fibular transposition
TRANSCRIPT
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91 4
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 .
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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
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