Articulations of fibula
Lateral condyle of tibia
- No knee joint component
Ankle
- Distal end of fibula forms malleolus that articulates medially with talus.
What happens to posterior intermuscular septum when soleus muscle harvested
Septum is harvested in continuity with paddle of skin and fascial of lateral leg
Which free flap is highly tolerant of radiation therapy
Radial forearm flap
What length of proximal and distal fibula is kept intact for knee/ankle
6cm
Innervation of fibula flap
Common peroneal –> Lateral sural (calf) cutaneous n.
Blood supply to skin paddle
Intramuscular (sometimes septocutaneous) perforators from peroneal artery
Sequence to identify fibula perforators
- First look for septal perforators to skin from anterior approach (between muscle and muscle fascia, retracting muscle posteriorly to visualize interosseus septum (membrane)
- If no septal perforators then posterior approach to identify intermuscular perforators.
Minimum fibula segments
Rodriguez = 2.5cm (perforators feed periosteum feed bone)
Peroneal artery proximal branches
- AA
- Common illiac
- External illiac
- Common femoral
- Superficial femoral
- Popliteal (within knee joint)
- Branches x3
- Anterior tibial –> dorsalis pedis
- Peroneal (terminal)
- Posterior tibial –> plantar arteries
Flaps for mandible recon
- Fibula
- Scapula
- Iliac crest
Fibula vessels
Peroneal artery + concomitant veins x2
Compartments of lower leg distal to neck of fibula
4 compartments
- Anterior
- Lateral
- Superficial posterior
- Deep posterior
FFF Pedicle length
12cm
Maximum length of vascularized bone from FFF
25cm
Reconstruction Ladder/Elevator
Simple –> Complex
- Free flap
- Regional flap
- Local flap
- Skin graft
- Primary closure
- Secondary healing
Anterior fibula muscles (Extensors)
Proximal to distal
- Insertion of biceps femoris
- Peroneus (Fibularis) longus
- Extensor digitorum longus
- Extensor hallucis longus
- Peroneus (Fibularis) brevis
Indications for mandible recon with free tissue transfer
>6cm defect H/o XRT Osteomyelitis
Physical exam pearls preop assessment
Examine feet for signs of PVD
Palbable posterior/anterior tibial pulses
Modified allen’s (eval palbable pulse of anterior when compressing posterior, vice versa)
Caliber of peroneal artery
Large caliber 1.5-4mm
Maximum width of fibula skin paddle that can be closed primarily
5cm
How many surfaces does the fibula have?
4
Relationship of fibula vessels to fibula
Posteromedial aspect of fibula
Peroneal artery distal branches
No named branches. Only anterior tibial and posterior tibial arteries
How can the FFF pedicle be lengthened?
Dissect pedicle free from proximal fibula and use distal bone for reconstruction
