Fibular Transposition

7/25/2019 Fibular Transposition

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T HE JO UR N AL O F BO N E A ND JO INT SUR G ER Y

U SE O F T H E IPS IL A T E R A L V A SC U L A R ISE D FIB U L A F O R

T IB IA L R E C O N ST R U C T IO N

R . H ER TE L , M . P ISA N , R . P . JAK O B

F rom the U nive rsity o f B ern e, Sw itze rlan d

Betw een 1989 and 1994 w e u sed a va scu lar ised

ip sila tera l fibu lar gra ft in 24 patien ts w ith segm en ta l

t ib ia l d e fec ts. W e report 12 pa tien ts w ith a m in im um

follow -up o f tw o years. T he graft w as e ith er tran sposed

m ed ia lly or inver ted on its vascu la r p ed ic le . Fu ll

we ight-bear ing

w as

a chiev ed at b etw een four and seven

m onth s. W e had few com p lication s and con sid er that

th e u se o f th is m ethod is a va luab le op tion in

recon s tru ction o f th e tib ia .

J B on e Jo in t Su rg B r

1995;77-B:914-9 .

Rece ived 4

M ay 19 94; A ccep ted a fter re v ision 23 M a rch 1 995

S egm en ta l de fec ts o f the tib ia p re sen t a cha lleng in g p rob -

lem , pa rticu lar ly in the p resen ce o f in fec tion an d in stab ility .

T he v a riou s techn iques w h ich have been used in clu de

com press ion , d eco rtic a tio n , b one g ra f tin g , segm en ta l tran s-

p orta tion and tib io f ib u lar syno stos is . T h e in d ications fo r a

p articu la r te chn iq ue a re p oorly d efined . T ib io f ibu la r sy nos-

to s is is reg ard ed as a sa lv ag e p rocedu re (D avis 1 94 4;

M cM aste r 1 9 54 ; B e ll 196 1

;

M cC ab e 1 96 1

;

P aris ien 1 963 ;

M cM aste r and H oh l 1 96 5 ; D oh erty and P atte rson 1 967 ;

A g iza 19 81) . D iff icu lty m ay b e encou n te red in p lacin g th e

fib u la in clo se approx im a tion to th e tib ia , and la rge

am ou n ts o f cance llous bo ne gra ft m ay b e n eeded to o b ta in

fusio n , w ith u npred ic tab le re su lts .

In 1 981 , C hacha , A hm ed an d D aruw a lla sug gested th e

d issectio n and tran spos ition o f the fib u la , p reserv in g its

va scu la r su pp ly , and w e began to use th is p rocedure in

1 9 8 8 .

P A T IE N T S A N D M E T H O D S

W e p er form ed ip s ila tera l vascu lar ised fibu lar tran sp la n ta -

R . H erte l, M D , H ead o f U pp er E xtrem ity Un it

M . P isan , M D , R esid ent

R . P . Jakob , M D , P rofessor of O rthopaed ic

Surgery

R eco ns truc tiv e and U pp er E xtrem ity U n it, D ep artm e nt of O rth op aed ic

S urg ery , U n ive rsi ty o f B ern e, In selsp ital, C H -301 0 B ern e, Sw itz erland .

C orrespon de nce sho uld be sen t to D r R . H erte l.

