Bony defects are most often caused by trauma, tumor, infection, or congenital anomaly, and this can lead to poor quality of life and occasionally amputation. Despite the development of newer techniques like bridging endoprostheses and distraction osteogenesis, bone grafts are still used for the management of nonunions and defects to promote healing. Bone grafts have been used in reconstructive surgery for a century and recent advances in microvascular techniques have made free fibula flap transfer a viable option for reconstruction of long bone defects.
In 1975, Taylor et al transferred the first free fibula through the posterior approach and the technique was further improved by Gilbert who described the lateral approach, which was later evolved by Chuang et al, who popularized the osteomyocutaneous fibular flap. In 1994, Hidalgo further expanded indications for fibular free tissue transfer by describing osteotomy techniques that permit shaping the fibula to mimic that of the mandible, making the fibula the workhorse for head and neck reconstruction that it is today.
There are many ways of employing fibular bone for reconstruction: cancellous and cortical autografts, bone allografts, endoprosthetic replacement, vascularized bone grafts, fibular osteocutaneous flaps, and fibular osteomuscular flaps. Among these options, free vascularized fibular graft is unique in that it provides immediate mechanical support but it also can grow or hypertrophy depending on the patient's situation. Vascularized fibular grafting is not a solution in all cases that require bony reconstruction; however, it is a frequently-used option for bony defects >6 cm, failed conventional bone grafting, infected nonunion with a bony defect, or following tumor resection, particularly when postoperative radiation therapy is planned.
The fibula is a long and straight, thick bone measuring approximately 3 cm x 40 cm, slightly longer in males than females. It has a tricortical profile, or triangular cross-section, with the muscle attachments to the fibula determining this shape. The mean fibula length is 387.4 ± 23.7 mm in males and 361.5 ± 12.3 mm in females.
Joints and Supporting Structures
1. Proximal tibiofibular joint
The synovial joint between the head of the fibula and lateral condyle of the tibia is supported by a capsule and anterior and posterior superior tibiofibular ligaments. The lateral collateral ligament and biceps femoris support the joint coronally. External rotation of the ankle produces a small amount of movement at the proximal tibiofibular joint.
2. Distal tibiofibular joint (ankle syndesmosis)
The fibrous joint between the fibular notch and distal tibia is made up of the interosseous membrane, the anterior and posterior inferior tibiofibular ligaments, and the inferior transverse tibiofibular ligaments. For this reason, the distal 5 cm of the fibula is essential for ankle joint stability; any disruption to the syndesmotic structures can cause ankle instability.
The blood supply of the fibula is important for graft viability and union. Penetrating periosteal vessels supply the metaphysis and epiphysis while nonpenetrating periosteal vessels supply the diaphysis. The major blood supply occurs through the anterior tibial artery, peroneal artery, and posterior tibial artery. The epiphysis and proximal fibula are supplied by the anterior tibial artery, and the peroneal artery supplies the middle third.
Understanding this anatomy is very important for deciding which part of the fibula is needed for a particular patient's case. The length of the vascular pedicle can be up to 15 cm if the distal fibula is harvested, less if the more proximal bone is used. Additionally, perforating vessels from the peroneal artery can support a skin paddle measuring up to 10 x 20 cm in area, useful in head and neck reconstruction. Vascularized bone grafts may withstand early mechanical loading better than non-vascularized grafts and minimize the likelihood of bone resorption and stress fracture, as they can remodel over time.
Vascularized free fibula can be used in the following scenarios:
Free Fibular flaps are contraindicated in the following scenarios:
The following equipment is needed:
A team consisting of the following personnel is required:
Recipient site evaluation includes identification of appropriate vessels to perfuse the flap, determining appropriate patient positioning, choosing the method of bone fixation. All types of implants should be available (e.g., plates, screws, K-wires, external fixators, and intramedullary nails).
