Abstract
One hundred and ninety-eight consecutive patients (247 vascularized fibular grafts) were studied to determine the prevalence of morbidity at the donor site after the grafts had been obtained. Objective motor weakness, subjective discomfort in the ankle and other sites in the leg, and sensory abnormalities in the lower limb (or limbs) from which the graft had been obtained were recorded. The average duration of follow-up was forty-seven months (range, twenty-four to 144 months). Kaplan-Meier analysis was used to estimate the prevalence of each finding for the entire cohort over time.Forty-seven (19.0 per cent) of the 247 lower limbs had at least one of the findings, and eighteen (24.3 per cent) of the seventy-four limbs for which data were available at five years or more had findings at that time. Twenty-five (10.1 per cent) of the 247 limbs had evidence of motor weakness at three months postoperatively, although no limb had this finding subsequently. At five years or more postoperatively, the prevalence had decreased to two (2.7 per cent) of the seventy-four limbs. Twelve (4.9 per cent) of the 247 limbs had sensory deficits at three months; this increased to 11.8 per cent (95 per cent confidence interval, 7.7 to 17.7 per cent), according to the Kaplan-Meier analysis, at five years. Pain at sites other than the ankle was noted in nine (3.6 per cent) of the 247 limbs at three months and in 8.9 per cent (95 per cent confidence interval, 5.5 to 14.1 per cent), according to the Kaplan-Meier analysis, at five years. The prevalence of pain in the ankle also increased with time, from four (1.6 per cent) of the 247 limbs at three months to 11.5 per cent (95 per cent confidence interval, 7.4 to 17.6 per cent), according to the Kaplan-Meier analysis, at five years.Removal of a vascularized portion of the fibula is associated with a low prevalence of motor weakness and sensory deficits in the foot. The prevalence of pain in the ankle and lower limb increases with time, with some patients having a late onset of the symptoms. While free vascularized fibular grafts remain ideal for many applications, the morbidity must be weighed against the benefits.
The vascularized autogenous fibular graft is a useful tool in major reconstructions of the limbs because it provides a source for vascularized cortical bone. Among other applications, this graft has been used in the reconstruction of tumor-related defects in the proximal part of the humerus1,4 and in the treatment of congenital pseudarthrosis of the tibia23,32, infected non-unions of the femur and tibia, non-unions of the femoral neck, and, recently, avascular necrosis of the femoral head3,8,27. Most reports on reconstructive operations with use of vascularized fibular grafts have been of relatively small series and have provided very little information on morbidity associated with the donor site9,12-15,17,35. However, pain13, instability of the ankle9, motor weakness35, and nerve injury9 have all been reported.
We have used a large number of vascularized autogenous fibular grafts in the treatment of avascular necrosis of the femoral head. We believe that the removal of a diaphyseal portion of the fibula is associated with acceptable morbidity when weighed against the potential benefits that such a graft may provide in the treatment of a disabling condition of the ipsilateral hip. The purpose of the current report is to present our clinical experience with problems related to the donor site that we have encountered after these grafts have been obtained.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Duke University Medical Center, P.O. Box 2912, Durham, North Carolina 27710. Please address requests for reprints to Dr. Urbaniak.
One hundred and ninety-eight consecutive patients received a total of 247 vascularized fibular grafts for the treatment of avascular necrosis of the femoral head from November 1979 through May 1990. These patients are the subject of this study. The average age of the patients was thirty-three years (range, fourteen to sixty years). One hundred and fifty patients (76 per cent) were male, and forty-eight (24 per cent) were female. The average duration of follow-up was forty-seven months (range, twenty-four to 144 months). Two-year follow-up data were available for 215 (87 per cent) of the 247 limbs from which a graft had been obtained, and five-year data were available for seventy-four (60.2 per cent) of the 123 limbs from which the graft had been obtained at least five years before the review. The graft was obtained from the left fibula only in seventy-three patients (36.9 per cent), from the right fibula only in seventy-six (38.4 per cent), and from both fibulae in forty-nine (24.7 per cent).