1 019 95 B ritish E d ito ria l S oc iety of B o ne a nd Jo in t Su rge ry

030 1-6 20 X 19 5/6 10 65 $2.00

tion in 13 pa tien ts . O ne d ied early d ue to m e ta sta tic d isea se ,

leav ing 1 2 cases in the se r ies . T he re w ere n in e m en an d

th ree w o m en w ith a m ean age of 3 4 years (1 9 to 58 ). T he

m ean fo llow -up w as 32 m o nths (24 to 58 ). In n in e pa tien ts

the reason fo r the de fec t w as in ju ry : in e ig h t in fec ted

non un io ns w ere p re sen t. T h e o the r th ree p atien ts had h ad a

tum o ur. D ebridem en t an d v a riou s p rev io us a ttem p ts a t

recon struc tio n had resu lted in segm en ta l tib ia l d e fec ts o f

va ry ing leng th , w ith a m ean of 1 2 cm (1 to 19 ). In tw o

pa tien ts b ifocal d efec ts w ere du e to fa iled segm enta l tran s-

port. T he reco nstruc ted segm en t w as ve ry w eak in tw o

pa tien ts a fte r m ic rovascu la r rib transp lan tatio n . In a fu r the r

tw o pa tien ts tran sfer o f the ipsila te ra l fib u la had been

pe rfo rm ed as a p lan ned proced ure e igh t and n ine w eeks

af te r m ic ro vascu la r tran sp lan ta tion o f th e con tra late ral f ibu -

la , p rov id ing a d oub le stru t.

S o ft-tissu e recon stru ctio n had been neces sary in 11

pa tien ts; in fiv e flap cove rag e had b een ob ta ined a t th e tim e

of f ibu la r tran sfe r and in six it had b een u nde rtak en be fo re .

S ev en pa tien ts had b een trea ted w ith a free m icrov ascu la r

flap , tw o w ith a m ed ia l and tw o w ith a m ed ia l and la tera l

ga strocnem ius f lap .

T he m ean n um b er o f p rev ious op era tions w as

5. 5

fo r the

pos t-trau m a tic p atien ts . T h e m ean tim e in te rva l be tw een the

acc iden t an d th e f ibu la r transfe r w as 1 4 m on ths (7 to 36 ).

A ll p atien ts w ith a tum o ur had im m ed ia te recon stru c tio n

a fte r r es ec tio n.

O pera tiv e techn ique . T he

la tera l asp ec t o f the leg w as

alm o st inv a riab ly w ell p re serv ed , ev en a fter m ultip le op era -

tions and chro n ic in fectio n , and a s tra igh t la te ra l app ro ach

w as a lw ays po ss ib le . Th e pero nea l fascia w as in c ised . T he

pe ronea l n e rve and its b ranches w ere id en tified and p ro -

tec ted . T h e p e ron eal m u sc les w ere re trac ted an ter io r ly and

sha rp ly d issec ted o ff the f ibu la , leav ing a cu ff o f m usc le 1

to 2 m m th ick on the pe rio s teu m and b one . T h e an te ro -

late ral in te rm uscu la r sep tum w as inc ised .

P rox im a l and d ista l o steo tom ies w ere p erfo rm ed w ith an

osc illa tin g saw , allow ing ex tern al ro ta tio n of th e fib u lar

segm en t. T h e m ed ia l asp ec t o f th e f ibu la w as deco rtic a ted .

D issec tio n pro ceeded alo ng the in tero sseou s m em b rane

iso la ting the n eu ro vascu la r b und le w h ich w as le ft an te r io r

to the p lan e o f d issec tion . T he poste r io r a spec t o f th e f ib u la

w as lef t in tac t w hen sim ple m ed ial tran spos itio n w as

req u ired . D issec tion o f th e vascu la r ped ic le w as necessa ry

w h en m ajo r p rox im a l transla tion o r an in ve rs ion of the

g ra ft w as p lann ed (F ig . 1 ). D ecortica tion o f th e la tera l


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ig la ig lb ig lc

F ig . 2 a

U SE O F T H E IP SIL A T E R A L V A SC U L A R IS E D F IB U L A FO R T IB IA L R E C O N ST R U C T IO N

91 5

VO L . 77 -B , No . 6 , N O V EM BER

1995

D issection tech niq ue . F or tran spo sit ion o f th e fib ula p os terior d isse ctio n is n ot n ece ssa ry (a ,b). Fo r inv ers ion of th e f ibu la circum fe ren tial d is sec tion

of th e p eronea l ve sse ls is

re quired (c) .

aspec t o f th e tib ia , c rea ting an an te rio r ly -based o steope r-

io stea l f lap , p rov id ed an op tim a l con tac t su rface .