Preoperatively, donor site skin, muscle bulk, and vascular status are evaluated. Strong and independent pulses should be present at both the dorsalis pedis and the posterior tibial artery. Any uncertainty about their status should be further investigated with Doppler ultrasonography. In certain cases, CT (computed tomography) angiography or MR (magnetic resonance) angiography may be required to assess the vascular status. Documentation of a preoperative neurological assessment is necessary because transient postoperative nerve palsy can occur.
For tibial reconstruction, the contralateral fibula is preferred, while the ipsilateral fibula is generally used for femoral reconstruction. Upper limb recipient sites may use either fibula, and the choice of the fibula for head and neck reconstruction will depend on the status of neck vessels, as well as whether the mandible or maxilla is being reconstructed, and whether the skin flap will replace oral mucosa or facial skin.
After informed consent, prophylactic antibiotics are administered, and general anesthesia is induced. An Esmarch bandage is used to exsanguinate the leg, and a tourniquet is applied to either 150 mmHg above systolic blood pressure or 350 mmHg. All pressure points should be padded carefully because of the long duration of the case. Ideally, two teams work simultaneously to decrease operative time, one at the recipient site and the other at the harvest site. Particular attention should be paid to patient positioning to ensure both teams can work efficiently and that the microscope has enough room to be brought close to the field for microvascular anastomosis.
Recipient site surgery: Recipient site surgical dissection depends upon the diagnosis. For example, the extent of bone resection required in cases of pseudarthrosis or the amount of debridement and curettage for chronic osteomyelitis. Resection and reconstruction can be performed as a single procedure or can be done in 2 stages as in osteomyelitis (eradication of infection followed by free fibula transfer) or oncologic resection (ablation of tumor and lymph node dissection followed by fibula transfer after negative margins have been confirmed). It is critical to select and isolate appropriate recipient vessels for vascular anastomosis and to communicate the size of the defect to the fibular harvest team to ensure a graft of adequate length.
Donor site surgery: The lateral surgical approach is the most commonly used, with a longitudinal incision made along the lateral lower leg. The central portion of the fibula is harvest for most indications, as the distal 5 cm is important for ankle joint stability. The proximal 5 cm of bone is also left in place in order to protect the peroneal nerve. Bony cuts are made proximally and distally. Some surgeons consistently harvest the entire fibula between the proximal and distal 5 cm, planning to shorten the bone as necessary after harvest; some harvest only what length is needed to reconstruct the defect. Care is taken to avoid injury of the peroneal artery and its accompanying 2 venae comitantes. If a longer vascular pedicle is required, the use of the distal fibula will provide up to 15 cm in length. In some cases, a graft 2 to 3 cm longer than the bony defect may be required, as overlapping the graft on the osteotomy site may be necessary for fixation.
Fixation of graft: Fixation may be accomplished with a plethora of different techniques, depending on the type of reconstruction. Intramedullary nails, compression plates, and the Ilizarov fixator are all options. Hardware should not be changed once vascular anastomosis is complete, and care should be taken when placing the screws as they can compromise the blood supply to the graft.
Autogenous vascularized fibular grafting plays a vital role in the reconstruction of long bone defects, infected nonunions, and following tumor resection in adults and children. Vascularized fibular grafts not only provide osteoinductive and mechanical support but also have the ability to remodel and hypertrophy to withstand loading, making fibular grafting different from other types of bony reconstruction. A successful outcome depends not only on surgeon experience but also on appropriate patient selection and preoperative expectation management.
Patients are usually initially followed by a team of intensivists, surgeons, physical therapists, and speech/swallowing therapists in head and neck cancer reconstruction. Intraoperatively, an interprofessional group consisting of orthopedic/plastic/head and neck/oral surgeons, radiology technicians, surgical technologists, an anesthesiologist, and nursing staff must perform these complicated operations. When two surgical teams can operate simultaneously, the workload is divided operative time is decreased, which lowers the risk of perioperative cardiopulmonary complications.
Patients should be optimized medially before surgery, and the vascularity of the lower extremity should be evaluated with angiography or ultrasound. Careful preoperative evaluation of the patient will establish candidacy for microvascular fibular free tissue transfer and ensure the patient and surgeon share realistic expectations.
