- Email: [email protected]
The Medial Approach to the Fibula: A Feasible Alternative
J Oral Maxillofac Surg 66:319-323, 2008
The Medial Approach to the Fibula: A Feasible Alternative Felix Blake, MD, DMD,* Max Heiland, MD, DMD, PhD,† Rainer Schmelzle, MD, DMD, PhD,‡ Juergen Harms, MD, PhD,§ Heiner Werle, MD, DMD,储 Philipp Pohlenz, MD, DMD,¶ and Lei Li, MD, DMD, PhD# Purpose: Since the first harvesting of a microsurgical fibula in 1974 by Ueba and in 1975 by Taylor,
using the fibula for osseous reconstruction has proven to be a valuable approach. The harvesting technique, which has been refined by subsequent investigators, has become increasingly standardized, today providing a clear, reproducible method. The procedure involves elevating the fibular graft from lateral, choosing the shortest route to reach the fibula. One disadvantage of this approach is that the bone often obstructs visualization of the vascular pedicle, which lies medially, promoting unintentional injury. In addition, this method is associated with some donor site morbidity, prompting further investigations into accessing the fibula. Here we present an alternative approach for harvesting the fibula and highlight the pros and cons of each approach. Patients and Methods: Between 1999 and 2006, a total of 38 microsurgical (23 for the mandible, 9 for the extremities, and 6 for the maxilla) fibula grafts were harvested through the medial approach. Results: In all cases, the patency of the posterior tibial, peroneal vessels, and the tibial nerve could be visualized. Two flaps failed (both mandible, for a success rate of 94.7%). No ischemic or wound healing complications of the lower limb were observed. Conclusions: The medial approach for harvesting the fibula is a feasible alternative to the lateral approach and provides the surgeon with a comparable likelihood of success. If for some reason access from the lateral approach is contraindicated, then the medial route should be considered. © 2008 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 66:319-323, 2008 by Gilbert3 and first implemented in jaw reconstruction by Hidalgo4 in 1989, providing an easy-to-learn and readily reproducible technique. Preoperative imaging of the vessels of the lower limb is considered mandatory by many authors, demanding angiography, magnetic resonance imaging (MRI) angiography, or computed tomography (CT) angiography5-8 to visualize the degree of vascular disease or the presence of vascular anomalies. This must be considered a disadvantage during do-
The first harvesting of the fibula for microsurgical reconstruction was performed in 1974 by Ueba.1 Taylor et al2 repeated the same procedure in 1975 and published it before Ueba, and thus Taylor is often considered the pioneer of this technique. Regardless of who did it first, the microsurgical reanastomosed fibula is well-established for osseous reconstruction in various parts of the body to date and is in the repertoire of all larger centers of plastic and reconstructive surgery. This harvesting method was further refined *Senior Resident, Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. †Senior Resident, Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. ‡Head of Department, Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. §Head of Department, Department of Orthopedic Surgery, Karlsbad-Langenstein Clinic, Heidelburg, Germany. 储Resident, Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
¶Senior Resident, Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. #Head of Department, Department of Oral and Maxillofacial Surgery, Oldenburg City Hospital, Oldenburg, Germany. Address correspondence and reprint requests to Dr Blake: Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246 Hamburg, Germany; e-mail: [email protected] © 2008 American Association of Oral and Maxillofacial Surgeons
0278-2391/08/6602-0019$34.00/0 doi:10.1016/j.joms.2007.06.665
319
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MEDIAL APPROACH TO THE FIBULA
FIGURE 1. Schematic drawing of a cross section of the lower limb accessed from the medial. Blake et al. Medial Approach to the Fibula. J Oral Maxillofac Surg 2008.
nor site evaluation, being costly and time-consuming. Thus, conversely, numerous authors advocate imaging only if clinical examination of the pulses is ambiguous.9 In the method as described by Taylor et al2 and Ueba and Fukijawa,1 the fibula is elevated from the lateral side of the leg, where it lies directly beneath the skin. After the skin incision, the fibula is visible. The pedicle, containing the peroneal vascular bundle, lies medially and can be palpated, but often is not directly visible, being obstructed by the fibula. After preparation and osteotomy, the pedicle can be followed up to the tibioperoneal bifurcation, where the posterior tibial artery and peroneal artery originate. With this approach, 1 or more skin paddles can be elevated together with the osseous flap, with perfusion through the perforators.5 Furthermore, during reconstruction of the extremities, the proximal epiphysis can be included in the flap to facilitate bone growth, which is important for successful rehabilitation in adolescence, as seen in orthopedic surgery.10 Another factor meriting investigation is donor site morbidity. Although the fibula has no load-bearing
function,11 the surgical trauma causes deficiencies. Zimmermann et al12 reported a follow-up study (average, 34 months) in which they observed sensory deficits in 76.3% of the patients, motor deficits in 39.5% of the patients, and reduced strength in 44.7% of the patients. These values cannot be disregarded; numerous other reports have highlighted this problem, although the clinical implications have been interpreted differently.13-16 Inevitably, regardless of which approach is chosen, a certain degree of morbidity must be expected. An objective review of the advantages and disadvantages can allow the surgeon to include this method in his or her surgical repertoire.