T he fib u la w as transp osed w ithou t tens ion o n th e so ft

tissu es and fix ed w ith lag sc rew s to the tib ia . I f necessa ry ,

add itio na l p la te s w ere used fo r th e stab ilis atio n o f no nun ion

of th e fib u la o r an osteo to m y . A dd itiona l f ixa tion o f th e

tib ia w as som e tim es neces sa ry and a un ip lana r ex te rna l

fixa to r w as u sua lly ad equa te . T h e rem a in ing g ap be tw een

the tib ia and th e fibu la w as filled w ith cancello us b one

harves ted from th e iliac c rest. If an inv erted or a doub le-

stru t co n figu ra tio n w as p lanned , the fu lly d is sected tran s-

p lan t w as ro ta ted a t its ba se an d the fib u la r segm en t w as

p laced in the d efect and stab ilised by sh ort com p ressio n

p la te s an d a lo ng brid g in g p la te (F ig . 2 ).

M ob ilisa tion w as s tar ted a fte r 4 8 h ours, w ith 10 k g of

g rou nd co n tact a llow ed im m ed ia tely . R ad io g raph s w ere

Fig . 2b F ig . 2 c

Figure

2a

S im ple m ed ial tran sfe r; the peron eal va scu lar axis r em ain s pa ten t. F igure 2b

L igation of th e distal p ero ne al artery a nd ve ins a llow s m o re

dis tant tis sue tran sfe r. Th e m ost p rox im al p oin t o f rota tion is th e tib iop eroneal b ifurcat ion . F igure 2c F old ing th e f ibu la in tw o allow s the c ons tru ctio n

of a double strut .


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F ig . 3 a F ig . 3 b

91 6 R . H ER TE L , M . P ISAN . R . P . J AK O B

T H E JO U R N A L O F B O N E A N D JO IN T SU R G E R Y

D o uble stru t w ith a p rox im al p edicle (a) an d s ingle

stru t w ith a dista l pe dic le (b ).

ob tain ed a t in te rva ls o f six w eek s. W e igh t-bea rin g w as

inc rea sed acco rd ing to the degree o f hea ling .

R E S U L T S

Tw o pa tien ts w ith re sectio ns o f tu rno urs had a p lann ed

second cancello us b one gra ft 1 2 an d 1 3 w eeks a fte r the

fib u la r transfer . A ll o the r pa tien ts h ad un ion w ith a sin g le

operat ion .

F u ll, u np ro tec ted w e igh t-bea rin g fo r n o rm a l w a lk in g w as

ach iev ed a t a m ean of

5. 5

m o nths (4 to 7 ) af te r f ibu la r

transfer . T h e m ean w alk ing d istan ce as su b jec tive ly stated

b y the p a tien ts w as 12 k m (1 km to un lim ited ) w ith im pa ir-

m en t b ecause o f re sidua l con trac tu res o f th e ank le and knee

o r a rth rod es is o f th e k nee. C h ro n ic o ed em a and pa in w ere

th e cause o f lim ita tion in tw o p atien ts . T w o com pla ined o f

pa in fu l p re ssu re in the leg a fte r lo ng pe rio ds o f stan d ing o r

w alk ing w hich w as prom ptly re lieved b y e leva tion of the

l i m b .

T h e so ft tissu e s w ere stab le in all p atien ts and rem a ined

so d uring the en tire fo llow -up pe riod . S w e lling and oede rn a

o f the latiss im us d ors i flap and the fo o t w ere lim itin g

fac to rs in tw o pa tien ts . C o m pared w ith th e un in ju red s ide ,

the m ean d iffe ren ce in th igh circum fe rence w as 3 cm (-1 to

7) .

