USE

OF

THE

TIBIAL

M.

the

PISAN,

of Berne,

1989

and

ipsilateral
fibular
tibial
defects.
We
follow-up
medially

weight-bearing
months.
We
the
use
of

of the

Joint

Surg

4 May

we

(Br)

The
on

Accepted

techniques

and

particular

technique

after

revision

Agiza
fibula

synostosis.

The

bone

used

include

segmental

trans-

graft

supply,

and

we

began

synos-

(Davis

1944;
1963;
1967;

may

in placing
the
tibia,
and
large

be needed

fusion,
with unpredictable
results.
In 1981, Chacha,
Ahmed
and Daruwalla
dissection
and transposition
of the fibula,
to use

to obtain

suggested
preserving

this

reason

nonunions
tumour.

We

performed

AND

procedure

vascularised

fibular

had
with

patients

bifocal

defects

should

be sent

101995
British
Editorial
Society
0301-620X195/61065
$2.00

914

to Dr R. Hertel.
of Bone

and

Joint

Surgery

was

injury:

of

were

(19 to 58). The

In nine patients

in eight

infected

three patients
had had a
previous
attempts
at

in segmental

a mean

disease,
men and

tibial

12 cm

defects

(1 to

due to failed

of

19).

In two

segmental

trans-

transplanta-

reconstruction

in

Operative

almost

a tumour

technique.

invariably

tions

and

was

always

chronic

been

necessary

in

nerve
The

had

The

immediate

11

lateral

reconstruction

aspect

of

the

well preserved,

even after multiple

infection,

a straight

possible.

and

peroneal

The

and
peroneal

its branches
muscles

were
were

lateral

fascia

was

was

operaapproach

incised.

identified

retracted

leg

The

and

pro-

anteriorly

and

sharply
dissected
off the fibula,
leaving
a cuff of muscle
1
to 2 mm thick
on the periosteum
and bone.
The anterolateral
intermuscular
septum
was incised.
Proximal
and distal osteotomies
were performed
with an

saw,
The

Dissection
isolating
of Orthopaedic
Switzerland.

had

fibu-

The mean number

of previous
operations
was 5.5 for the
post-traumatic
patients.
The mean time interval
between
the
accident
and the fibular
transfer
was 14 months
(7 to 36).
All patients
with
after resection.

the
its

of the contralateral

patients;
in five flap coverage
had been obtained
at the time
of fibular
transfer
and in six it had been undertaken
before.
Seven
patients
had been treated
with a free microvascular
flap, two with a medial
and two with a medial
and lateral
gastrocnemius
flap.

segment.

Correspondence

of 34 years
(24 to 58).

The other
and various

resulted

length,

oscillating
R. Hertel,
MD, Head of Upper Extremity
Unit
M. Pisan,
MD, Resident
R. P. Jakob, MD, Professor
of Orthopaedic
Surgery
Reconstructive
and Upper
Extremity
Unit,
Department
Surgery,
University
of Berne,
Inselspital,
CH-3010
Berne,

defect

varying

tected.

METHODS
ipsilateral

the

reconstruction

peroneal
PATIENTS

for

were present.
Debridement

Soft-tissue

196 1 ; Parisien
and Patterson

be encountered
to the

women
with a mean age
follow-up
was 32 months

after microvascular
transplantation
la, providing
a double
strut.

for

Tibiofibular

procedure

One died early due to metastatic

in the series.
There
were nine

port. The reconstructed

segment
was very weak
in two
patients
after microvascular
rib transplantation.
In a further
two patients
transfer
of the ipsilateral
fibula
had been
performed
as a planned
procedure
eight
and nine weeks

indications

defined.

196 1 ; McCabe
1965; Doherty

1981). Difficulty
may
in close
approximation

vascular
1988.

the

1995

been

grafting,

as a salvage

of cancellous

23 March

have

bone

are poorly

1954; Bell
and Hohl

amounts

three
mean

present
a challenging
probof infection
and instability.

which

tibiofibular

is regarded

McMaster
McMaster

tion in 13 patients.
leaving
12 cases

tibia.

decortication,

portation

tosis

vascularised

graft was either

transposed
its vascular
pedicle.
Full

Segmental
defects
of the tibia
lem, particularly
in the presence
various

with segmental
with a minimum

1995;77-B:914-9.