Surgical Technique The pertinent difference between the medial and lateral approaches is the sequence in which the surgeons encounter the vascular pedicle and the fibula. In the medial approach, the access brings the surgeon directly to the pedicle first, allowing inspection and preparation (Fig 1). This can prove advantageous if an
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FIGURE 2. Medial view of the lower leg. The incision extends from the medial tibial epicondylus to 2 cm above the medial ankle.
FIGURE 3. Incision with view of the soleus and the long flexor digitorum muscle. The major saphenous vein is visible at the top of the incision.
Blake et al. Medial Approach to the Fibula. J Oral Maxillofac Surg 2008.
Blake et al. Medial Approach to the Fibula. J Oral Maxillofac Surg 2008.
anatomic anomaly is present that was not identified by preoperative imaging of the lower leg, if it was allotted at all. In addition, during the skin incision, typically the major saphenous vein is visible, allowing easy harvesting should a vascular graft be needed. Accidental injury of the peroneal nerve is practically impossible. After positioning of the lower leg, which is bent at the knee to about 40° to 50° and rotated outward with the tourniquet in place but not inflated, the skin incision begins approximately at the level of the medial tibial epicondylus and heads ventrally for 10 cm before turning in a caudal direction, parallel to the tibia, terminating about 2 cm above the medial ankle (Fig 2). During skin incision, care should be taken to not sever the major saphenous vein. Beneath the subcutaneous fatty tissue, the fascia of the soleus muscle and flexor digitorum longus muscle becomes visible; this is dissected 1 cm dorsal of the tibial bone (Fig 3), to allow entry between the 2 aforementioned muscles. At this point, the posterior tibial pedicle becomes visible; this can be palpated and dissected, allowing mobilization in ventral direction if desired. If the leg is rotated further outward, then the fibula can be felt at the bottom of the surgical field (Fig 4). The posterior tibial artery can be followed upward to the bifurcation where the peroneal artery originates (Fig 5). From this point on, the peroneal artery can be meticulously dissected in a caudal fashion. Once the needed length of fibula is determined, the artery is ligated and the fibula is osteotomized distally and proximally, leaving at least 7 cm distally to avoid instability of the ankle. At this point, the tourniquet is inflated, and, with gentle traction and with the help of a scissors, the fibula can be liberated from its bed in a cranial direction, with the vascular pedicle remaining visible at all
times. Once this is completed, the vascular pedicle is ligated and severed, freeing the fibula (Fig 6). Close scrutiny of the surgical site is required, and meticulous coagulation after deflation of the tourniquet is necessary to prevent hemorrhage. Closure of the site is simple, being limited to subcutaneous and cutaneous sutures only. The fascia is not readapted to preclude development of a compartment syndrome. Two drains are inserted to facilitate exudation, whereby easy flow or suction drainage can be implemented. Postoperative care is identical to that for the lateral approach, with ambulation on the second postoperative day under the supervision of a physiotherapist.
Patients and Methods In the cases under study, the decision to access the graft from the medial or lateral approach was based on the need for soft tissue reconstruction. In those
FIGURE 4. View of the trunk and bifurcation of the posterior tibial artery and peroneal artery. Blake et al. Medial Approach to the Fibula. J Oral Maxillofac Surg 2008.