All patients were asked preoperatively if they had had any problems with the ankle or leg. The patients were examined postoperatively at three months, six months, one year, eighteen months, two years, and yearly thereafter by the senior one of us (J. R. U.). At these postoperative visits, the patients were asked specifically whether they had had any pain at or in the vicinity of the donor site, either while they were at rest or when they were active. They were also questioned about any subjective sensory abnormalities or feelings of weakness or instability. Finally, they were asked whether they had any other comments or complaints related to the donor site. Any affirmative answer in any of these categories was recorded on the data sheet as a positive finding for a complication. Any detectable weakness of the extensor hallucis longus, flexor hallucis longus, flexors or extensors of the long toe, or peroneal muscles was not graded but was recorded as being present or absent. The patients were asked to indicate the exact location of any pain or sensory abnormality. All of the patients had had arteriography of the lower extremity preoperatively to assess the vascular anatomy at the donor site. Plain anteroposterior and lateral radiographs of the donor site were made if the patient complained of pain.
Operative Technique
The free vascularized fibular graft was obtained with the patient lying on the contralateral side. Except for one patient, the graft was obtained from the extremity in which it was to be used. Patients from whom grafts were obtained bilaterally always had the procedures done sequentially, a minimum of three months apart.
The entire lower extremity is prepared and draped from the toes to the hip. A sterile tourniquet is placed on the thigh and inflated to 300 millimeters of mercury (39.99 kilopascals) after the limb has been exsanguinated with an elastic bandage. The tourniquet was used for an average of 123 minutes (range, forty to 170 minutes).
The fibula is approached through a straight lateral incision, with the dissection carried deep between the posterior and lateral compartments of the leg. The fibula is then exposed by extraperiosteal dissection. The peroneal muscle is first separated from the anterior aspect of the fibula down to the intramuscular septum. Further elevation of the anterior compartment muscles reveals the intraosseous membrane. The posterior dissection is also carried out extraperiosteally. The superficial peroneal nerve and the portion of the peroneal artery deep to the fibula are protected both proximally and distally while a Gigli saw is used to divide the fibula. Further mobilization is then carried out by ligating the peroneal artery and veins at the level of the distal osteotomy and dividing the interosseous membrane.
With use of extraperiosteal dissection, the flexor hallucis longus, posterior tibial muscle, and remaining muscle origins of the anterior compartment are then separated from the fibula. The fibula is elevated gradually from the wound, proceeding distally to proximally, while the intact pedicle is maintained proximally. Smaller vascular branches entering the soleus muscle are clipped and divided. The peroneal vascular pedicle is then dissected proximally to its bifurcation from the tibial vessels. Twelve centimeters of the diaphyseal portion of the fibula is obtained together with a long (usually four to six-centimeter) peroneal artery and vein. The peroneal artery and vein are usually three to four millimeters in diameter, or just slightly larger than the recipient vessels of the lateral femoral circumflex artery. The posterior tibial nerve, the peroneal nerve, and the nerve to the flexor hallucis longus must be identified and protected. One peroneal vein is then ligated and divided. The tourniquet is then deflated. After the blood flow to the fibula has been confirmed, the peroneal artery and the additional peroneal vein are clipped and divided, leaving as long a pedicle on the fibula as possible. The wound is closed over a suction drain after irrigation. The muscle intervals are not sutured together or to the interosseous membrane, and the fascia is not sutured. The subcutaneous tissues are closed in layers with Vicryl suture (Ethicon, Somerville, New Jersey), and the skin is closed with an intracuticular Vicryl suture and Steri-Strips (3M, St. Paul, Minnesota).
Postoperative Regimen
Postoperatively, a posterior splint is applied to the leg for comfort. The splint is removed three days postoperatively, at which time the patient begins non-weight-bearing progressive walking with crutches and physical therapy. At the end of six weeks, the patient is allowed to increase weight gradually on the extremity but still uses crutches for a total of six months. During this period, the patient is encouraged to perform strengthening and range-of-motion exercises for the muscles about the hip, knee, and ankle on the involved side. These include isometrics and gravity-resisted exercises, but there is no addition of weights or resisted exercises. The postoperative regimen is designed to protect the avascular femoral head, which is initially at risk because of the large-caliber tunnel created in the femoral neck to accommodate the fibular graft. In the one patient in whom the graft was obtained from the contralateral fibula, weight-bearing was allowed as tolerated on that side, and touch-down weight-bearing was allowed initially on the recipient side, with the same guidelines for rehabilitation as described for the other patients.
