Overview of Fibula Tissue Transfer
Autologous grafts are tissue transplants using a person’s own body parts. These have been key to repairing bone defects for over a hundred years. The first recorded instance of a free fibular graft transfer – moving the fibula bone – was in 1975. More recently, a method to easily get to and harvest the fibula bone was promoted, and another method was developed to move the fibula, along with skin and muscle, to rebuild the forearm.
There are many ways to fix bone defects. These include autografts using cancellous and cortical (spongy and hard outer bone tissue) bone from the patient, bone transplants from a cadaver, placing an artificial limb joint, moving bones, and using vascularized (blood vessel-rich) bone grafts like the hip bone, rib, shoulder blade, and fibula. The fibula bone is commonly used for fixing bone defects bigger than 6 cm due to its long length, straight shape, strength, predictable blood vessel connection, and ability to thicken and adjust for long-term bone repairs.
Currently, the fibula transfer is often used after removing a tumor, saving a false joint, rebuilding the jawbone defect, and treating chronic bone infection. A vascularized growth end bone transfer is used for youngsters with complex injuries to preserve the potential for ongoing growth and provide a living joint surface for good joint function.
Anatomy and Physiology of Fibula Tissue Transfer
The fibula is a long bone located on the outside of the lower leg. It’s connected to the tibia, the bone in the shin, by a flexible sheet of tissue called the interosseous membrane and by two joints at both ends. The top joint is a ‘synovial joint’ which helps reduce twist and turn stress in the leg and the bottom joint, known as syndesmotic, has very little movement.
When considering the structure of the fibula, it consists of four main parts:
- Head – the top part of the bone
- Neck – the slimmer area below the head
- Shaft – the long middle section of the bone
- Distal end – the bottom part that includes the ankle
The bone’s outer surfaces are classified into three groups: the lateral (outside), medial (inside), and posterior (back). The shape of the fibula is influenced by the muscles attached to it. The bottom of the fibula forms a part of our ankle that is in contact with a bone in the foot. On average, the fibula is roughly 39cm (15.5 in) in males and 36cm (14.5 in) in females.
The fibula develops and hardens, in a process called ossification, in three parts; the middle and the two ends. This hardening process usually finishes in our twenties. It’s important to know that a significant nerve (the common peroneal nerve) loops around the neck of the fibula, so it could potentially get injured if the fibula is fractured.
Knowledge of the blood flow in the fibula is vital for specific surgeries such as a ‘vascularized fibula flap’, where a piece of the fibula is moved to another part of the body. The fibula has three main blood supplies: the anterior tibial, the peroneal, and the posterior tibial arteries. Before surgery, it is important to identify the dominant artery to avoid serious complications such as foot ischemia, a condition caused by poor blood flow to the foot.
The fibula has two main joints:
- The Proximal Tibiofibular Joint, connecting the top part of the fibula and the shin bone, has a joint capsule and is held together by the anterior and posterior superior tibiofibular ligaments, the outside collateral ligament, and a tendon of the thigh muscle called the biceps femoris.
- The Distal Tibiofibular Joint, connecting the bottom part of the fibula and the shin bone is held together by an interosseous membrane, the anterior and posterior inferior tibiofibular ligaments, and the transverse tibiofibular ligament.
Why do People Need Fibula Tissue Transfer
Doctors use fibular tissue grafts, which is a fancy way of saying that they take tissue from the fibula (the smaller of the two bones in your lower leg), in several situations. These include:
- Major loss of bone from an injury (greater than 6 cm) in either the upper or lower limbs
- Significant loss of bone after removing a tumor
- Non-healing bone fractures in long bones
- Difference in leg lengths
- Repairing defects in the jaw or cheekbone area
- Chronic bone infections that don’t get better with antibiotics
- Transferring a part of the growing end of a bone, known as epiphyseal transfer
- Adding bone tissue (osteconductive) to help bone healing in conditions where it’s not joining together (non-union) or for the stimulation of new bone growth (osteoinductive)
- When the head of the upper arm bone (humerus) or the thigh bone (femur) is damaged or dying, a condition known as osteonecrosis
Choosing the right surgical technique can be pretty complex and depends on what’s best for the patient. There are many treatment options for different bone problems, and doctors aren’t always in agreement about the best option for each issue. However, fibular grafting is a good choice in many instances because it tends to have high success rates and few complications.
When a Person Should Avoid Fibula Tissue Transfer
There are certain cases in which using a piece of the fibula bone (the smaller of the two bones in your lower leg) to replace a missing or damaged bone elsewhere in the body might not be safe to do. These cases could result in issues following the transfer:
If you have a history of peripheral vascular disease (a condition that affects the circulation of blood to the limbs) in that limb, this might make a fibular graft inappropriate.