T h e rang e o f k nee m o vem en t w as norm a l in e igh t

pa tien ts . In th ree pa tien ts w ith a tum o ur a kn ee fus ion w as

necessa ry . In one pa tien t the range of m ov em en t w as

im pa ired d ue to an in tra-a rticu la r frac tu re . Im pa irm en t o f

an k le m ov em en t w as com m on . T he m ean rang e w as 35 { 176 }

15 to 60 . B efore

fibu lar tran sfe r six pa tien ts in the trau -

m atic gro up had an eq uin us con trac tu re. A t th e fina l rev iew

on ly on e d id no t reach the p lan tig rade po sition . H e m ain -

tam ed a fixed equ inus o f 10 {17 6} .

In seven p a tien ts the ax ia l a lign m en t w as n orm a l. In

th ree th e re w as an asym ptom atic v alg us de fo rm ity o f

be tw een 6 {1 76}nd 1 1

{ 176}

O n e had a v arus ang u la tion o f 6 { 17 6}nd

an o the r a 9 {17 6}lex ion de fo rm ity . O n e pa tien t had an ex te rna l

ro ta tiona l de fo rm ity o f 10 {1 76}u t in the rem a ind er th e ro ta tion

w as norm a l. S horten ing o f b etw een 1 an d 2 cm w as

ob serv ed in e ig h t pa tien ts .

T hicken in g , inc rea sin g rad io density and su rface irregu -

lar ity o f th e f ibu la w ere seen as so on as fo u r m on th s a fte r

tran spos ition . T h is pe r io stea l reac tion w as in te rp re ted as

ind ica ting sa tisfac to ry pe rfusio n and v iab ility . T h e ex ten t o f

th is reactio n w as va riab le an d w as prob ab ly re la ted to the

m echan ica l load ing of the f ibu lar s eg m en t. O n stan da rd

rad iog raphs w e o bse rved a m ean in crease in d iam ete r o f

3 m m (I to 4 ) .

T h e can ce llou s bon e g ra f t w as inco rpo ra ted as a rad io -

dense b one m ass in a ll in stances . P a rtia l g raf t reso rp tion

w as seen in o ne p atien t, w h o lo st abou t 50% of the

tran sp lan ted can cello us b one . H e had a so und fusion w ith

strong bridg in g callu s at th e p rox im a l an d d ista l ends o f the

f ib u la w h ich w as m ech an ically su ffic ien t, and no reg ra fting

w as n ec essa ry .

R efrac tu re occu rred in o ne pa tien t 1 3 m on th s a fte r trans-

fer . T h e d eg ree o f traum a w as pro bab ly adequa te to accoun t

fo r the frac tu re and the p a tien t w as und e r the in fluence of

d rug s a t th e tim e .

N o other loca l o r sys tem ic com plications have o ccurred

and w e have seen no case s o f in fec tion o r no nun ion .


4/6

7

1 i

_

F ig . 4b

F ig .4 c F ig . 4 d

U S E O F T H E IPS IL A T E R A L V A SC U L A R ISE D FIB U L A F O R T IB IA L R E C O N ST R U C T IO N 917

V O L . 77 -B , N o. 6 . N O V E M B E R 995

F ig . 4 a

Illustrative case s sh ow ing m edial tran sfe r for infe cte d n onu nio n of the tib ia (a ), m ed ial tran sfer for a

bifoca l d efec t a fte r fai led seg m e nta l transpor t (b ), inve rsio n o f a single stru t fo r ra dio -os teo nec ros is an d

atroph ic n onu nion of the tib ia (c) and inv ers ion of a dou ble stru t af ter rese ctio n o f a tu m o ur a t th e kn ee

(d) .


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91 8 R . H E R T E L . M . PIS A N . R . P . JA K O B

T H E JO U R N A L O F B O N E A N D JO IN T S U R G E R Y

N ine pa tien ts retu rn ed to fu ll- tim e w ork , f ive to the ir

p rev ious leve l o f w ork activ ity an d fou r to a p hysica lly

less -d em an d ing job . O n e p atien t rem a ined unem p loyed ,

on e d id n o t retu rn to w ork b ecause o f a lcoho l add ic tion ,

an d o ne d ied from a d ru g o ve rd ose .