322
MEDIAL APPROACH TO THE FIBULA
Results
FIGURE 5. View of the operation site. The tibial nerve is held below the retractors, with the peroneal pedicle clearly visible. Blake et al. Medial Approach to the Fibula. J Oral Maxillofac Surg 2008.
cases where insufficient or strongly compromised soft tissue was present at the recipient site, the lateral approach was implemented, allowing simultaneous elevation of a skin paddle. Between 1999 and 2006, a total of 38 fibular grafts were elevated through the medial approach. In all patients, either MRI angiography or a conventional angiography was done before surgery. The fibula was used for mandible reconstruction in 23 patients (12 unilateral and 11 bilateral reconstruction), for limb reconstruction in 9 patients (4 humerus, 2 femur, and 3 tibia), and for maxilla augmentation in 6 patients. Before flap elevation, low-dose heparin (Liquemin; Hoffmann-La Roche AG, Switzerland), 200 IE/kg body weight/day by steady intravenous infusion, was administered. The duration of ischemia of the flap (ie, period between ligation of the peroneal artery and reperfusion after reanastomosis of the artery) was divided into 4 categories: 30 to 60 minutes, 60 to 90 minutes, 90 to 120 minutes, and over 120 minutes. With reference to these times, it must be stated that the osteotomy, osteosynthesis, and fixation of the fibula were performed before reanastomosis, prolonging the duration of ischemia. All microsurgical anastomoses were done with 8/0 or 9/0 nylon sutures (Medipoint, Hamburg, Germany), using interrupted sutures under a surgical microscope (S8, OPMI-Vario; Carl Zeiss AG, Jena, Germany). The target vessels in the head and neck region were the superior thyroid or facial pedicle, with predominantly end-to-end anastomoses. In isolated cases, endto-side anastomoses to the external carotid artery and internal jugular vein were necessary. For limb reconstruction, end-to-side anastomoses were used to ensure continuous perfusion of the limb.
In all 38 flaps, harvesting from the medial approach was possible without any difficulty. In all cases, the peroneal and posterior tibial pedicles were visible. The duration of ischemia was 30 to 60 minutes in 8 flaps, 60 to 90 minutes in 22 flaps, 90 to 120 minutes in 6 flaps, and flaps over 120 minutes in 2 flaps. Two flaps were lost, both for reconstruction of the mandible, 1 with an ischemic time of 60 to 90 minutes and the other with an ischemic time of 90 to 120 minutes. In all patients, ambulation was possible after 2 days, and no ischemic sequelae of the lower limb, protracted wound healing, or wound infection was noted.
Discussion In the early 1980s, after encountering an anatomic anomaly while harvesting the fibula from the lateral approach, Schmelzle and Harms consulted Professor Lang of Würzburg, an anatomist, who recommended anatomic preparation of the fibula as described by Lanz and Wachsmuth.17 This procedure was simulated in cadaver studies and proved its practicability for intraoperative implementation, which was inaugurated in 1985. Although this procedure has been performed for more than 20 years, it has gained little attention from and acceptance by microvascular reconstructive surgeons. The debate concerning preoperative imaging of the vasculature of the lower leg continues, with no stratification of imaging results and their clinical implications visible on the surgical horizon. Currently, the chief surgeon determines whether angiographic findings allow ligation of the peroneal pedicle without endangering perfusion of the foot, a highly subjective determination that can lead to widely varying results. Lutz et al,9 in a prospective study, examined 120 patients, 114 solely clinically and 6 with additional imaging. In 5 of these 6
FIGURE 6. The elevated fibular graft liberated from its bed. Blake et al. Medial Approach to the Fibula. J Oral Maxillofac Surg 2008.
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patients, the planned fibula transplantation was done without ischemic sequelae; 1 patient suffered from a hemangioma of the peroneal artery on the planned side. Thus, the rate was 99.1% (119/120). In contrast to these results, Kessler et al8 investigated 52 patients and, based on the imaging results, included only 21 patients in the planned therapy with alternative flaps (40.3%). Are such widely varying findings due to significantly different patient collectives, greatly divergent clinical and angiographic findings, or the particular chief surgeons’ interpretations? This situation further supports the need for a procedure that allows easy visualization and preparation of the posterior tibial and peroneal artery over its full length, enabling clinical discrimination of its patency. Moreover, the medial approach readily allows temporary clipping of both pedicles to ascertain the residual perfusion of the foot, as described by Lutz.9 During preparation, the major saphenous vein is typically encountered and thus is at the surgeon’s disposal should a vein graft be needed. In addition, a medially lying scar is considered by some patients to be more inconspicuous, being partially covered by the other leg. When using the lateral approach, we often osteotomize about 2 cm of fibula, which provides a clear view of the medially lying pedicle with subsequent preparation. This leads to a 2-cm loss of fibular length, which is generally well tolerated. This procedure is unnecessary in the medial approach, however. Moreover, the potential danger of injuring the peroneal nerve, which lies very superficially in the vicinity of the lateral tibial epicondylus, is mitigated with the medial approach. Also noteworthy is the donor site morbidity of the lateral approach. Although it is the first choice in bilateral mandibular reconstruction, the lateral approach is, according to some authors, associated with marked morbidity. In a follow-up study (average 34 months), Zimmermann et al12 reported of sensory deficits in 76.3% of patients, motor deficits in 39.5%, and reduced strength in 44.7%. Other studies on this phenomenon have reported widely varying results, ranging from little impairment14,15 to significant impairment. Fortunately, the subjective impairment seems much less pronounced than the often-objective findings detected by clinical investigation.13 To what extent the medial approach might contribute to the reduction of such long-term morbidity cannot be determined at this point. One disadvantage of the medial approach is the inability to harvest a skin flap in conjunction with the fibula. Preparation of the perforator vessels is not possible. In cases where additional soft tissue coverage is needed, the lateral approach must be favored. In addition, in cases where the head of the fibula is included in the flap, as occurs in limb reconstruction in orthopedic surgery,10 only the lateral approach is feasible.