Attentive nursing care is critical in the immediate postoperative period to monitor for flap complications. Physical therapists will help to mobilize the patient early, which can prevent such perioperative complications as deep vein thrombosis and pulmonary embolism. In cases of mandibular or maxillary reconstruction, speech and swallowing therapists and nutritionists are critical to helping maintain the patient's caloric intake.
Monitoring the flap for signs of failure is critical in the first two weeks of healing, but even more so during the first 72 hours, during which the anastomosed vessels are re-epithelializing. Signs of flap failure include a dusky or pale color, a cool temperature (unless the flap is intraoral), the rigidity of the soft tissue due to edema, either very rapid or absent capillary refill of the skin paddle, either very rapid return of dark blood or no return of blood at all when pricked with a lancet, and absent Doppler signals. Often, loss of the Doppler signal is the last sign of a flap failure, because venous congestion accounts for 80% to 90% of flap failures, and the arterial signal may not disappear until very late in the process. In the case of vascular failure, rapid return to the operating room for revision of the anastomoses is critical.
|||Wagels M,Rowe D,Senewiratne S,Theile DR, History of lower limb reconstruction after trauma. ANZ journal of surgery. 2013 May; [PubMed PMID: 22989362]|
|||Taylor GI,Miller GD,Ham FJ, The free vascularized bone graft. A clinical extension of microvascular techniques. Plastic and reconstructive surgery. 1975 May; [PubMed PMID: 1096183]|
|||Bumbasirevic M,Stevanovic M,Bumbasirevic V,Lesic A,Atkinson HD, Free vascularised fibular grafts in orthopaedics. International orthopaedics. 2014 Jun; [PubMed PMID: 24562850]|
|||Chuang DC,Chen HC,Wei FC,Noordhoff MS, Compound functioning free muscle flap transplantation (lateral half of soleus, fibula, and skin flap). Plastic and reconstructive surgery. 1992 Feb; [PubMed PMID: 1732905]|
|||Hidalgo DA, Fibula free flap mandibular reconstruction. Clinics in plastic surgery. 1994 Jan [PubMed PMID: 8112010]|
|||Mata-Ribeiro L,Casal D,Ferreira JA,Costa DS,Lacerda J, The use of free fibula-flexor hallucis longus osteomuscular flap for calcaneal reconstruction after partial calcanectomy for the chronic osteomyelitis: A case report. International journal of surgery case reports. 2019 [PubMed PMID: 31733617]|
|||Toy PC,White JR,Scarborough MT,Enneking WF,Gibbs CP, Distal femoral osteoarticular allografts: long-term survival, but frequent complications. Clinical orthopaedics and related research. 2010 Nov; [PubMed PMID: 20645036]|
|||Yadav PS,Ahmad QG,Shankhdhar VK,Nambi GI, Successful management of free osteocutaneous fibula flap with anomalous vascularity of the skin paddle. Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India. 2009 Jul [PubMed PMID: 20368871]|
|||Beris AE,Lykissas MG,Korompilias AV,Vekris MD,Mitsionis GI,Malizos KN,Soucacos PN, Vascularized fibula transfer for lower limb reconstruction. Microsurgery. 2011 Mar; [PubMed PMID: 21360586]|
|||Golas AR,Levine JP,Ream J,Rodriguez ED, Aberrant Lower Extremity Arterial Anatomy in Microvascular Free Fibula Flap Candidates: Management Algorithm and Case Presentations. The Journal of craniofacial surgery. 2016 Nov; [PubMed PMID: 28005769]|
|||Sparks DS,Saleh DB,Rozen WM,Hutmacher DW,Schuetz MA,Wagels M, Vascularised bone transfer: History, blood supply and contemporary problems. Journal of plastic, reconstructive [PubMed PMID: 27843061]|