1994;

compression,

used

in 24 patients
12 patients

was achieved
at between
four and seven
had few complications
and consider
that
this
method
is a valuable
option
in

reconstruction

The

FOR

Switzerland

1994

graft
report

of two years.
or inverted

Received

FIBULA

R. P. JAKOB

University

Between

J Bone

VASCULARISED

RECONSTRUCTION

R. HERTEL,

From

IPSILATERAL

allowing

medial

proceeded
the

external

aspect

along

neurovascular

rotation

of the fibula

the
bundle

of the
was

interosseous
which

fibular

decorticated.

membrane

was

left

anterior

to the plane of dissection.

The posterior
aspect of the fibula
was
left intact
when
simple
medial
transposition
was
required.
Dissection
of the vascular
pedicle
was necessary
when
major
proximal
translation
or an inversion
of the
graft

was

planned

(Fig.

1).

Decortication

THE JOURNAL

OF BONE

of
AND

the

JOINT

lateral
SURGERY

USE OF THE

IPSILATERAL

VASCULARISED

Fig. la

creating

of the

fibula

posterior

aspect

of the

iosteal
The

flap, provided
an optimal
contact
surface.
fibula
was transposed
without
tension
on

tissues

and

fixed

with

an anteriorly-based

lag screws

to the tibia.

dissection

Fig. 2a

VOL.

77-B,

No. 6, NOVEMBER

RECONSTRUCTION

915

osteoper-

the

1995

(a,b).

tibia

and

harvested

the

soft

from

For

the
the

inversion

of the fibula

fibula

was

iliac

crest.

circumferential

filled

with

If an

dissection

cancellous

inverted

or

bone
a double-

strut configuration
was planned,
the fully dissected
transplant was rotated
at its base and the fibular
segment
was
placed
in the defect
and stabilised
by short compression

If necessary,

Fig.

transfer;
the peroneal
vascular
most proximal
point of rotation

Fig. lc

is not necessary

additional
plates were used for the stabilisation
of nonunion
of the fibula
or an osteotomy.
Additional
fixation
of the
tibia was sometimes
necessary
and a uniplanar
external
fixator
was usually
adequate.
The remaining
gap between

Figure 2a - Simple medial

distant
tissue transfer. The
of a double
strut.

FOR TIBIAL

Fig. lb

Dissection
technique.
For transposition
of the peroneal
vessels
is required
(c).

tibia,

FIBULA

plates and a long bridging

Mobilisation
was started
ground

contact

allowed

plate (Fig. 2).

after 48 hours,
immediately.

2b

axis remains
patent.
is the tibioperoneal

Fig.

Figure
2b
bifurcation.

Ligation
of the distal peroneal
Figure 2c - Folding
the fibula

with

Radiographs

artery
in two

10 kg of
were

2c

and veins allows

more
allows
the construction

916

R. HERTEL,

M. PISAN.

R. P. JAKOB

Double
strut with
strut with a distal

Fig.

obtained
increased

3a

at intervals
according

Fig.

of six weeks.
Weight-bearing
to the degree
of healing.

3b

was

second

In
resections
bone graft

of turnours
had a planned
1 2 and 13 weeks
after the

fibular
transfer.
All other patients
operation.
Full, unprotected
weight-bearing
achieved

at a mean
The

mean

by the patients
ment because
or arthrodesis

of 5.5
walking

had

union

with

limb.
The

a single

walking

months

(4 to 7) after

distance

as subjectively

was

was

promptly

relieved

by

elevation

of
or

of

the

tissues

were

stable

in all patients

and

remained

7).

range

of

patients.

In three

necessary.

In

one

knee

movement

patients

with

patient

the

impaired
due to an intra-articular
ankle
movement
was common.
(15

to 60).

