisting scars, the incision

is not placed in the old scar: skin sloughing betweenincision and old scar. Cutaneoplasty.

• Distance between medial and lateral scar < 7 cm: in-creasing risk of soft tissue necrosis.

• Application of tourniquet in spite of extensive scar-ring at site of surgery: increased risk of circulatorydisturbances. Open tourniquet after 2 h.

• Omission to remove exuberant callus: during the in-ternal fixation the distal fragment will be forced in-to an undesirable position. Persistence of the mal-position, risk of pain and development of os-teoarthritis. Check position of distal fragment atend of internal fixation. Do not bend the plate butremove the callus.

Figures 10a to 10da) 41-year-old patient, 9 months after fixation of a bimalleolar grade II open fracture. The immobilization has been achieved for 2months with an external fixateur. Lateral subluxation of the talus and shortening of the distal fibula; malposition of medial malleo-lus. Bimalleolar swelling, painful gait, and need for a cane. Extensive scarring. No drainage.b) Postoperative radiograph: correction of the medial malleolus and fixation with two small cancellous bone screws and tension bandwiring. Lengthening osteotomy of the lateral malleolus and fixation with an LC-DC plate (Synthes). Note the presence of twoKirschner wires fixing the tibia to the fibula.c) Photograph of the lateral side of the same patient’s distal leg, 4 months after corrective osteotomy. The longitudinal incision wasplaced in two of the three sides of the Mercedes-like star of the scar. Uneventful wound healing.d) Radiographic control after implant removal, 15 months after corrective osteotomy. Marked formation of osteophytes and narrow-ing of the lateral tibiotalar cartilage space similar to the finding before osteotomy. Minimal lateral translation of the talus. Patientsymptom-free. He can walk for 2 h, hiking in the mountains.

Figure 10a Figure 10b Figure 10c Figure 10d

• Osteotomy placed too distal: insufficient fixation ofdistal fragment possibly leading to a secondary lossof correction. To increase fixation strength, addKirschner wires which should be removed after ap-pearance of callus.

• Insufficient preparation of the fibular notch in thetibia: persistence of lateral displacement, of malro-tation and of talar subluxation. Revision with repeatremoval of osteophytes and soft tissue scars.

• Exposure of cancellous bone during preparation ofthe notch: risk of tibiofibular bony bridge. Placestrip of fascia between bone fragments.

• Insufficient correction of a malrotation often diffi-cult to recognize on intraoperative radiographs:persistence of talar subluxation. Repeat radio-graphs with both legs in identical rotation.

• Eccentric insertion of the second screw into theplate: under- or overcorrection of length. In general,start fixation of malleolus again, this time with footin increased internal rotation. Place the secondscrew into this hole only at end of plate fixation.Then change direction of screw, overdrill the nearcortex, and implant the screw using the lag screwprinciple.

• Insufficient bending of plate (AO-LC-DCP) to en-sure proper adaption to bone: the distal fragmentwill be forced into a faulty position. Improve con-touring of plate using bending irons.

• Use of a too thin plate (third tubular): the plate maybreak upon resumption of weight bearing. Replacewith a more rigid plate.



Patient/ Age Fracture Arthritis Interval Type Ext./flex. Complications Ext./ Arthritis Subjec-sex (years) pre-OT to OT (months of OT pre-OT flex. post-OT tive

between ini- (°) post-OT resultstial operation (°)and OT)

1/m 21 Bimalleolar Slight 60 Z 5/0/40 – 5/0/30 Moderate Good+ Volkmann

2/w 50 Bimalleolar Slight 36 Z 0/0/20 Breakage of 0/0/15 Slight Moderate+ Volkmann plate, revision

of internal fixation

3/w 36 Distal tibia Fibula type B None 5 H 10/0/40 – 10/0/40 None Excellent

4/w 40 Tibial pilon Moderate 28 Z 5/0/20 Infection after 0/10/10 Ankylosis GoodFibula type B initial internal

fixation; external fixation after OT; painless ankylosis

5/m 62 Proximal None 24 H 10/0/30 – 15/0/35 None Excellent+ distal fibula

6/m 37 Fibula type C Moderate 60 H 0/0/30 Arthrolysis 5/0/25 Marked Moderatedone at timeof implant removal

7/m 45 Tibial pilon Medial 20 O 5/0/40 – 5/0/40 Medial ExcellentFibula type C only only

8/m 41 Bimalleolar open Lateral 9 O 0/0/30 – 5/0/35 Lateral Excellentonly only

Table 1Our patients. m: man; w: woman; OT: osteotomy; Z = Z-shaped; H = horizontal; O = oblique; arthritis: slight: osteophytes barely visible;moderate: marked osteophytosis; medial/lateral: osteophytes and joint space narrowing; Ext./flex.: extension/flexion of ankle; subjec-tive results: moderate: daily pain, but less than before OT, no regular analgesics; good: occasional pain, no analgesics; excellent: only re-action to changes of weather, able to hike in mountains for several hours.Part of this table was already published in Weber et al. [12]; with permission of Springer-Verlag.



