Predictable regeneration and protective effect against ankle valgus following non-vascularized fibular graft harvest in children

doi:10.5312/wjo.124681

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World Journal of Orthopedics

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2218-5836

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Prospective Study

Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Orthop. Aug 18, 2026; 17(8): 124681
Published online Aug 18, 2026. doi: 10.5312/wjo.124681

Predictable regeneration and protective effect against ankle valgus following non-vascularized fibular graft harvest in children

Md Zafar Iqbal, Anil Agarwal, Shivank Khurana, Aakash Deep, Sagarika Sahoo

Md Zafar Iqbal, Anil Agarwal, Shivank Khurana, Aakash Deep, Sagarika Sahoo, Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, New Delhi 110031, Delhi, India

Author contributions: Iqbal MZ and Khurana S contributed to the conception and design of the study, patient recruitment, data acquisition, statistical analysis, interpretation of the data, and drafting of the manuscript; Agarwal A contributed to data acquisition, interpretation of results, and critical revision of the manuscript, supervised the study, provided administrative and academic oversight, critically reviewed the manuscript for important intellectual content; Deep A and Sahoo S participated in study design, supervised data collection, interpreted the findings, and critically revised the manuscript; all authors have read and approved the final manuscript, and agree to be accountable for all aspects of the work.

AI contribution statement: No AI tool was used in the preparation of the manuscript.

Institutional review board statement: The study was approved by the Institutional Review Committee, No. 101/269.

Clinical trial registration statement: This study was a prospectively done observational study and not a clinical trial. Hence, we did not register it as clinical trial.

Informed consent statement: All participants provided informed consent.

Conflict-of-interest statement: All authors declare no conflict of interest in publishing the manuscript.

CONSORT 2010 statement: The authors have read the CONSORT 2010 Statement, and the manuscript was prepared and revised according to the CONSORT 2010 Statement.

Data sharing statement: The datasets generated and/or analyzed during the current study are not publicly available due to institutional and patient confidentiality requirements but are available from the corresponding author upon reasonable request.

Corresponding author: Md Zafar Iqbal, Department of Paediatric Orthopaedics, Chacha Nehru Bal Chikitsalaya, Geeta Colony, New Delhi 110031, Delhi, India. docmdzafariqbal@gmail.com

Received: June 23, 2026
Revised: July 21, 2026
Accepted: July 28, 2026
Published online: August 18, 2026
Processing time: 52 Days and 16.8 Hours

Abstract

BACKGROUND

Non-vascularized fibular grafts are frequently used in pediatric orthopaedics because of their structural strength and low donor-site morbidity. Preservation of the periosteal sleeve may permit regeneration of the harvested fibula; however, the predictability of regeneration and its influence on ankle alignment remain incompletely understood. This prospective study evaluated the timing of fibular regeneration following long-segment fibular graft harvest in children and its association with ankle valgus deformity.

AIM

To analyse the timing of fibular regeneration after long segment fibular graft harvest in children and its association with ankle valgus deformity.

METHODS

Sixteen children (27 operated limbs) aged ≤ 12 years undergoing long-segment non-vascularized fibular graft harvest were prospectively followed. Radiographic assessment of the donor site was performed at 6 weeks, 3 months, 6 months, and final follow-up. Fibular regeneration was defined as radiological continuity across the harvested segment. Ankle valgus was assessed using the lateral distal tibial angle and distal fibular station (Malhotra grading). Associations between regeneration and ankle valgus were analyzed using the Pearson χ² test.

RESULTS

Mean follow-up was 25.8 ± 17.9 months. Complete fibular regeneration was observed in 33.3% of limbs at 3 months, 63.0% at 6 months, and 77.8% at final follow-up. Mean time to regeneration was 5.0 ± 2.9 months. The mean lateral distal tibial angle decreased significantly from 89.1° preoperatively to 87.8° at 6 months (P = 0.047) and 86.6° at final follow-up (P = 0.001). At final follow-up, ankle valgus was present in 83.3% of limbs without regeneration compared with 33.3% of regenerated limbs. Fibular regeneration was associated with significantly lower odds of ankle valgus (odds ratio = 0.10, P = 0.030).

CONCLUSION

Fibular regeneration following non-vascularized graft harvest in children is common when the periosteal sleeve is preserved, with most cases achieving continuity within 6 months. Successful regeneration appears to be associated with a low incidence of ankle valgus deformity, underscoring the importance of meticulous periosteal preservation and postoperative surveillance.

Keywords: Fibular regeneration; Non-vascularized fibular graft; Ankle valgus deformity; Periosteal preservation; Donor-site morbidity

Core Tip: Fibular regeneration following non-vascularized fibular graft harvest in children is common when the periosteal sleeve is preserved, with most cases achieving continuity within six months. This prospective study demonstrates that successful regeneration is associated with a substantially lower incidence of ankle valgus deformity, highlighting its protective role in maintaining lateral ankle stability. However, regeneration is not universal, and valgus deformity may occur despite regeneration, emphasizing the need for meticulous surgical technique, preservation of the periosteum, and serial postoperative surveillance of the donor site.