D I S C U S S I O N

In 1 87 7 A lbe rt firs t p rop osed the u se o f th e f ibu la as a

subs titu te fo r the tib ia . H e o b ta ined fusio n b e tw een the

fibu la and the fem ur in a pa tien t w ith co ngen ital absence o f

the p ro x im a l tib ia . S in ce then , th e fib u la h as been used as a

sub stitu te fo r a m issin g segm en t o f tib ia o r to re in fo rce a

w eaken ed sec tio n . T he techn ique has evo lved from a u n i-

fo cal to a b ifoca l transfe r w ith p ro x im a l and d ista l o steo to -

m ie s, firs t in tw o stages b u t late r in on e stage on ly

( C am p an acc i an d Z ano li 19 66) . W ilso n (194 1) desc r ib ed

b ip o la r o steo tom y an d m ed ial tran sfe r o f the fib u la fo r p ost-

trau m a tic tib ial p seu da rth ros is . W ith h is m in im ally invasiv e

tech n iqu e su ffic ien t m ed ia l translo ca tion cou ld no t b e

ob ta ined and com p ress io n o f the so ft tissues jeopard ised the

pe rfus ion of th e tran sp lan t. S uch p rob lem s led to the dev el-

op m en t o f in d irec t m eth ods such as tib io f ibu la r sy nos tosis

w ith in te rposed cance llous b one g ra f t (G ird le sto ne and

F o ley 1 933 ; R am ad ie r 1 961

;

S alam an 1 963 ), b u t th e lon g

tim e to co nso lid atio n and th e n eed fo r a la rge am oun t o f

au to lo gou s cance llou s bo ne gra ft w e re d isadv an tag es.

T he d eve lopm en t o f techn iques fo r ha rv es tin g m ic ro -

vascu la r f ibu la r tran sp lan ts (T ay lo r, M iller and H am 19 75 ;

O B rien e t a l 19 88) in d icated the po ten tia l u se o f the

ipsila te ra l f ibu la , reta in in g th e pe rio stea l and end ostea l

c ircu la tio n (C hacha et a l 19 81) . S hap iro e t al (199 3) desc r i-

b ed n ine ips ilate ral v ascu lar ised fibu la r transp ositio ns fo r

trea tm en t o f tib ia l d efects and no nun ions w ith en co urag ing

resu lts , s im ila r to our f ind in gs. C o lem an and C olem an

(1 99 4) reported five ip silate ral fib u la r transfers w ith a

vascu la r p ed ic le fo r co ng en ita l p seu da rth ro sis of th e tib ia;

a ll con so lid ated and no re fractu re had occurred du rin g a

fo llow -up pe rio d of

1. 5

to

5

years .

B esid es sim p le m ed ia l transpo sition , a v ascu la rised seg -

m en t o f th e f ibu la o f up to 25 cm in leng th can b e ro ta ted

1 8 0 { 1 7 6}ro und the o rig in o f its va scu la r ax is , g iv ing co nsid er-

ab le ve rsa tility . T he transp lan t can be used as a sim p le

tran spo sition w ith m ed ial sh if t o f the f ibu la o r w ith inve r-

sion of a sing le fibu la r stru t o r o f a fo lded , dou b le stru t

(F ig s 2 an d 3 ). In s im p le transp osition the pe ro neal v ascu lar

ax is rem a ins in tac t. In inv ersion th e pe ro nea l va scu la r ax is

m u st be in te rrup ted eith er d is ta lly o r p ro x im a lly , d ep en d ing

o n w he the r an an teg rade o r re trog rade flow is d es ired .

F igu re 4 show s illu s tra tive ca se s usin g these tech n iqu es.

T he m a jo r ad van tage o f a p erfu sed transp lan t is to reta in

th e b io log ical po ten tial o f liv ing b one . T h is g ive s a sho rte r

tim e to co nso lid atio n , in c rea sed p o ten tia l fo r rem od ellin g ,

g rea ter re sis tan ce to in fec tion and be tte r lo ng-te rm m echan-

ic al p ro pe rtie s.

