Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 16:
Fibular Free Flaps
  Problems with the fibular flap include possible injury to the common peroneal nerve, disruption of the ankle mortise with an excessively distal osteotomy, and ankle motion problems, owing to the detachment of the flexor hallucis and posterior tibialis muscles particularly in children. Several series31-39 report a low incidence of complications, and an awareness of these pitfalls will minimize their occurrence.


The many attributes of the fibular flap and its composite tissue variations make it useful for reconstruction of several difficult problems of extremity defects. These include fractures with segmental bone loss with or without soft tissue deficit,31-39 osteomyelitis 52,53 requiring wide sequestrectomy and reconstruction in a scarred and potentially infected bed, reconstruction after tumor resection,52,54-60 treatment of congenital pseudarthrosis, 32,33,61-65 and transfer of growth plates66-69 in pediatric cases. More recently, the fibula has been proffered for mandible reconstruction.70

Technical Considerations

The fibular head lies 3 cm below the lateral femoral condyle. The lateral malleolus and distal fourth of the fibula are subcutaneous and palpable. The common peroneal nerve traverses the fibula neck and divides into the superficial and deep peroneal nerves that lie deep to the peroneal muscle and the extensor digitorum longus. Deep to the soleus muscle, the posterior tibial artery bifurcates and forms the peroneal artery that continues distally along the posteromedial border of the fibula toward the foot. Along its route, multiple nutrient vessels and musculocutaneous branches are transmitted from the peroneal vessels. At the juncture between the upper and middle third of the fibula (15 cm to 27 cm from the fibular head), several cutaneous vessels are present in the intermuscular septum between the peroneus longus and soleus muscles. These vessels must be preserved if a skin paddle is to be harvested with the fibula. The axis of the skin flap is placed along the posterior border of the fibula. These cutaneous vessels may supply a skin area from 22 to 25 cm in length and 10 to 14 cm in width; however, the reliability of such a large paddle has been questioned. The peronei, flexor hallucis longus, and posterior tibialis muscles are attached to the fibula proximally and are contiguous with it along much of its length.


Plates XVI-1 and XVI-2 show the relationship of the fibula, common peroneal nerve, peroneal vessels, cutaneous branches, and surrounding musculature. Note also the position of the soleus and gastrocnemius muscles and their relationship to the posterior tibial neurovascular bundle.

Operative Technique

To reduce the operative time, two teams work simultaneously, one at the donor site and the other at the recipient site. The flap pedicle is maintained until the recipient site is ready, by which time it has been divided and the flap transferred. This minimizes ischemia time.

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