Statistical Analysis
The positive findings for motor weakness, pain, sensory deficits, and other complications were analyzed by generating Kaplan-Meier prevalence curves with 95 per cent confidence intervals on the proportion that was positive at each follow-up interval. The cumulative prevalence of specific complications as a function of time is an attempt to estimate the first-time likelihood of a particular complication, given the variable number of patients available at each follow-up interval15. The cumulative prevalence is a very critical analysis because it includes all events and does not eliminate patients in whom the symptoms may have diminished or disappeared with time.
Motor Weakness
The most frequent early complication after the vascularized fibular grafts had been obtained was some degree of muscle weakness. Early in the postoperative period, most patients had muscle weakness that could be attributed to inhibition due to pain, but it became evident, from the clinical evaluation of motor function at three months, that twenty-five (10.1 per cent) of the 247 limbs had real, although mild, muscle weakness. However, no limb had weakness that was greater than a mild difficulty in overcoming gravity. The extensor hallucis longus and flexor hallucis longus muscles were affected most frequently. Two patients initially had weakness of the extensor digitorum longus, which had resolved by the eighteen-month postoperative visit. One patient had weakness of the peronei that persisted for two years and then resolved. When motor weakness occurred, it did so early in the postoperative course. There were no new occurrences of weakness after three months, with a predicted prevalence of 10.1 per cent (95 per cent confidence interval, 7.0 to 14.6 per cent) at five years (Fig. 1). Muscle weakness was present in two of the seventy-four limbs that were evaluated at five years or more.
Two patients had an additional operation in the first postoperative year. In these patients, contracture of the flexor hallucis longus created a tenodesis effect as the result of operative scarring or removal of its site of origin on the fibula. The contracture was corrected by a z-lengthening of the flexor hallucis longus at the level of the ankle.
Pain
The prevalence of discomfort or aching after activity, at both the ankle and other sites in the leg, actually increased substantially with time. The ankle joint or the area adjacent to it was the most frequently cited anatomical location of pain. There was pain at sites other than the ankle in nine (3.6 per cent) of the 247 limbs at three months postoperatively; the Kaplan-Meier analysis revealed an increase to 8.9 per cent (95 per cent confidence interval, 5.5 to 14.1 per cent) at five years (Fig. 2). There was pain at the ankle joint in four (1.6 per cent) of the 247 limbs at three months; the Kaplan-Meier analysis revealed an increase of 11.5 per cent (95 per cent confidence interval, 7.4 to 17.6 per cent) at five years (Fig. 3). The pain or discomfort was not associated with effusion or subjective instability of the ankle in any patient. The most frequent description was that of an aching or tired feeling after activity. No patient complained of pain at rest, loss of sleep, or symptoms necessitating medication stronger than occasional non-steroidal anti-inflammatory agents.
Some patients did not report pain until later in the follow-up period, after having been symptom-free earlier. At every follow-up visit from two months to two years, one patient described aching at the site of the distal osteotomy after walking several hundred meters. Another patient did not complain of pain at the site of the distal osteotomy until the two-year follow-up visit. At that time, the patient began to describe activity-related soreness, but radiographs of the ankle did not suggest any proximal migration of the distal fibular segment, widening of the mortise, or degenerative changes in the ankle joint. A sensation of muscle-cramping was reported by four patients initially, but it had resolved in all of them at four years. One patient who had not initially complained of muscle-cramping had cramping one year postoperatively. Four patients had pain directly over the site of the fibular osteotomy; two did not have the pain until two years postoperatively. Another patient had pain along the course of the peroneal tendons posterior and just proximal to the lateral malleolus in response to eversion stress and tenderness in response to direct pressure. The pain persisted from the early postoperative period to the five-year follow-up visit.
