Surgical Highlights

The osteocutaneous fibular flap is harvested simultaneously with the ablative portion of the procedure with the patient in the supine position and the knee slightly flexed. A pneumatic tourniquet around the thigh may be used but is not required. The

Medial Sural Cutaneous Nerve

Figure 39 Fibular sensory nerves (see text).

Medial Sural Cutaneous Nerve

Figure 39 Fibular sensory nerves (see text).

PCIM follows the posterior border of the fibula and is an essential landmark in flap harvest. It is on a line from the fibular head to the lateral malleolus (the process at the lateral side of the lower end of the fibula). The skin paddle is typically 6 cm wide by 6-20 cm long and must lie over the PCIM to accommodate the septocutaneous vascular perforators that supply the skin of the lateral leg (Fig. 40). The need to harvest a very long skin paddle in the hope of capturing a septocutaneous perforator can be obviated by incising the anterior portion of the skin paddle first and dissecting down to the PCIM to look for perforators. Once a perforator is identified, a skin paddle of any size can be designed around it. Prior to dissection of the skin paddle superiorly, the common peroneal nerve should be identified as it courses anteroinfer-ior to the head of the fibula.

After the skin paddle is dissected, the peroneus longus and brevis muscles and the extensor hallucis muscle are retracted anteriorly by carefully incising the longitudinal muscle fibers just outside the periosteum. The anterior tibial vessels and nerve are encountered and must be preserved. Bone cuts are prepared by carefully dissecting a cuff of periosteum around the circumference of the bone at the desired proximal and distal osteotomy sites, preserving at least 5 cm proximal fibula and 10 cm distal fibula. The inferior and superior osteotomies free the bone graft laterally since only the peroneal vessels and interosseus membrane now tether it. The distal peroneal vessels are found immediately behind the inferior osteotomy and divided. In an inferior-to-superior direction, the interosseus septum is divided, greatly freeing the osteocutaneous unit. Remaining muscular attachments including the soleus, flexor hallucis longus, and tibialis posterior are divided. A portion of the soleus and flexor hallucis muscles must be preserved around perforating peroneal musculo-cutaneous vessels if no purely septocutaneous vessels can be identified to supply the skin paddle. The flap may remain attached to its vascular pedicle in the leg while the ablative team is working (Fig. 41). Shaping osteotomies and application of hardware may also be performed at the donor site. To harvest the flap, the proximal peroneal vascular pedicle is dissected and taken distal to its branching from the posterior tibial artery. Dividing the pedicle intact is desirable since dissecting the vena comitans away from the peroneal artery is tedious and can lead to excessive bleeding.

A suction drain is placed into the wound and the muscles are allowed to fill the wound passively without suture fixation. The skin is closed primarily or covered with

Figure 40 Fibula surface markings in preparation for harvest of an osteocutaneous flap. Note that the skin paddle is designed over the distal half of the lateral leg because the septocutaneous perforators tend to be more numerous in this region.

Figure 41 Pedicled osteocutaneous flap at donor site. Note the peroneal vessels over the background material. If desired, shaping osteotomies may be performed while the flap is being perfused.

a skin graft harvested from the lateral thigh (Fig. 42). A below-the-knee plaster splint is placed and the leg is kept elevated on a pillow while the patient is supine. Weight bearing with assistance can be started after 2 days, and full ambulation can begin as early as 1 week postoperatively.

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