Dolph Houben

36 CHAPTER 2 The blood supply of the epiphysis becomes more important when longitudinal growth in children is necessary. The optimal vascular pedicle to include the proximal epiphysis of the fibula has never been agreed on. The proximal fibular epiphysis receives its vascular supply through an arcade of vessels derived from the lateral inferior genicular artery and the anterior tibial artery. This arcade is formed superiorly by branches of the inferior lateral genicular artery, and inferiorly by branches of the anterior tibial artery, the most important branches are the first and second recurrent epiphyseal arteries [63] . Raising a free fibula flap including the proximal epiphysis demands a different approach. When a long segment is harvested including the epiphysis it preferably requires a double pedicle including the anterior tibial artery or inferior genicular artery along with the peroneal artery for diaphyseal blood flow. One could dispute using either the branches of the anterior tibial artery or from the lateral inferior genicular artery. One study used only one pedicle (the anterior tibial artery) when raising a fibular flap including the growth plate with good results [64] . Donor site: free fibula harvest by a lateral approach [42, 57] After induction of general anesthesia, intubation, and monitoring of the patient. The patient positioning should be supine with a bolster under the ipsilateral buttock, or in the lateral decubitus position on the operation, table depending upon optimal recipient site access. Thereafter, the entire fibula should be outlined with a marker (Fig. 1.1). The fibula graft should always include the middle third to include the nutrient artery. In the case of an osteocutaneous flap, the skin paddle is designed and outlined around identified perforators (Fig. 2). Depending on surgeons prefference, a pneumatic tourniquet can be used be used after limb exsanguination. A longitudinal incision is made directly over the outlined fibula extending 5-6 cm above and below the required length of the fibula. In the case of an osteocutaneous flap, this incision is made through the anterior border of the skin flap, protecting the identified perforators posteriorly. Dissection through subcutaneous tissues will expose the underlying muscles. Distally, the broad peroneus longus tendon serves to identify the lateral compartment, centered on its muscle belly. A fat stripe is visualized posterior to the muscle belly (Fig. 1.2). The identification of this fat stripe, characterizes the anatomic interval between the posterior (soleus) muscle compartment and the lateral muscle compartment (peroneus longus and brevis). This anatomic interval or septum is a key landmark for further dissection of the fibula. Once the muscle interval is identified, a limited posterior dissection is next performed in the proximal third of the fibula, to identify and protect the peroneal vascular pedicle. As peroneal cutaneous perforators generally lie more distally, they should not be an issue in this dissection. The posterior muscles are retracted posteriorly beginning at the fat stripe. Gentle probing will demonstrate the soleus origin firmly attached to the lateral and posterior aspect of the proximal fibula. It must be carefully elevated from the bone. (Fig 1.3). During this dissection, one or more vascular branches entering the deep (anterior) surface of the soleus are visualized, arising from the peroneal vessels. As the interval is developed, the proximal border of the flexor hallucis longus (FHL) muscle is visualized, covering the posterior surface of the fibular diaphysis. This is confirmed by visualizing the peroneal vessels passing distally deep (anterior) to the proximal edge of the FHL, as visualized once the soleus is released. Visualization of the vessel and FHL