On the basis of this series, we cannot determine whether the 2 failed flaps suffered marked damage during harvesting or whether their demise was due to other factors. The high success rate of 94.7% prompts us to encourage its further implementation and distribution, with examination and evaluation of larger series. In summary, the medial approach to fibula harvesting is a feasible alternative to the lateral approach and provides the surgeon with a comparable likelihood of success. This method allows direct visualization of the vascular structures, promoting their preservation. The early donor site morbidity seems comparable with that of the lateral approach. Should for some reason lateral access be contraindicated, the medial route should be considered, making this procedure a worthy addition to the repertoire of every microvascular reconstructive surgeon.
References 1. Ueba Y, Fujikawa S: Nine-year follow-up of a vascularized fibula graft in neurofibromatosis: A case report and literature review. Orthop Trauma Surg 26:595, 1983 2. Taylor GI, Miller GDH, Ham FJ: The free vascularized bone graft: A clinical extension of microvascular techniques. Plast Reconstr Surg 55:533, 1975 3. Gilbert A: Vascularized transfer of the fibular shaft. Int J Microsurg 1:100, 1979 4. Hidalgo DA: Fibula free flap: A new method of mandible reconstruction. Plast Reconstr Surg 84:71, 1989 5. Wolff KD, Hölzle F: Fibular flap, in Schröder G (ed): Raising of Microvascular Flaps. Berlin, Springer, 2005 6. Disa JJ, Cordeiro PG: The current role of preoperative arteriography in free fibula flaps. Plast Reconstr Surg 102:1083, 1998 7. Chow LC, Napoli A, Klein MB, et al: Vascular mapping of the leg with multi-detector row CT angiography prior to free-flap transplantation. Radiology 237:353, 2005 8. Kessler P, Wiltfang J, Schultze-Mosgau S, et al: The role of angiography in the lower extremity using free vascularized fibular transplants for mandibular reconstruction. J Craniomaxillofac Surg 29:332, 2001 9. Lutz B, Wei FC, Ng SH, et al: Routine donor leg angiography before vascularized free fibula transplantation is not necessary: A prospective study in 120 clinical cases. Plast Reconstr Surg 109:121, 1999 10. Ceruso M, Falcone C, Innocenti M, et al: Skeletal reconstruction with a free vascularized fibula graft associated to bone allograft after resection of malignant bone tumor of limbs. Handchir Mikrochir Plast Chir 33:277, 2001 11. Takabe K, Nakagawa A, Minami H, et al: Role of the fibula in weight-bearing. Clin Orthop Res 184:289, 1984 12. Zimmermann CE, Börner BI, Hasse A, et al: Donor site morbidity after microvascular fibula transfer. Clin Oral Invest 5:214, 2001 13. Anthony JP, Rawnsley JD, Benhaim P, et al: Donor leg morbidity and function after fibula free flap mandible reconstruction. Plast Reconstr Surg 96:146, 1995 14. Shindo M, Fong BP, Funk GF, et al: The fibula osteocutaneous flap in head and neck reconstruction: A critical evaluation of donor site morbidity. Arch Otolaryngol Head Neck Surg 126: 1467, 2000 15. Vail TP, Urbaniak JR: Donor site morbidity with use of vascularised autogenous fibular grafts. J Bone Joint Surg Br 78:204, 1996 16. Garrett A, Ducic Y, Athre RS, et al: Evaluation of fibula free flap donor site morbidity. Am J Otolaryngol 27:29, 2006 17. Lanz T, Wachsmuth W: Leg, in Tillmann B (ed): Practical Anatomy (ed 2) Berlin, Springer, 1972 [in German]
The Medial Approach to the Fibula: A Feasible Alternative Felix Blake, MD, DMD,* Max Heiland, MD, DMD, PhD,† Rainer Schmelzle, MD, DMD, PhD,‡ Juergen Harms, MD, PhD,§ Heiner Werle, MD, DMD,储 Philipp Pohlenz, MD, DMD,¶ and Lei Li, MD, DMD, PhD# Purpose: Since the first harvesting of a microsurgical fibula in 1974 by Ueba and in 1975 by Taylor,
using the fibula for osseous reconstruction has proven to be a valuable approach. The harvesting technique, which has been refined by subsequent investigators, has become increasingly standardized, today providing a clear, reproducible method. The procedure involves elevating the fibular graft from lateral, choosing the shortest route to reach the fibula. One disadvantage of this approach is that the bone often obstructs visualization of the vascular pedicle, which lies medially, promoting unintentional injury. In addition, this method is associated with some donor site morbidity, prompting further investigations into accessing the fibula. Here we present an alternative approach for harvesting the fibula and highlight the pros and cons of each approach. Patients and Methods: Between 1999 and 2006, a total of 38 microsurgical (23 for the mandible, 9 for the