Sensory Deficits
The prevalence of subjective sensory changes and intermittent paresthesias also increased slightly with the duration of follow-up. As with the other subjective findings, any history or complaint of dysesthesia or paresthesia was recorded. The prevalence of subjective sensory abnormalities increased slightly, from twelve (4.9 per cent) of the 247 limbs at three months to 11.8 per cent (95 per cent confidence interval, 7.7 to 17.7 per cent) at five years (Fig. 4). The abnormalities were specifically located in discrete and isolated anatomical areas, such as the heel in one patient, the dorsum of the foot in five, the lateral side of the foot in two, and the lateral part of the calf in one, with a decreasing prevalence recorded over time. After four years, no new sensory abnormalities were reported in these discrete areas. Nevertheless, mild and intermittent dysesthesia or paresthesia, often not present at the time of the examination but reported by the patient, continued to appear. These new occurrences in seven of seventy-four limbs last seen at five years or more were the reason that the prevalence of sensory abnormalities showed an increase over time.
Examples of patients with sensory findings included one patient who had subjective hypoesthesia in the distribution of the superficial peroneal nerve at the two-month, six-month, one-year, and two-year follow-up visits. The hypoesthesia changed in quality subjectively during that time frame but did not resolve entirely. We could not implicate the duration of use of the tourniquet in the development of sensory abnormalities in any patient. Three patients had subjective hypoesthesia in the dorsum of the foot, but the symptoms had resolved in all of them by two years postoperatively. One patient complained of subjective hypoesthesia over the dorsum of the foot for the first time at the two-year postoperative visit, but this patient had recently gained a lot of weight and had multiple unrelated somatic symptoms. Three patients had subjective hypoesthesia in the lateral aspect of the foot; the tourniquet had been used for an average of 102 minutes in these patients. One of these patients was symptom-free at one year; the other two had persistent but decreased symptoms at two years.
Miscellaneous Complications
Four patients had a thromboembolic complication in association with the transfer of the vascularized autogenous fibular graft to the hip. One patient had a spontaneous thrombosis in the contralateral popliteal artery, which was successfully treated with heparin. Another patient had a symptomatic deep venous thrombosis in the ipsilateral lower extremity, which also responded to therapy with heparin. The two remaining patients had an anatomical variation that led to a complication. In one of them, there was no communication between the peroneal vessel and the fibula. The portion of the fibula that had been removed was replaced, and the contralateral fibula was used. In the other patient, the lower extremities had only two dominant vessels distal to the knee, and in the limb from which the graft had been obtained the peroneal vessel turned out to be the dominant vessel to the foot. A reverse saphenous-vein graft was necessary to maintain the distal flow beyond the fibular branch.
There were several other isolated complications. One patient had superficial cellulitis in the wound, which resolved after intravenous administration of cephalosporin. Four patients had an ulceration along the suture line during the early healing period. The wounds ultimately healed, but the blistering resulted in an unsightly scar. One patient had a palsy of the deep peroneal nerve in the contralateral limb, presumably caused by positioning on the operating table. The palsy resolved slowly during the first few days postoperatively, and there were no permanent sequelae. Another patient complained of a painless herniation of muscle through the fascia at the site of the incision. An additional patient had early intolerance to cold in the foot, which resolved after approximately three months.
Radiographic Follow-up
Routine anteroposterior and lateral radiographs of the donor site were made postoperatively only for the thirty-two patients who complained of pain at the donor site. The radiographs demonstrated rounding of the cut ends of the fibula and decreased cortical-bone density in the distal fragment relative to other areas of the tibia and fibula. There was no regeneration of fibular bone in the fibular bed, other than a small amount of irregular new-bone formation at the cut ends. Three patients had clear evidence of proximal migration of the fibula, as judged by measurement of the angle subtended by the tip of the lateral malleolus and the ankle joint. Two of these patients were completely asymptomatic at six and two years postoperatively. The third patient was among those who had had appositional bone formation at the cut ends of the fibula and intermittent stocking-like paresthesias.