Before

fibular

was

a tumour

transfer

range

normal
a knee
of

six patients

6#{176}
and 1 1

normal.

At the final review

was

valgus

normal.

In

deformity

of

One had a varus angulation

of 6#{176}
and
deformity.
One patient
had an external
of 10#{176}
but in the remainder
the rotation
of

between

1 and

2 cm

was

patients.

fibula
This

radiodensity

were seen
periosteal

and

as soon
reaction

surface

radiographs
we
3 mm (I to 4).

observed

cancellous

bone

a mean
graft

after
as

The extent of
related
to the
On standard

increase

was

irregu-

as four months
was interpreted

indicating
satisfactory
perfusion
and viability.
this reaction
was variable
and was probably
mechanical
loading
of the fibular
segment.

in diameter

incorporated

of

as a radio-

dense
bone mass in all instances.
Partial
graft resorption
was seen
in one patient,
who
lost about
50%
of the
transplanted
cancellous
bone.
He had a sound
fusion
with
strong

bridging

callus

fibula which was

was necessary.

eight
was

fer. The

was

for the fracture

Refracture

of
drugs
35#{176} No

in the trau-

alignment

He main-

#{176}.

increasing

larity of the
transposition.

in

Impairment
range
was

axial

position.

asymptomatic

Shortening

in eight

fusion

movement

fracture.
The mean

contracture.

the
an

a 9#{176}
flexion
deformity

observed

The
soft

so during
the entire follow-up
period.
Swelling
and oederna
of the latissimus
dorsi
flap and the foot were
limiting
factors
in two patients.
Compared
with the uninjured
side,
the mean difference
in thigh circumference
was 3 cm (-1 to
The

another
rotational

was

Thickening,

stated

complained
of standing

patients

there

between

fibular

was 12 km (1 km to unlimited)
with impairof residual
contractures
of the ankle and knee
of the knee. Chronic
oedema
and pain were

which

had an equinus

seven

was
for normal

the cause of limitation

in two patients.
Two
painful
pressure
in the leg after long periods
walking

group

three

patients
with
cancellous

transfer.

matic

only one did not reach the plantigrade

tamed
a fixed equinus
of 10#{176}.

RESULTS
Two

(a) and single

a proximal
pedicle
pedicle
(b).

and

at the proximal

mechanically

occurred

degree

in one patient

of trauma

and distal

sufficient,

ends

adequate

was under

of the

no regrafting

1 3 months

was probably

and the patient

and

after

trans-

to account

the influence

at the time.
other

we have

local

seen

or systemic

no cases

complications

of infection

THE JOURNAL

OF BONE

have

occurred

or nonunion.
AND JOINT

SURGERY

of

USE OF THE

IPSILATERAL

VASCULARISED

L1.i

FIBULA

FOR TIBIAL

RECONSTRUCTION

_
Fig.

Fig.4c

Illustrative
cases
showing
bifocal
defect
after failed
atrophic
nonunion
of the
(d).

VOL.

77-B,

No. 6. NOVEMBER

995

4a

Fig.

4b

Fig.

4d

medial
transfer
for infected
nonunion
of the tibia (a), medial
transfer
for a
segmental
transport
(b), inversion
of a single
strut for radio-osteonecrosis
and
tibia (c) and inversion
of a double
strut after resection
of a tumour
at the knee

917

918

R. HERTEL.

Nine

patients

previous
level
less-demanding
one
and

did
one

returned

to full-time

work,

of work
activity
and four
job.
One patient
remained

not return
died from

to work because
a drug overdose.

five

M. PISAN.

to their

operation
and later by radiological
techniques.
If the transplant is viable early union of the osteotomies
occurs
within
eight to ten weeks
and there will be a periosteal
reaction

to a physically
unemployed,

of alcohol

R. P. JAKOB

addiction,

around
width

the transplant
of the graft.

Sacrifice

1877

Albert

substitute
fibula and
the proximal
substitute
weakened
focal

first

as a

ulae,

for the tibia.