• The Kirschner wires do not penetrate both tibialcortices, risk of backing out laterally after mobiliza-tion: loss of reduction. Use longer Kirschner wiresfor fixation or a screw finding purchase in all fourcortices.

• Too early weight bearing: swelling around the site ofsurgery; risk of wound healing disturbances. Insiston proper elevation of limb between exercises.

ResultsOur experience rests on eight patients: in three a Z-shaped and in another three a transverse osteotomy wasdone. The remaining two were corrected with anoblique osteotomy. There were three women and fivemen with an average age of 43.5 (24–64) years. Themean interval between original and corrective surgerywas 32.5 (5–60) months. A breakage of a third tubularplate (AO) was seen once in a patient who had under-gone a Z-shaped osteotomy; a revision of internal fixa-tion became necessary.

At the time of follow-up (average 3.9 [1.5–8.3]years), all patients reported a decrease in pain and animproved use of ankle and lower limb. All patients stat-ed that they would undergo this operation again. Therange of motion of the ankle was not significantly al-tered but in one patient; in general, there was a slightimprovement in extension. One patient, who sufferedfrom an infection after the initial internal fixation, de-veloped a nonsymptomatic bony ankylosis in 10° flex-ion. In another patient an arthrolysis became necessaryat the time of implant removal. Six patients (Table 1)showed evidence of osteoarthritis before the osteotomy,in five of them there was no or a very small increase indegenerative changes. No signs of osteoarthritis at thetime of osteotomy were seen in two patients; at the timeof follow-up no changes were noted.

Although the number of our patients was small, wecould not detect any difference in outcome regardingthe technique of osteotomy. Neither the patient’s agenor the kind of initial treatment nor the interval be-tween initial surgery and osteotomy seem to haveplayed a role in the outcome. The end result seems todepend more on the presence of degenerative changesof the ankle at the time of osteotomy. As a rule, thesechanges increase only discretely after the osteotomy.

Our results correspond to the experiences reportedby Weber & Simpson [11] using a transverse osteotomyand later by Marti et al. [3] who used the same tech-

nique. Marti et al. stated that “there is almost no pro-gression of arthritis after reconstruction, and that anyarthritis already present is well tolerated as long as themalalignment is corrected”. To our knowledge, thenumber of patients reported by Weber & Simpson (n =25) and by Marti et al. (n = 31) constitute the largest se-ries ever published. Since then thanks to perfect inter-nal fixations, malunion of the lateral malleolus are for-tunately very rare.

References1. Curtis MJ, Michelson JD, Urquhart MW, et al. Tibiotalar contact

and fibular malunion in ankle fractures. A cadaver study. Acta Or-thop Scand 1992;63:326–9.

2. Hughes JL. Corrective osteotomies of the fibula after defectivelyhealed ankle fractures. J Bone Joint Surg Am 1976;58:728.

3. Marti RK, Raaymakers ELF, Nolte PA. Malunited ankle fractures.The late results of reconstruction. J Bone Joint Surg Br 1990;72:709–13.

4. Moody ML, Koeneman J, Hettinger E, et al. The effects of fibularand talar displacement on joint contact areas about the ankle.Orthop Rev 1992;XXI:741–4.

5. Müller ME, Allgöwer M, Schneider R, et al. Manual of internalfixation. Techniques recommended by the AO-ASIF-group, 3rdedn. Berlin–Heidelberg–New York–Tokyo: Springer, 1991.

6. Peter RE, Harrington RM, Henley MB, Tencer AF. Biomechanicaleffects of internal fixation of the distal tibiofibular syndesmoticjoint: comparison of two fixation techniques. J Orthop Trauma1994;8:215–9.

7. Ramsey PL, Hamilton W. Changes in tibiotalar area of contactcaused by lateral talar shift. J Bone Joint Surg Am 1976;3:356–7.

8. Rolfe B, Nordt W, Sallis JG, et al. Assessing fibular length using bi-malleolar angular measurements. Foot Ankle 1989;10:104–9.

9. Wang Q, Whittle M, Cunningham J, et al. Fibula and its ligamentsin load transmission and ankle joint stability. Clin Orthop 1996;330:261–70.

10. Ward AJ, Ackroyd CE, Baker AS. Late lengthening of the fibula formalaligned ankle fractures. J Bone Joint Surg Br 1990;72:714–7.

11. Weber BG, Simpson LA. Corrective lengthening osteotomy of thefibula. Clin Orthop 1985;199:61–7.

12. Weber D, Friederich NF, Müller W. Lengthening osteotomy of thefibula for post-traumatic malunion. Indications, technique andresults. Int Orthop 1998;22:149–52.

13. Yablon IG, Heller FG, Shouse L. The key role of the lateral malleo-lus in displaced fractures of the ankle. J Bone Joint Surg Am1977;59:169–73.

Address for CorrespondenceDr. Daniel WeberOrthopedic ClinicCanton Hospital (Bürgerspital)4500 SolothurnSwitzerlandPhone (+41/32) 627-3121, Fax -4609e-Mail: [email protected]

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Osteotomy of the Distal Fibula for Correction of Posttraumatic Malunion