P e rfus ion o f the transp lan ts is ch ecked a t the tim e of

o pe ra tion and la ter by rad io log ica l te ch n iqu es . If the tran s-

p lan t is v iab le ea rly un ion of the osteo to m ies occu rs w ith in

e igh t to ten w eek s and th ere w ill be a p erio stea l reac tion

a roun d th e transp lan t by fo u r to s ix m on ths, w ith inc rea sing

w id th o f the g ra ft.

S ac rif ic e o f th e fib u la d oes n o t have an y de tec tab le

fun ctio na l d isa dva nta ge.

W e h av e a lso success fu lly transposed pseud arth ro tic fib -

u lae , eith er d irectly , u sing os teo syn th esis w ith a com pres-

s ion p la te , o r in a tw o -stage p roced ure w ith deco rtica tion

and co m p ression p la ting o f the n onu n ion of th e f ibu la ,

fo llo w ed b y transp ositio n a t a late r stage . In te rrup tio n of

th e pe ro nea l va scu la r ax is in in ve rsio n pro ced ure s causes

n o prob lem w hen th e an te rio r and p oste rio r tib ial ve sse ls

a re pa ten t. R esidu a l s tiffn ess of the ank le is n o t d irec tly

re lated to the f ibu la r transfer . In all ou r ca se s it w as p re sen t

b efo re the transfe r and w as rela ted to the ea rlie r

m anagem ent .

T he ideal loca tion of the transp lan t is d eb atab le . A n

eccen tric pos ition , in a dou b le-stru t configu ra tion , g rea tly

in creases th e po la r m o m en t o f in er tia and th us the stren g th

o f the struc tu re. It a lso g ives the o p tim a l m echan ica l and

b io log ica l env iron m en t fo r con so lid atio n o f the o steo tom ies

w ith a stab le os teo syn th esis an d the b one su rface s in

con tact .

E rro rs in ax ia l a lignm en t can b e avo ided b y ca re fu l

te chn ique and in trao pe ra tive rad io g rap h ic con tro l. C orn -

pa red w ith o the r reconstruc tive op tio ns, such as m assive

cance llous b one gra fting o r segm en ta l b one transp ort, the

m ain adv an tages o f vascu la rised fibu la r segm en ts a re the

short hea ling tim e , th e red uced nu m ber o f seco nda ry p ro ce -

du res,

an d

the low er inc idence o f com p lica tion s.

T he u se o f the ip sila tera l as com pared w ith th e con -

tra la tera l v a scu la rised fibu la o ve rcom es the need fo r o pe ra -

tion o n the sou nd lim b , v irtu ally gu aran tees p erfu sion an d

shortens the ope ratin g tim e .

N o be nef its in a ny fo rm ha ve bee n re ceived o r w ill be rece ive d from a

com m erc ial p arty re lated d irec tly o r ind irec tly to the su bje ct of th is

ar t icle .

R E F E R E N C E S

A giza A R H . T re atm en t of tib ial o ste om yelitic de fects and in fec ted p seu d-

ar th roses by th e H u ntin gto n fib ula r trans ferenc e op era tion . J Bone

Jo in t S urg Am

l981;63-A:814-9 .

Bell H . Th e fib u la r by-pass op erat ion fo r n on-union of the tib ia . J Bone

Jo in t S urg B r

I96l;43-B:404.

C am p ana cci M , Z ano li S . D o uble t ib io fib ula r syno sto sis

J ibu la pm tib ia

for no n-u nio n a nd d elay ed un ion o f the tib ia: en d-resu lt re vie w of o ne

h und red sev enty-o ne cases.

J Bone Jo in t S urg Am 1966;48-A:44-

56 .

Chach a PB , Ahm ed M , D aruw alla JS .

V a scu lar p ed icle gra ft o f the

ips ila tera l f ibu la fo r non -un ion of the tib ia w ith a larg e de fec t: a n

exper im en ta l

an d c lin ical study .

J B on e Jo in t S urg B r

1 9 8 1 ;

63-B:244-53.

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Fibular Transposition

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