|||[PubMed PMID: 21772626]|
|||[PubMed PMID: 20680274]|
|||[PubMed PMID: 20567733]|
|||Pellini R,Mercante G,Spriano G, Step-by-step mandibular reconstruction with free fibula flap modelling. Acta otorhinolaryngologica Italica : organo ufficiale della Societa italiana di otorinolaringologia e chirurgia cervico-facciale. 2012 Dec; [PubMed PMID: 23349561]|
|||Morsy M,Sur YJ,Akdag O,Sabbagh MD,Suchyta MA,El-Gammal TA,Lachman N,Moran SL, Vascularity of the Proximal Fibula and Its Implications in Vascularized Epiphyseal Transfer: An Anatomical and High-Resolution Computed Tomographic Angiography Study. Plastic and reconstructive surgery. 2019 Jan; [PubMed PMID: 30589807]|
|||Rose PS,Shin AY,Bishop AT,Moran SL,Sim FH, Vascularized free fibula transfer for oncologic reconstruction of the humerus. Clinical orthopaedics and related research. 2005 Sep; [PubMed PMID: 16131873]|
|||Bauer AS,Singh AK,Amanatullah D,Lerman J,James MA, Free vascularized fibular transfer with langenskiöld procedure for the treatment of congenital pseudarthrosis of the forearm. Techniques in hand [PubMed PMID: 23970196]|
|||Steinlechner CW,Mkandawire NC, Non-vascularised fibular transfer in the management of defects of long bones after sequestrectomy in children. The Journal of bone and joint surgery. British volume. 2005 Sep; [PubMed PMID: 16129754]|
|||Chhabra AB,Golish SR,Pannunzio ME,Butler TE Jr,Bolano LE,Pederson WC, Treatment of chronic nonunions of the humerus with free vascularized fibula transfer: a report of thirteen cases. Journal of reconstructive microsurgery. 2009 Feb; [PubMed PMID: 18925551]|
|||Goldfuss S,Wittmann S,Würschinger F,Bitzinger D,Seyfried T,Holzamer A,Fischer M,Camboni D,Sinner B,Zausig YA, Anaesthesia-related complications and side-effects in TAVI: a retrospective study in Germany. BMJ open. 2019 May 1 [PubMed PMID: 31048439]|
|||Tjeertes EK,Ultee KH,Stolker RJ,Verhagen HJ,Bastos Gonçalves FM,Hoofwijk AG,Hoeks SE, Perioperative Complications are Associated With Adverse Long-Term Prognosis and Affect the Cause of Death After General Surgery. World journal of surgery. 2016 Nov [PubMed PMID: 27302465]|
|||Shammas RL,Avashia YJ,Farjat AE,Catanzano AA,Levin LS,Eward WC,Brigman BE,Erdmann D, Vascularized Fibula-Based Physis Transfer: A Follow-Up Study of Longitudinal Bone Growth and Complications. Plastic and reconstructive surgery. Global open. 2017 May; [PubMed PMID: 28607872]|
|||Gaskill TR,Urbaniak JR,Aldridge JM 3rd, Free vascularized fibular transfer for femoral head osteonecrosis: donor and graft site morbidity. The Journal of bone and joint surgery. American volume. 2009 Aug; [PubMed PMID: 19651942]|
|||Pannunzio ME,Chhabra AB,Golish SR,Brown MR,Pederson WC, Free fibula transfer in the treatment of difficult distal tibia fractures. Journal of reconstructive microsurgery. 2007 Jan; [PubMed PMID: 17230315]|
|||Vigouroux F,Mezzadri G,Parot R,Gazarian A,Pannier S,Chotel F, Vascularised fibula or induced membrane to treat congenital pseudarthrosis of the Tibia: A multicentre study of 18 patients with a mean 9.5-year follow-up. Orthopaedics [PubMed PMID: 28559144]|
|||Cheng H,Clymer JW,Po-Han Chen B,Sadeghirad B,Ferko NC,Cameron CG,Hinoul P, Prolonged operative duration is associated with complications: a systematic review and meta-analysis. The Journal of surgical research. 2018 Sep [PubMed PMID: 29936980]|
|||[PubMed PMID: 33085388]|