extremities, and 6 for the maxilla) fibula grafts were harvested through the medial approach. Results: In all cases, the patency of the posterior tibial, peroneal vessels, and the tibial nerve could be visualized. Two flaps failed (both mandible, for a success rate of 94.7%). No ischemic or wound healing complications of the lower limb were observed. Conclusions: The medial approach for harvesting the fibula is a feasible alternative to the lateral approach and provides the surgeon with a comparable likelihood of success. If for some reason access from the lateral approach is contraindicated, then the medial route should be considered. © 2008 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 66:319-323, 2008 by Gilbert3 and first implemented in jaw reconstruction by Hidalgo4 in 1989, providing an easy-to-learn and readily reproducible technique. Preoperative imaging of the vessels of the lower limb is considered mandatory by many authors, demanding angiography, magnetic resonance imaging (MRI) angiography, or computed tomography (CT) angiography5-8 to visualize the degree of vascular disease or the presence of vascular anomalies. This must be considered a disadvantage during do-
The first harvesting of the fibula for microsurgical reconstruction was performed in 1974 by Ueba.1 Taylor et al2 repeated the same procedure in 1975 and published it before Ueba, and thus Taylor is often considered the pioneer of this technique. Regardless of who did it first, the microsurgical reanastomosed fibula is well-established for osseous reconstruction in various parts of the body to date and is in the repertoire of all larger centers of plastic and reconstructive surgery. This harvesting method was further refined *Senior Resident, Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. †Senior Resident, Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. ‡Head of Department, Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. §Head of Department, Department of Orthopedic Surgery, Karlsbad-Langenstein Clinic, Heidelburg, Germany. 储Resident, Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
¶Senior Resident, Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. #Head of Department, Department of Oral and Maxillofacial Surgery, Oldenburg City Hospital, Oldenburg, Germany. Address correspondence and reprint requests to Dr Blake: Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246 Hamburg, Germany; e-mail: [email protected] © 2008 American Association of Oral and Maxillofacial Surgeons
0278-2391/08/6602-0019$34.00/0 doi:10.1016/j.joms.2007.06.665
319
320
MEDIAL APPROACH TO THE FIBULA
FIGURE 1. Schematic drawing of a cross section of the lower limb accessed from the medial. Blake et al. Medial Approach to the Fibula. J Oral Maxillofac Surg 2008.
nor site evaluation, being costly and time-consuming. Thus, conversely, numerous authors advocate imaging only if clinical examination of the pulses is ambiguous.9 In the method as described by Taylor et al2 and Ueba and Fukijawa,1 the fibula is elevated from the lateral side of the leg, where it lies directly beneath the skin. After the skin incision, the fibula is visible. The pedicle, containing the peroneal vascular bundle, lies medially and can be palpated, but often is not directly visible, being obstructed by the fibula. After preparation and osteotomy, the pedicle can be followed up to the tibioperoneal bifurcation, where the posterior tibial artery and peroneal artery originate. With this approach, 1 or more skin paddles can be elevated together with the osseous flap, with perfusion through the perforators.5 Furthermore, during reconstruction of the extremities, the proximal epiphysis can be included in the flap to facilitate bone growth, which is important for successful rehabilitation in adolescence, as seen in orthopedic surgery.10 Another factor meriting investigation is donor site morbidity. Although the fibula has no load-bearing
function,11 the surgical trauma causes deficiencies. Zimmermann et al12 reported a follow-up study (average, 34 months) in which they observed sensory deficits in 76.3% of the patients, motor deficits in 39.5% of the patients, and reduced strength in 44.7% of the patients. These values cannot be disregarded; numerous other reports have highlighted this problem, although the clinical implications have been interpreted differently.13-16 Inevitably, regardless of which approach is chosen, a certain degree of morbidity must be expected. An objective review of the advantages and disadvantages can allow the surgeon to include this method in his or her surgical repertoire.
