The Pedicled Fibula Flap for Lower Limb Reconstruction

Abstract

The pedicled fibula flap is a reliable technique to treat large defects in the tibia. Despite increasing evidence of its efficacy and good long-term outcomes, a knowledge gap exists in its indications and technique. This instructional article presents a comprehensive overview of the indications, pre-operative planning, step-by-step surgery, and subsequent post-operative management.

How to cite this article: Noorlander-Borgdorff MP, Giannakópoulos GF, Winters HAH, et al. The Pedicled Fibula Flap for Lower Limb Reconstruction. Strategies Trauma Limb Reconstr 2023;18(3):186-193.

Keywords: Critical bone defect; Fibula flap; Limb reconstruction; Orthoplastic; Pedicled flap; Skin island; Surgical technique; Tibia; Vascularised bone flap.

Fig. 1

Case example of an open comminuted proximal tibia fracture leading to significant bone loss

Fig. 2

Debridement of debris and devitalized tissue after which a cement spacer was placed in the defect. Primary stabilisation was achieved through external fixation

Fig. 3

Cadaver example of a segmental defect of the proximal tibia after debridement

Fig. 4

Lateral view of the lower leg, with a mark 5 cm below the fibular head and 8 cm above the lateral malleolus, indicating the two levels of osteotomies (1, 2). Interrupted line indicating the posterolateral septum (3). Design of a skin island (bold lines) after locating skin perforator(s) (with Doppler) (4)

Fig. 5

After releasing the lateral gastrocnemius (1) and the soleus (2) from the posterolateral intermuscular septum (3) and preserving two skin perforators (4, 5)

Fig. 6

Anterior approach of the fibula when including the skin island. Release the fibula (1) from the peroneus longus and brevis muscles (2)

Fig. 7

The proximal fibula (1) exposed with the superficial peroneal nerve (2) and the deep peroneal nerve (3) indicate deep peroneal nerve

Fig. 8

Opening the anterior compartment with the scissors close to the fibula to avoid damage of the deep peroneal nerve

Fig. 9

Anterior approach to the distal osteotomy site with the distal fibula (1) and the peroneal muscles (2)

Fig. 10

Distal osteotomy

Fig. 11

Proximal osteotomy

Fig. 12

The distal pedicle may be ligated and released when performing a proximally pedicled flap

Fig. 13

Freeing the fibula upwards dissecting the tibialis posterior muscle following the middle of the V pattern of the muscle fibres (1), keeping the peroneal artery and the FHL muscle cuff (2) with the fibula

Fig. 14

Reaching the end of the pedicle, the bifurcation of the peroneal artery and the posterior tibial artery (1). The tibial nerve is visible posteriorly (2)

Fig. 15

The fibula and flap fully dissected and only connected by the proximal pedicle

Fig. 16

Measuring the defect size before planning the osteotomy

Fig. 17

The fibula segment and skin island after the osteotomy for creating a double barrel (1), including distal and proximal periosteal flaps (2)

Fig. 18

Tunnelling of the fibula flap after creating a tunnel underneath the lateral and anterior compartments

Fig. 19

Placement of the double-barrel fibula into the defect, ensuring cortex-to-cortex contact and fit

Fig. 20

Configuration of the double-barrel fibula

Fig. 21

Result after suturing in the skin island and closing the donor site primarily

Fig. 22

Post-operative X-ray with plate fixation in the comparable case example (same patient as Figs 1 and 2)