He obtained
fusion
between
the
the femur in a patient
with congenital
absence
of
tibia. Since then, the fibula has been used as a
for a missing
segment
of tibia or to reinforce
a
section.
The technique
has evolved
from a uni-

sion
and

to a bifocal

mies,

first

in

proposed

transfer
two

the

with

stages

use

of the

proximal

but

fibula

and distal

later

in

one

and

perfusion

compression

of the

of the transplant.

soft

Such

tissues

only

jeopardised

problems

The
vascular

and the need for a large amount

bone graft were disadvantages.

development
of techniques
fibular
transplants
(Taylor,

OBrien
ipsilateral
circulation

et

bed nine
treatment

ipsilateral
of tibial

results,
(1994)

pedicle

all consolidated
follow-up
period

of

for harvesting
microMiller
and Ham 1975;

vascularised
defects
and

fibular
nonunions

to our findings.
five ipsilateral

for congenital

pseudarthrosis

and no refracture
of 1.5 to 5 years.

had

Coleman
with

of the tibia;

occurred

during

versatility.

The

transplant

can

be

used

as

In inversion
either distally

the peroneal
vascular
axis
or proximally,
depending

of living
increased

greater
resistance
to infection
ical properties.
Perfusion
of the transplants

bone. This gives a shorter

potential
for remodelling,

and better
is checked

long-term
at the

time

Residual

of

detectable

pseudarthrotic

osteosynthesis

with

fib-

a compres-

procedure
with decortication
the nonunion
of the fibula,

stiffness

to the fibular
the
transfer

The

ideal

eccentric

transfer.
and

location

position,

contact.
Errors
technique

of the ankle

is not directly

In all our cases it was

was
related
to the

of

the

transplant

in a double-strut

in axial
alignment
and intraoperative
with

main

other

present
earlier

is debatable.

grafting

advantages

An

configuration,

greatly

thus the strength

mechanical
and
of the osteotomies
bone
surfaces

can be avoided
by
radiographic
control.

reconstructive

bone

options,

such

or segmental

of vascularised

bone

fibular

short healing
time, the reduced
dures,
and the lower
incidence

in

careful
Corn-

as massive
transport,

segments

the
are

number
of secondary
of complications.

the

proce-

The use of the ipsilateral

as compared
with the contralateral
vascularised
fibula overcomes
the need for operation on the sound
limb, virtually
guarantees
perfusion
and
shortens
the operating
time.
No benefits
commercial
article.

in any form
party
related

have been
directly

received
or will
or indirectly
to

be received
the subject

from a
of this

and infected
operation.

pseudJ Bone

of the

J Bone

REFERENCES

Agiza ARH.
arthroses

Treatment
of tibial osteomyelitic
defects
by the Huntington
fibular
transference
Surg (Am)
l981;63-A:814-9.

by-pass operation
I96l;43-B:404.

H. The fibular
Joint Surg (Br)

for

non-union

tibia.

Campanacci
M, Zanoli
S. Double
tibiofibular
synostosis
(Jibula
pm tibia)
for non-union
and delayed
union of the tibia: end-result
review
of one
hundred
seventy-one
cases.
J Bone Joint Surg (Am)
1966;48-A:44-

56.
Chacha
PB,
ipsilateral

Ahmed
M, Daruwalla
JS. Vascular
pedicle
graft
of the
fibula
for non-union
of the tibia with a large defect:
an
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and clinical
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J Bone
Joint
Surg
(Br)
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63-B:244-53.

Coleman
SS, Coleman
DA.
Congenital
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of the ipsilateral
J Pediatr
Orthop
l994;l4:l56-60.
Davis AG. Fibular
26:229-37.

mechan-

any

have

transposed

using

increasing

management.