The vascularized fibular graft has been chosen for free tissue transfer because of its structural integrity and relatively reliable vascular pedicle. The advantages of a vascularized autogenous segment of bone have been clearly demonstrated in both human and animal applications2,5,6,10,11,25,29-31. However, the potential morbidity after partial fibulectomy has been the topic of several reviews5,9,12,13,17,35. Gore et al.13 followed forty-one patients for an average of twenty-seven months. In contrast to our operative procedure, the fibula had been removed in a subperiosteal plane for use as a graft in the cervical spine. (With our procedure, the vascularized fibular graft is removed through meticulous dissection in an extraperiosteal plane, necessitating the division of muscle fibers before they are inserted in the fibula. Thus, the planes of tissue damage were distinctly different in the patients of Gore et al. than in our patients.) Only sixteen (39 per cent) of their patients were asymptomatic, and six (15 per cent) complained of moderate or severe pain associated with the donor site, most of which was related to the incision. Only three of their patients had pain in the ankle. The average muscle torque, as tested by force generated against inversion, eversion, plantar flexion, and dorsiflexion stress, was lower on the involved than on the uninvolved side, but the difference was substantial only for the evertor muscles in male patients. No significant relationships were found between the range of motion of the ankle on the involved side and the age of the patient, the level of pain, the duration until the pain subsided, or the length of the fibular defect. In contrast, Youdas et al.35, in a more detailed biomechanical study of ten patients who were followed for a shorter duration, found an inverse relationship between the length of the resected part of the fibula and the strength of the evertor muscles of the ankle. Those authors also noted moderate changes in the motion of the knee, ankle, and foot as the patients walked on level, side-slope, and ramp surfaces at a maximum of ten months postoperatively. Ganel and Yaffe9 reported late instability of the ankle in a female gymnast who had ligamentous laxity after removal of a vascularized segment of the fibula. Late valgus angulation of the ankle and epiphyseal changes have also been reported after partial fibulectomy in growing children10,14,21,22,30,34.
While none of our patients complained of instability of the ankle, twenty-five (10.1 per cent) of the 247 limbs had motor weakness at some time-point in the study, compared with only two (2.7 per cent) of seventy-four limbs at five years or more. Therefore, there was no change in the prevalence of 10.1 per cent (95 per cent confidence interval, 7.0 to 14.6 per cent) at five years. The decreased motor function may have at least one of three causes: (1) isolated injury of a motor nerve; (2) functional lengthening of a muscle, especially if its site of origin has been removed; and (3) contracture of a muscle with a resultant tenodesis effect as a result of its partial resection. On the basis of physical examination of the patients, we believe that the third cause is the most common. In the early postoperative period, if a patient complains of difficulty with motor function, the surgeon should determine if this is due to weakness or contracture of the muscle. If contracture is present, the patient is instructed about passive stretching exercises. If contracture persists, tendon-lengthening may be indicated.
The fibula has the dual biomechanical role of providing a site of origin for the muscles and of serving as a rigid body in load transfer. Many authors have studied the static and dynamic function of the fibula in stability of the ankle and load transfer. Lambert16 reported that one-sixth of the static load of the leg is carried by the fibula and that the interosseous membrane transmits little of the load. In another strain-gauge study, by Skraba and Greenwald26, three ankle specimens from cadavera were loaded in positions ranging from 10 degrees of dorsiflexion to 10 degrees of plantar flexion while the strain measurements on the fibula were recorded. After the interosseous membrane had been sectioned, strain on the fibula decreased essentially to zero, suggesting a role for the interosseous membrane in transfer of load to the fibula. This concept is supported by the earlier work of Vukicevic et al.28, who used holograms to investigate the tibiofibular interosseous membrane in embalmed and fresh-frozen cadaveric specimens. It therefore seems apparent that the interosseous membrane transmits some of the load between the tibia and the fibula, which is in keeping with its ultrastructural characteristics20.
