Dolph Houben

40 CHAPTER 2 Finally, the flexor hallucis longus muscle is dissected from the fibular segment. Again, dissection progresses from distal, meticulously identifying and ligating or bipolar-cauterizing small muscular perforators. The dissection is performed directly on the vessel surface rather than at the fibula itself. This results in a small strip of remaining muscle lying on the fibula and next to the peroneal vessels, protecting the bone blood supply. At this point, the fibular segment is fully isolated on the peroneal artery and associated veins. The peroneal vessels should be fully mobilized up to the point where they join the posterior tibial vessels (Fig. 3.5). Any remaining muscular branches should be ligated and divided. If a tourniquet is used during the harvest procedure, release the tourniquet for 5-10 min before the finial cutting of the pedicle to perfuse the bone while getting hemostasis of the leg. Depending on surgeons preference, two suction drains can be placed - one in between the flexor hallucis longus and soleus, the other subcutaneously. The flexor hallucis longus is loosely repaired to the peroneal muscle with a running absorbable suture and the skin closed in layers (Fig. 3.6). Figure 3: The distal osteotomy should be made 7-8 cm above the ankle joint (1), the fibula can now be rotated laterally and the interosseous membrane sharply divided (2), the peroneal vessels are identified and ligated at the distal end of the osteotomy leaving a silk tie long at the proximal stump will facilitate dissection of the vessel from distal to proximal (3), the tibialis posterior muscle is divided just above the peroneal vessels and muscular branches ligated (4), the flexor hallucis longus is then divided of the bone, now the fibula is isolated on the peroneal vessels (5), before the final ligation and cutting of the pedicle vessels, release the tourniquet for 5-10 min to perfuse the bone while getting hemostasis of the leg (6).