Surgical Technique The pertinent difference between the medial and lateral approaches is the sequence in which the surgeons encounter the vascular pedicle and the fibula. In the medial approach, the access brings the surgeon directly to the pedicle first, allowing inspection and preparation (Fig 1). This can prove advantageous if an
321
BLAKE ET AL
FIGURE 2. Medial view of the lower leg. The incision extends from the medial tibial epicondylus to 2 cm above the medial ankle.
FIGURE 3. Incision with view of the soleus and the long flexor digitorum muscle. The major saphenous vein is visible at the top of the incision.
Blake et al. Medial Approach to the Fibula. J Oral Maxillofac Surg 2008.
Blake et al. Medial Approach to the Fibula. J Oral Maxillofac Surg 2008.
anatomic anomaly is present that was not identified by preoperative imaging of the lower leg, if it was allotted at all. In addition, during the skin incision, typically the major saphenous vein is visible, allowing easy harvesting should a vascular graft be needed. Accidental injury of the peroneal nerve is practically impossible. After positioning of the lower leg, which is bent at the knee to about 40° to 50° and rotated outward with the tourniquet in place but not inflated, the skin incision begins approximately at the level of the medial tibial epicondylus and heads ventrally for 10 cm before turning in a caudal direction, parallel to the tibia, terminating about 2 cm above the medial ankle (Fig 2). During skin incision, care should be taken to not sever the major saphenous vein. Beneath the subcutaneous fatty tissue, the fascia of the soleus muscle and flexor digitorum longus muscle becomes visible; this is dissected 1 cm dorsal of the tibial bone (Fig 3), to allow entry between the 2 aforementioned muscles. At this point, the posterior tibial pedicle becomes visible; this can be palpated and dissected, allowing mobilization in ventral direction if desired. If the leg is rotated further outward, then the fibula can be felt at the bottom of the surgical field (Fig 4). The posterior tibial artery can be followed upward to the bifurcation where the peroneal artery originates (Fig 5). From this point on, the peroneal artery can be meticulously dissected in a caudal fashion. Once the needed length of fibula is determined, the artery is ligated and the fibula is osteotomized distally and proximally, leaving at least 7 cm distally to avoid instability of the ankle. At this point, the tourniquet is inflated, and, with gentle traction and with the help of a scissors, the fibula can be liberated from its bed in a cranial direction, with the vascular pedicle remaining visible at all
times. Once this is completed, the vascular pedicle is ligated and severed, freeing the fibula (Fig 6). Close scrutiny of the surgical site is required, and meticulous coagulation after deflation of the tourniquet is necessary to prevent hemorrhage. Closure of the site is simple, being limited to subcutaneous and cutaneous sutures only. The fascia is not readapted to preclude development of a compartment syndrome. Two drains are inserted to facilitate exudation, whereby easy flow or suction drainage can be implemented. Postoperative care is identical to that for the lateral approach, with ambulation on the second postoperative day under the supervision of a physiotherapist.
Patients and Methods In the cases under study, the decision to access the graft from the medial or lateral approach was based on the need for soft tissue reconstruction. In those
FIGURE 4. View of the trunk and bifurcation of the posterior tibial artery and peroneal artery. Blake et al. Medial Approach to the Fibula. J Oral Maxillofac Surg 2008.