The dynamic function of the fibula has been studied by Weinert et al.33. Cineradiographs of healthy college athletes showed downward and lateral movement of the fibula during the strike phase of gait. The inference is that this motion, caused by muscle forces, acts to deepen the ankle mortise and to stabilize the ankle while it is in dorsiflexion, the point at which it receives the highest loads. A potential concern, in obtaining grafts from the fibula, is whether removal of the diaphyseal segment of the fibula and its corresponding muscular attachments will eliminate the possibility of dynamic function as well as cause the weakness of the peroneal muscles that has been demonstrated clinically13,17. Certainly, restriction of motion of the fibula can result in clinical sequelae24, such as the breakage of retained syndesmotic screws and pain in the anterior aspect of the ankle associated with calcification of the syndesmotic ligament. Although function after partial fibulectomy has been investigated13,16,26,33, we are not aware of any studies in which motion of the fibula after partial fibulectomy has been measured directly. Given the complex and varied contributions of the fibula to load transfer of the lower extremity, it is not surprising that removal of a portion could result in weakness and pain in some patients.
The finding of pain in the leg was much less frequent in our patients, with regard to muscle-cramping, pain related to the incision, pain in the ankle, and pain over the tip of the lateral malleolus, than in forty-one who were reported on by Gore et al.13 after subperiosteal partial fibulectomy. The average age of the patients in the series of Gore et al. was forty-eight years, compared with thirty-three years in the current series. This age difference may be a factor in the rate of complications, assuming that younger patients who have an isolated disability of the lower extremity may attempt to be more active than older patients. However, our patients had a severe debilitating condition of the ipsilateral hip, which necessitated a six-week period of non-weight-bearing and possibly a lower initial level of activity, compared with that of the patients of Gore et al., in whom the graft was used in the cervical spine. Our patients also were followed for longer, which demonstrated a trend toward an increased prevalence of pain with time.
We reported two complications in the current series that were related to unusual but not previously unreported variations in the vascular anatomy of the fibular pedicle. According to Lippert and Pabst18, the anterior and posterior tibial arteries most frequently continue to the foot, with one of four possible variants: the dorsalis pedis artery originates from a perforating branch of the peroneal artery, the plantar artery derives from the peroneal artery rather than the posterior tibial artery, the dorsalis pedis artery arises from equally dominant branches of the anterior tibial and peroneal arteries, or the peroneal artery is absent. With regard to the blood supply to the fibula itself, McKee et al.19 found that 318 (96 per cent) of 332 nutrient foramina of the fibula were in the middle third, reflecting the diaphyseal entry of the blood supply; however, eighteen (6 per cent) of the 323 fibulae had no apparent foramen. In the current study, all patients had arteriography preoperatively to rule out vascular anomalies. In the past year, we have stopped making a preoperative arteriogram, in order to lower costs. However, we are aware of the potential for vascular anomalies and are careful to look for them during the operation.
We believe that the delayed healing that was seen in four of our patients was also most likely due to diminished vascularity. The peroneal artery supplies the surrounding muscles, nerves, subcutaneous tissue, and skin in addition to the fibula. Removal of the peroneal artery and vein with the fibular graft may result in decreased blood flow and altered microcirculation7 to the lateral skin of the calf, with delayed wound-healing (Fig. 5).
Before we analyzed the data, it was our impression that the complications related to the donor site were rare. Specific, detailed questioning, as well as physical examination of the donor site of each patient, was necessary to reveal the actual prevalence. We recognize the limitations of using multiple examiners, with the inherent interexaminer variation. Our inclusion of any positive response by a patient to any examiner was an attempt to be especially critical in our review. We believed that, if an error were to be made in recording, it would be better to make it in overrecording than in underrecording of abnormal findings.
On the basis of our clinical observations, we are convinced that obtaining vascularized fibular grafts is associated with a small but demonstrable clinical and theoretical morbidity related to altered fibular function and localized motor weakness. The motor weakness and altered fibular dynamics may be intimately related, as the local muscles depend somewhat on the fibula for a stable origin, and the fibula may depend on its muscular attachments for appropriate distal movement during heel-strike. We believe that these considerations merit continued laboratory and clinical study. Meanwhile, the success of vascularized autogenous fibular transfer in major reconstruction of the limb makes these grafts ideal for many applications, provided that the surgeon weighs the limitations and the potential for morbidity at the donor site.
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