This flap is indicated for reconstruction of upper extremity skeletal defects larger than 6 cm that result from oncologic resection, trauma, osteomyelitis, non-union, or congenital malformations. It can also be used for smaller bony defects with skin loss.

This flap is indicated in bone gaps of any size where prior attempts at bone grafting have failed.

This flap is indicated for arthrodesis of the wrist and shoulder following tumor extirpation.

An osteocutaneous fibula flap is indicated in cases where skeletal defects occur in conjunction with moderate soft-tissue loss ( Fig. 32.1a–d ).

The free fibular flap is relatively contraindicated in patients with severe atherosclerotic disease of the lower extremity.

An estimated ~ 5–7% of patients have a single-vessel blood flow to the foot and lower leg, with the dominant vessel being the peroneal artery (peronea arteria magna). The patient with a dominant peroneal artery may still have a normal palpable distal pulse. In these patients, the contralateral leg should be used. Alternatively, a vein graft is required to reconstruct the peroneal artery after harvest of the fibula.

The history should focus on symptoms of arterial and venous insufficiency as well as any history of prior trauma or vascular surgery to the donor leg.

A careful neurovascular examination of the foot and lower leg is essential. The examiner should note the presence or absence of pedal and popliteal pulses, sensation in the foot, and signs of chronic arterial and/or venous insufficiency.

Angiography is required for patients with a history of peripheral vascular disease, for patients with severe trauma, or for patients with abnormal pedal pulses. In young patients with normal arterial pulses, the role of angiography is less clear. The presence of a peronea arteria magna is perhaps the most compelling indication for routine preoperative angiography, as harvest of the fibula in patients with this variant will result in an ischemic distal leg and foot. This requires immediate revascularization with a saphenous vein graft.

The peroneal artery is the dominant blood supply to the fibular flap. This vessel arises from the posterior tibial artery. Along with the anterior tibial artery, these vessels are the main arteries supplying the leg.

The peroneal artery arises from the tibial peroneal trunk proximally 3–4 cm distal to the takeoff of the anterior tibial artery.

The pedicle courses between the flexor hallucis longus and tibialis posterior muscles within the deep posterior compartment of the leg ( Fig. 32.2a ).

The blood supply to the vascularized fibular graft is both endosteal and periosteal. The endosteal blood supply is derived from the nutrient artery, which arises 6–14 cm from the peroneal artery bifurcation. It enters the middle third of the fibula and divides into ascending and descending branches ( Fig. 32.2b ). The blood supply to the distal fibula is mainly periosteal.

The peroneal artery also contributes to the blood supply of the skin covering the lateral leg. Several septocutaneous perforators arise from the peroneal artery and course along the posterior intermuscular septum of the lateral compartment via the lateral intramuscular septum to supply the overlying skin. When an osteocutaneous flap is needed, these perforators must be identified and protected at the start of the procedure ( Fig. 32.2c ). The location of the perforators can be determined with Doppler ultrasound. A skin paddle of up to 24 × 12 cm can be transferred. In addition, portions of the soleus or flexor hallucis longus muscle can be included to reconstruct soft-tissue defects or to cover exposed bone.

The peroneal pedicle has a length of 6 to 8 cm and an arterial diameter of 1.5 to 3.0 mm accompanied by two venae comitantes of 2.5 to 4 mm in size.

Nearly the entire length of the fibula may be harvested for vascularized bone grafting, however, at least 7 cm must be preserved at the distal end of the fibula to maintain stability of the ankle joint. An equivalent length of bone must be maintained proximally to maintain stability of the knee joint. A long, straight segment of up to 30 cm can be harvested.

The common peroneal nerve crosses over the head of the fibula before dividing into the superficial and deep peroneal nerves. The superficial peroneal nerve courses along the lateral cortex of the fibula before passing between the peroneus longus and brevis. Care must be taken to protect this nerve when elevating the flap proximally and when performing the proximal osteotomy.

Flap harvest is performed using loupe magnification.

A tourniquet is placed around the thigh. The leg is partially exsanguinated and the tourniquet is inflated to 350 mm Hg. Partial exsanguination of the leg makes identification of cutaneous perforators easier.

The patient is positioned with a “bump” under the hip and with the knee flexed at 90 degrees. This position maximizes exposure.

Markings: The head of the fibula, lateral malleolus, and anterior and posterior borders of the fibula are marked. The proximal and distal ends of the fibula are marked at a distance no less than 7 cm from the knee and ankle joints, respectively ( Fig. 32.3 ).

The author′s preferred technique is based upon the original description by Chen and Yan.2 The posterior border of the fibula corresponds to the location of the posterior intermuscular septum and can be located by palpating the peroneal tendons that lie anterior to it. When required, a skin paddle is designed in the shape of an ellipse, centered with its long axis in line with the posterior fibula. This centers the skin paddle over the posterior intermuscular septum and the septocutaneous perforators that traverse it. The long axis of the ellipse parallels the long axis of the fibula. The skin paddle should also be centered at the junction of the middle and distal thirds of the leg, as the cutaneous perforators are most commonly found near this point ( Fig. 32.3 ).

The anterior portion of the skin island is incised. The thick fascia overlying the anterior and lateral compartments of the leg is incised as well, in line with the skin incision ( Fig. 32.4 ).

The skin island is elevated in the subfascial plane from the muscles of the anterior and lateral compartments. At this stage, the cutaneous perforators traversing the posterior intermuscular septum must be identified and protected, and the septum itself must be left intact. The paratenon over the peroneus longus and brevis tendons must be preserved as well ( Fig. 32.5 ).

Following identification of the perforator(s), the peroneus longus and brevis are elevated anteriorly from the fibula. Elevation should proceed carefully to avoid damaging the periosteum of the fibula as well as the superficial peroneal nerve proximally ( Fig. 32.6 ).