Having a history of trauma or past surgery in the lower part of your leg could also be a concern if you’re considering a fibular graft.
If the anterior tibial artery (a major blood vessel in the lower leg) is underdeveloped, known as Hypoplastic, it may be unsafe to perform the graft.
If you have poor vein function, known as venous insufficiency, this could potentially cause problems at the site where the bone is taken from.
If you have repeated infections, using a non-vascularized fibular graft (using the fibula bone without its blood vessels) might not be a good choice.
Equipment used for Fibula Tissue Transfer
For your procedure, your doctor needs to have the following tools and equipment ready:
A skin marker, which is used to highlight the area of the body where the surgery will be performed.
A Doppler ultrasound probe, a machine that uses sound waves to visualize and check blood flow in the arteries and veins.
Bard-Parker #3 scalpel handle and #15 blade, a type of small knife that’s used to make incisions or cuts in the body.
Povidone-iodine or chlorhexidine surgical antiseptic, used to clean the skin to prevent infections.
Langenbach retractors, tools used to hold back the skin, muscles or organs so the surgeons can see and operate on the area of concern.
A periosteal elevator, a tool used to separate tissue from the bone.
Plain and toothed forceps, like Adson-Brown, Gerald, or DeBakey, are tools to hold and move tissues during surgery.
Bone saws, like an oscillating saw or Gigli, are used to cut through bone.
Acland “bulldog” clamps, used to restrict blood flow in a vessel during surgery.
A microvascular instrument set, which includes tiny tools used for operating on small blood vessels.
An operating microscope, helps the surgeons to see the surgical site with more clarity.
Saline treated with heparin, used to prevent blood clots during the surgery.
2% lidocaine or 3% papaverine, types of local anesthetics used to numb the surgical area.
Microsutures and micro-couplers, tiny stitches and connectors used while operating on small or delicate areas.
Surgical clips, used to prevent bleeding by clamping off blood vessels.
Vessel loops, used to isolate and control blood vessels during surgery.
Plates, screws, and an intramedullary rod might be necessary, depending on the procedure. These are used to stabilize and heal the bone.
A drill and bits for pre-drilling screw holes, if plates or screws are needed.
A screwdriver, for secure application of the screws.
Suction drains, used to remove fluids from the surgical area.
Finally, absorbable and nonabsorbable sutures will be used to close the incision after the procedure. The absorbable sutures get dissolved by body over time, while the nonabsorbable sutures need to be removed by your doctor. They might use materials like polyglactin, poliglecaprone, and polypropylene or nylon. Dressing supplies will be used to cover and protect the wound.
Who is needed to perform Fibula Tissue Transfer?
We suggest having the following medical professionals present:
An anesthetist is a specialist who ensures that you’re comfortably asleep and don’t feel any pain during your surgery. They will monitor your vital signs throughout the procedure.
A primary surgeon is in charge of the surgery. In some cases, two primary surgeons might be needed. For example, if a part of your fibula (a bone in your leg) needs to be removed and transplanted, one surgeon will handle the removal and the other, the transplantation.
Surgical assistants, who are trained medical staff, will also be on hand to help the primary surgeon as needed.
An operating room assistant ensures everything in the room is in place and assists with things such as passing the necessary surgical tools to the surgeons during the operation.
A staff nurse takes care of you before, during, and after the surgery, making sure you’re comfortable and that your needs are met.
All these people play crucial roles in ensuring your surgery goes smoothly and safely.
Preparing for Fibula Tissue Transfer
When considering a surgery that involves moving a piece of fibula (a bone in the lower leg) to another site in your body, it is important to assess the blood flow in the leg from which the bone will be taken. This needs to be done before the day of surgery. The health of the blood vessels in the leg, particularly the peroneal artery, is crucial. It can be checked by performing ultrasound or CT scan. If there’s an issue with the peroneal artery – if it is not sufficient or if it is too dominant – the doctors will choose a different donor site, such as the hip bone or shoulder blade. This is to ensure the transferred bone gets enough blood supply and also, the foot of the donor leg remains healthy after the surgery.
On the day of surgery, you will have a detailed conversation with your doctor about the procedure. They will explain other alternatives to this procedure, potential risks and what you can expect after the surgery. This procedure comes with several risks like failure of the transferred bone, problems with walking, unstable ankle, pain, bleeding, infection, and the possibility of needing more surgeries in the future.