322
MEDIAL APPROACH TO THE FIBULA
Results
FIGURE 5. View of the operation site. The tibial nerve is held below the retractors, with the peroneal pedicle clearly visible. Blake et al. Medial Approach to the Fibula. J Oral Maxillofac Surg 2008.
cases where insufficient or strongly compromised soft tissue was present at the recipient site, the lateral approach was implemented, allowing simultaneous elevation of a skin paddle. Between 1999 and 2006, a total of 38 fibular grafts were elevated through the medial approach. In all patients, either MRI angiography or a conventional angiography was done before surgery. The fibula was used for mandible reconstruction in 23 patients (12 unilateral and 11 bilateral reconstruction), for limb reconstruction in 9 patients (4 humerus, 2 femur, and 3 tibia), and for maxilla augmentation in 6 patients. Before flap elevation, low-dose heparin (Liquemin; Hoffmann-La Roche AG, Switzerland), 200 IE/kg body weight/day by steady intravenous infusion, was administered. The duration of ischemia of the flap (ie, period between ligation of the peroneal artery and reperfusion after reanastomosis of the artery) was divided into 4 categories: 30 to 60 minutes, 60 to 90 minutes, 90 to 120 minutes, and over 120 minutes. With reference to these times, it must be stated that the osteotomy, osteosynthesis, and fixation of the fibula were performed before reanastomosis, prolonging the duration of ischemia. All microsurgical anastomoses were done with 8/0 or 9/0 nylon sutures (Medipoint, Hamburg, Germany), using interrupted sutures under a surgical microscope (S8, OPMI-Vario; Carl Zeiss AG, Jena, Germany). The target vessels in the head and neck region were the superior thyroid or facial pedicle, with predominantly end-to-end anastomoses. In isolated cases, endto-side anastomoses to the external carotid artery and internal jugular vein were necessary. For limb reconstruction, end-to-side anastomoses were used to ensure continuous perfusion of the limb.
In all 38 flaps, harvesting from the medial approach was possible without any difficulty. In all cases, the peroneal and posterior tibial pedicles were visible. The duration of ischemia was 30 to 60 minutes in 8 flaps, 60 to 90 minutes in 22 flaps, 90 to 120 minutes in 6 flaps, and flaps over 120 minutes in 2 flaps. Two flaps were lost, both for reconstruction of the mandible, 1 with an ischemic time of 60 to 90 minutes and the other with an ischemic time of 90 to 120 minutes. In all patients, ambulation was possible after 2 days, and no ischemic sequelae of the lower limb, protracted wound healing, or wound infection was noted.
Discussion In the early 1980s, after encountering an anatomic anomaly while harvesting the fibula from the lateral approach, Schmelzle and Harms consulted Professor Lang of Würzburg, an anatomist, who recommended anatomic preparation of the fibula as described by Lanz and Wachsmuth.17 This procedure was simulated in cadaver studies and proved its practicability for intraoperative implementation, which was inaugurated in 1985. Although this procedure has been performed for more than 20 years, it has gained little attention from and acceptance by microvascular reconstructive surgeons. The debate concerning preoperative imaging of the vasculature of the lower leg continues, with no stratification of imaging results and their clinical implications visible on the surgical horizon. Currently, the chief surgeon determines whether angiographic findings allow ligation of the peroneal pedicle without endangering perfusion of the foot, a highly subjective determination that can lead to widely varying results. Lutz et al,9 in a prospective study, examined 120 patients, 114 solely clinically and 6 with additional imaging. In 5 of these 6
FIGURE 6. The elevated fibular graft liberated from its bed. Blake et al. Medial Approach to the Fibula. J Oral Maxillofac Surg 2008.
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BLAKE ET AL
patients, the planned fibula transplantation was done without ischemic sequelae; 1 patient suffered from a hemangioma of the peroneal artery on the planned side. Thus, the rate was 99.1% (119/120). In contrast to these results, Kessler et al8 investigated 52 patients and, based on the imaging results, included only 21 patients in the planned therapy with alternative flaps (40.3%). Are such widely varying findings due to significantly different patient collectives, greatly divergent clinical and angiographic findings, or the particular chief surgeons’ interpretations? This situation further supports the need for a procedure that allows easy visualization and preparation of the posterior tibial and peroneal artery over its full length, enabling clinical discrimination of its patency. Moreover, the medial approach readily allows temporary clipping of both pedicles to ascertain the residual perfusion of the foot, as described by Lutz.9 During preparation, the major saphenous vein is typically encountered and thus is at the surgeon’s disposal should a vein graft be needed. In addition, a medially lying scar is considered by some patients to be more inconspicuous, being partially covered by the other leg. When using the lateral approach, we often osteotomize about 2 cm of fibula, which provides a clear view of the medially lying pedicle with subsequent preparation. This leads to a 2-cm loss of fibular length, which is generally well tolerated. This procedure is unnecessary in the medial approach, however. Moreover, the potential danger of injuring the peroneal nerve, which lies very superficially in the vicinity of the lateral tibial epicondylus, is mitigated with the medial approach. Also noteworthy is the donor site morbidity of the lateral approach. Although it is the first choice in bilateral mandibular reconstruction, the lateral approach is, according to some authors, associated with marked morbidity. In a follow-up study (average 34 months), Zimmermann et al12 reported of sensory deficits in 76.3% of patients, motor deficits in 39.5%, and reduced strength in 44.7%. Other studies on this phenomenon have reported widely varying results, ranging from little impairment14,15 to significant impairment. Fortunately, the subjective impairment seems much less pronounced than the often-objective findings detected by clinical investigation.13 To what extent the medial approach might contribute to the reduction of such long-term morbidity cannot be determined at this point. One disadvantage of the medial approach is the inability to harvest a skin flap in conjunction with the fibula. Preparation of the perforator vessels is not possible. In cases where additional soft tissue coverage is needed, the lateral approach must be favored. In addition, in cases where the head of the fibula is included in the flap, as occurs in limb reconstruction in orthopedic surgery,10 only the lateral approach is feasible.
