Overview

The procedure is performed with the patient under general anesthesia and with the adjunct of an epidural block, which remains in place for 24 to 48 hours postoperatively. The patient is placed in the lateral decubitus position and supported by a pegboard. The entire lower extremity to the level of the iliac crest proximally is prepared and draped. The leg is covered with an impervious stocking up to the mid thigh, over which a sterile tourniquet is placed just proximal to the knee; this is to be used during the fibular graft harvest (Figure 31-1). A Betadine-impregnated occlusive drape is used for both the hip and the leg. The operative procedure on the hip and the harvest of the fibular graft occur contemporaneously and, as such, require cooperation between the surgeons.

Figure 31–1 The patient is positioned in the lateral decubitus position, and the entire lower extremity is prepared above the anterosuperior iliac spine. An impervious stocking is placed on the leg, and a tourniquet is placed over that for use during the fibular harvest. Care is taken to ensure that the tourniquet is above the superior pole of the patella to prevent peroneal nerve compression.

Fibular Graft Harvest

With the use of tourniquet control, a straight, lateral, 15-cm longitudinal incision is made coincident with the natural sulcus between the lateral and posterior compartments of the leg. The incision is begun at least 10 cm distal to the fibular head, and it ends at least 10 cm proximal to the lateral malleolus. The peroneal muscles are reflected in an extraperiosteal fashion off of the lateral aspect of the fibula, working from posterior to anterior and stopping when the anterior intermuscular septum is visualized (Figure 31-2).

Figure 31–2 A view of the lateral fibula, with the lateral compartment (*) reflected anteriorly. The arrow points to the anterior compartment fascia. This is divided, and then the anterior compartment is reflected to expose the underlying interosseous membrane.

The anterior intermuscular septum is then divided to expose the anterior musculature, which is reflected bluntly off of the fibula. At this point, the interosseous membrane is easily visualized, and the adjacent anterior musculature, with its accompanying deep peroneal nerve and anterior tibial artery, is gently swept off of the interosseous membrane and away from the fibula. With the use of a specially designed right-angle beaver blade, the interosseous membrane is divided close to its fibular attachment along the entire length of the proposed fibular graft. The posterior intermuscular septum is then divided to expose the posterior muscles: the soleus proximally and the flexor hallucis longus distally.

Fibular Osteotomy

Directly beneath the distal aspect of the flexor hallucis longus muscle, the distal pedicle of the peroneal vessels is identified, and malleable retractors are passed between this pedicle and the fibula. Diligent care is critical during the placement of the retractors to ensure the protection of the pedicle during the osteotomy. After reconfirming that the planned osteotomy is at least 10 cm proximal to the distal tip of the fibula, an oscillating saw is used to cut the fibula. Irrigation during the osteotomy is vital to prevent thermal osteonecrosis. Next, the proximal pedicle is identified deep to the soleus muscle along the posterior aspect of the fibula (Figure 31-3). It is protected, and the proximal fibular osteotomy is performed in a manner similar to that of the distal osteotomy. The fibular cuts are made 15 cm apart to ensure an adequate pedicle length. It is important when performing the proximal osteotomy to identify and protect the superficial peroneal nerve, which is exposed proximally on the deep surface of the peroneus longus muscle.

Figure 31–3 A view of the proximal fibula just before the osteotomy, with visualization of the proximal peroneal artery and two veins (arrow).

After the proximal and distal fibular osteotomies are performed, a bone clamp is placed around the fibula to allow for better control and easier rotation during the delicate pedicle dissection. Starting distally, the peroneal vessels are again identified, isolated, and divided with the use of hemostatic clips. The now-free distal pedicle is attached to the distal aspect of the fibula with a hemoclip to ensure that the peroneal vessels and any nutrient branches to the bone are not avulsed from the fibula during the remainder of the harvest. The fibula and the adjoining peroneal vessels are then dissected from the surrounding flexor hallucis longus, posterior tibialis, and soleus muscles. The fibula is elevated until it is tethered only by the proximal vascular pedicle. The tibial nerve can often be seen coursing in close proximity to the peroneal vessels at this level and should be carefully dissected away. After adequate pedicle length is established, the vessels are ligated with two large hemostatic clips and divided with scissors, and the graft is passed to a back table. The tourniquet is then deflated, the wound is copiously irrigated, and any bleeding is addressed. The leg wound is closed a short time later during the vascular anastomosis at the hip. The deep fascial layers of the leg are not closed in an effort to prevent compartment syndrome. The subcutaneous layer and the skin are closed over a drain, and the leg is wrapped in a soft, bulky dressing.