Generally, the surgery takes place under general anesthesia. You will also receive antibiotics before the anesthesia starts to help prevent infections, and more doses will be given during the surgery as needed. The areas involved in the surgery will be cleaned with disinfectant before starting. To keep the surgery site bloodless and easier to work on, a special kind of bandage can be used on the leg and a device (tourniquet) to block the blood flow is put in place.
While positioning you for the surgery, care will be taken to pad all the sensitive areas to prevent injury during the long procedure, which can extend up to 8 hours or more. The surgery usually involves two teams working simultaneously, one preparing the site where the bone will be transferred to and the other working on the leg from which the bone will be taken.
How is Fibula Tissue Transfer performed
For your surgery, both your body and the body of the donor are prepared at the same time by separate surgical teams. This method can save time and reduce complications.
In your body – the “recipient site” – the process depends on why a graft was needed and the specific issues with your bone. Cancer surgery and lymph node removal may be necessary, or it may just involve cleaning out the bone area. The top and bottom areas around the bone piece are ideally left intact, as this can help healing. Once all this is complete, the team measures the length of the bone section that needs to be replaced to guide the graft harvesting team. If we’re using what’s called a “vascularized tissue transfer”, they will also need to find suitable blood vessels to support the graft.
The graft – taken from a fibula (calf bone) – is usually harvested using a technique known as the “anterolateral approach”. The team will make incisions deep to the fibula, protecting a nerve at the front. Cuts are made in the bone to match the length of the segment to be replaced, although some surgeons prefer to use the whole fibula (apart from 5-6 centimeters at each end) to maintain stability and protect a nerve at the top. After the graft is harvested, it can be shaped as necessary.
In closing the “donor site” (the area where the graft is taken from), certain muscles are stitched together and the skin is closed, except for where the graft was taken which is usually covered with a thin skin graft.
To place the graft in your body, there are a few different techniques the surgical team can use depending on the specifics of your situation. In some cases, the graft could be split and folded upon itself to make it wider. This is known as the “double-barrel” technique. The graft is then placed into the space where the bone issue was and fixed as necessary. If a vascularized graft is being used, your surgeon will connect the arteries using very fine stitching under a microscope.
After the surgery, you will be given medicine to prevent blood clots and monitored using ultrasound. If a skin graft was required, a walking boot will be used to protect it. After about two or three days, gradual weight-bearing can typically begin as tolerated.
Possible Complications of Fibula Tissue Transfer
Complications can sometimes occur after surgery due to the anesthesia (medicine that makes you unconscious or ‘puts you to sleep’). These can include discomfort, feelings of sickness or vomiting, damage to teeth, a sore throat or damage to the voice box, allergic reactions to the anesthetic medicine, problems with the heart, problems with breathing, lung inflammation due to inhaling food or drink, or a drop in body temperature.
During surgery, there may be some complications too, such as excessive bleeding, mistakes in shaping the graft (a piece of tissue moved from one part of the body to another), accidental bone fracture, or damage to the bundle of nerves and blood vessels.
Post-surgery complications can include fractures of the tissue graft (which is the most common complication), infections (which is the second-most common), a collection of blood outside blood vessels (hematoma), pins moving out of place, different leg lengths, incorrect alignment of the ankle, a posture issue of the ankle, the big toe bending too much (which may require lengthening surgery), muscle weakness mainly because of pain, issues with the peroneal nerve (a nerve on the outside of the calf), low blood count requiring blood transfusion immediately after surgery, or delayed healing not joining.
Other complications can include growth deformities due to abnormalities in the growth plate or uneven growth, not enough soft tissue coverage, early opening of the surgical wound, amputation due to failed treatment of the main source of bone defect or failure of the graft joining, or failure of sufficient blood supply to a skin flap.
What Else Should I Know About Fibula Tissue Transfer?
The fibula, a bone in your leg, can provide up to 30 cm of healthy bone for grafting, which is when doctors use pieces of bone to repair other bones in your body. This is a common method because it’s typically safe for the patient and doesn’t affect their movement very much after the fact.
Bone grafts from the fibula can be used for many different medical situations. These include treating cancer, chronic infections, physical injuries, and birth defects. There are even cases where the fibula has been used to repair long defects in the tibia, another bone in your leg.
Bone grafts from the fibula are also useful because they can increase the blood flow to the area where the graft is, which helps the healing process. This is especially beneficial for patients with long-term infections or those who have had radiation therapy.
Although the procedure can be complex, using the fibula for grafting can be quicker and safer than other methods, such as the Ilizarov technique, which is used for leg length discrepancies.
Fibula grafting can be used for many different medical issues, and various specialists use it to solve reconstruction problems in their patients. These specialists may include orthopedic doctors, plastic surgeons, ear, nose, and throat doctors, and oral and facial surgeons.