On the basis of this series, we cannot determine whether the 2 failed flaps suffered marked damage during harvesting or whether their demise was due to other factors. The high success rate of 94.7% prompts us to encourage its further implementation and distribution, with examination and evaluation of larger series. In summary, the medial approach to fibula harvesting is a feasible alternative to the lateral approach and provides the surgeon with a comparable likelihood of success. This method allows direct visualization of the vascular structures, promoting their preservation. The early donor site morbidity seems comparable with that of the lateral approach. Should for some reason lateral access be contraindicated, the medial route should be considered, making this procedure a worthy addition to the repertoire of every microvascular reconstructive surgeon.
References 1. Ueba Y, Fujikawa S: Nine-year follow-up of a vascularized fibula graft in neurofibromatosis: A case report and literature review. Orthop Trauma Surg 26:595, 1983 2. Taylor GI, Miller GDH, Ham FJ: The free vascularized bone graft: A clinical extension of microvascular techniques. Plast Reconstr Surg 55:533, 1975 3. Gilbert A: Vascularized transfer of the fibular shaft. Int J Microsurg 1:100, 1979 4. Hidalgo DA: Fibula free flap: A new method of mandible reconstruction. Plast Reconstr Surg 84:71, 1989 5. Wolff KD, Hölzle F: Fibular flap, in Schröder G (ed): Raising of Microvascular Flaps. Berlin, Springer, 2005 6. Disa JJ, Cordeiro PG: The current role of preoperative arteriography in free fibula flaps. Plast Reconstr Surg 102:1083, 1998 7. Chow LC, Napoli A, Klein MB, et al: Vascular mapping of the leg with multi-detector row CT angiography prior to free-flap transplantation. Radiology 237:353, 2005 8. Kessler P, Wiltfang J, Schultze-Mosgau S, et al: The role of angiography in the lower extremity using free vascularized fibular transplants for mandibular reconstruction. J Craniomaxillofac Surg 29:332, 2001 9. Lutz B, Wei FC, Ng SH, et al: Routine donor leg angiography before vascularized free fibula transplantation is not necessary: A prospective study in 120 clinical cases. Plast Reconstr Surg 109:121, 1999 10. Ceruso M, Falcone C, Innocenti M, et al: Skeletal reconstruction with a free vascularized fibula graft associated to bone allograft after resection of malignant bone tumor of limbs. Handchir Mikrochir Plast Chir 33:277, 2001 11. Takabe K, Nakagawa A, Minami H, et al: Role of the fibula in weight-bearing. Clin Orthop Res 184:289, 1984 12. Zimmermann CE, Börner BI, Hasse A, et al: Donor site morbidity after microvascular fibula transfer. Clin Oral Invest 5:214, 2001 13. Anthony JP, Rawnsley JD, Benhaim P, et al: Donor leg morbidity and function after fibula free flap mandible reconstruction. Plast Reconstr Surg 96:146, 1995 14. Shindo M, Fong BP, Funk GF, et al: The fibula osteocutaneous flap in head and neck reconstruction: A critical evaluation of donor site morbidity. Arch Otolaryngol Head Neck Surg 126: 1467, 2000 15. Vail TP, Urbaniak JR: Donor site morbidity with use of vascularised autogenous fibular grafts. J Bone Joint Surg Br 78:204, 1996 16. Garrett A, Ducic Y, Athre RS, et al: Evaluation of fibula free flap donor site morbidity. Am J Otolaryngol 27:29, 2006 17. Lanz T, Wachsmuth W: Leg, in Tillmann B (ed): Practical Anatomy (ed 2) Berlin, Springer, 1972 [in German]