Bell

on whether
an antegrade
or retrograde
flow is desired.
Figure
4 shows
illustrative
cases using these techniques.
The major advantage
of a perfused
transplant
is to retain
the biological
potential
time to consolidation,

related
before

Joint

a simple

transposition
with medial
shift of the fibula or with inversion of a single
fibular
strut or of a folded,
double
strut
(Figs 2 and 3). In simple
transposition
the peroneal
vascular
axis remains
intact.
must be interrupted

not

with

followed
by transposition
at a later stage.
Interruption
of
the peroneal
vascular
axis in inversion
procedures
causes
no problem
when
the anterior
and posterior
tibial vessels

cancellous

transpositions
for
with encouraging

Coleman
and
fibular
transfers

directly,

plate,
or in a two-stage
compression
plating
of

pared

Besides
simple
medial
transposition,
a vascularised
segment of the fibula of up to 25 cm in length
can be rotated
1 80#{176}
around
the origin of its vascular
axis, giving
considerable

does

biological
environment
for consolidation
with
a stable
osteosynthesis
and the

al 1988)
indicated
the potential
use of the
fibula,
retaining
the periosteal
and endosteal
(Chacha
et al 1981). Shapiro
et al (1993)
descri-

similar
reported

vascular

fibula

increases
the polar moment
of inertia
and
of the structure.
It also gives the optimal

the

led to the devel-

opment
of indirect
methods
such as tibiofibular
synostosis
with
interposed
cancellous
bone
graft
(Girdlestone
and
Foley
1933; Ramadier
1961 ; Salaman
1963), but the long
time to consolidation
autologous
cancellous

either

are patent.

osteoto-

stage

(Campanacci
and Zanoli
1966).
Wilson
(1941)
described
bipolar
osteotomy
and medial
transfer
of the fibula for posttraumatic
tibial pseudarthrosis.
With his minimally
invasive
technique
sufficient
medial
translocation
could
not be
obtained

the

to six months,

functional
disadvantage.
We have also successfully

DISCUSSION
In

of

by four

substitution

Doherty
JH, Patterson
nonunion
of the
49-A: 1470-I.

for tibial

pseudarthrosis
fibula
with
defects.

J Bone

RL. Fibular by-pass

operation
tibia
in adults.
J Bone
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THE JOURNAL

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AND

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1944;

in the treatment
of
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(Am)
1967;

JOINT

SURGERY

USE OF THE

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WB.
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1961 ;43-A:462.

McMaster
PE. Cross
tibial-bone
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OBrien

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bone-grafting
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tibial

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diaphysis:
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between
the fibula and
Surg [Am)
1954;36-A:172.

Tibiofibular
ununited

cross-peg
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tibial fractures.
J Bone

BM, Gumley
GJ, Dooley
BJ, Pribaz
JJ. Folded
fibula transfer.
P/ast Reconstr
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Parisien
V. Fibular
1963;24:
142-6.

VOL.

Extensive
loss
l933;20:467-71.

transplants

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M.
procedure
for complicated
[Am)
l965;47-A:l
146-8.

IPSILATERAL

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Bu//

Hosp

tibio-

Joint
the

tibia

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for

a salvage
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free vascu-

FIBULA

Ramadier
JD.
tibio-fibular
Salaman
fibular

Dis

RECONSTRUCTION

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919

of pseudarthrosis
Joint Surg (Am)

of the leg by
196l;43-A:289-90.

R. The treatment
of infected
pseudarthrosis
of the tibia
synostosis.
J Bone Joint Surg [Br) l963;45-B:805.

Shapiro
MS, Endrizzi
DP, Cannon
RM,
defects
and nonunions
using ipsilateral
tion. C/in Orthop
1993;296:207-l2.
Taylor
GI, Miller
clinical
extension
1975;55:533-44.

Wilson
Joint

FOR TIBIAL

GD,
of

Ham
FJ.
microvascular

The

Dick HM.
vascularized

Treatment
fibular

free vascularised
techniques.
Plast

PD. A simple
method
of two-stage
transplantation
use in cases of complicated
and congenital
pseudarthrosis
J Bone Joint Surg 194l;23:639-75.

the

inter-

by tibioof tibial
transposi-

bone
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a
Reconstr
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of the tibia.