Expertise from the following personnel are needed:

• Anesthetist
• Primary Surgeon
• 1 or 2 surgical assistants (2-team surgeons allows a faster operative time)
• Operating room assistant
• Staff nurse
• Cleaner

Informed consent, check skin condition & vascular status of the donor site and recipient site are in the preoperative period. A preoperative angiography/doppler ultrasound is required to analyze the dominant vessel, in case that the peroneal artery is the dominant one, then a vascularized graft is contraindicated.

The procedure is performed under general anesthesia and antibiotic prophylactic is given at the induction with a repeated dose every 4 hours during the surgery. The donor and recipient sites are prepared with aseptic measures for surgical intervention. An Esmarch bandage is used to exsanguinate the lower extremity and a tourniquet is applied.  The patient is positioned in the supine/lateral decubitus position with a sterile tourniquet on the affected limb set to 150mm Hg above the mean arterial pressure. All pressures points are carefully padded e.g. contralateral fibular head (to protect the peroneal nerve), pelvis, heel, and contralateral axilla (to protect the brachial plexus). Usually, the surgery is performed by 2-team surgeons at the same time: the first team works on the recipient site while the other is approaching the donor site.[15]

Both recipient and donor sites can be approached simultaneously by two microsurgical teams to diminish operative time, bleeding, and related complications.

Recipient Site Surgery

The recipient site of the surgery depends on the etiology factor and site of the bone defect. For example, chronic tibial shaft osteomyelitis with a wide bone resection needed for curative purposes, large posttraumatic skeletal defects, or a cubital atrophic pseudarthrosis with a significant lack of bone stock. Proximally and distally, the periosteum is usually preserved in order to aid for future fusion. The length of the defect is measured preoperatively with Xrays or CT scan when appropriate, and the final length is measured intraoperatively after the bone resection of the recipient site.[16] 

Donor site Surgery

The harvesting of the fibular graft is performed through an anterolateral approach as described by Gilbert.[3] The interval between the peroneus longus and the soleus is developed and dissection is done deep to the fibula protecting the superficial peroneal nerve anteriorly. Bony cuts are made according to the measured reconstruction length, taking care, and protecting the peroneal vessels which are located just beyond the proximal cut. By carefully dissecting the flexor hallucis longus, the fibula is retracted anteriorly. Towel clamps are applied at the ends of the fibula and rotated gently outward. If a vascularized graft is required, the peroneal vessels are lifted together with the fibula.[17] In closing the donor, the flexor hallucis longus is sutured to the interosseous membrane and the peroneus longus is sutured to the soleus. Skin is closed primarily except in the area of the cutaneous paddle, which is typically covered with a split-thickness skin graft

Graft Placement

The surface contact area of the fibula into the recipient site can be increased by using a double barrel technique in case of femoral or tibial defects. The bone segment is trimmed according to the recipient site and fixed into the bone defect with appropriate fixation. This is generally accomplished with small plates and screw constructs, rush rods, or K-wires. In the case of performing a vascularized fibular graft transfer, vascular anastomosis is preferred utilizing nylon 8 or 9/0. The incorporation of a skin flap, supplied by the peroneal artery, is not only for composite reconstruction of bone and soft-tissue defects of the extremities, but also serves as postoperative monitoring of the viability of the fibular graft. Distal tibial fibula fusion is usually performed as suggested by Langenskio¨ld procedure to prevent valgus deformity of the ankle.[7]

In cases of bone defects associated with soft tissue involvement such as tumoral resections or large posttraumatic skeletal defects, the fibular graft is usually harvested together with a skin paddle and is used as an osteocutaneous flap at the same stage, accomplishing then bone, soft tissue, and skin coverage simultaneously. 

Postoperative Care

Patients should be placed on low-molecular-weight heparin for deep venous thrombosis prophylaxis and aspirin for 2 weeks. In the case of using osteocutaneous grafts, the flaps are monitored by visual inspection of the cutaneous paddle and by ultrasound doppler. In cases in which a skin graft is required for covering the donor site, the patient wears a posterior splint and should remain non-weight-bearing for at least 48 to 72 hours after surgery. After this, wears a walker boot to avoid ankle plantar or dorsiflexion, therefore preventing dislodging of an immature skin graft from the leg. The patient is then allowed to weight-bearing progressively as tolerated. 

 Anesthesia-related Complication

These are usually the side effects of anesthesia medication and procedures.

• Pain
• Nausea and vomiting
• Damage to teeth
• Sore throat and laryngeal damage
• Anaphylaxis to anesthetic agents
• Cardiovascular collapse
• Respiratory depression
• Aspiration pneumonitis
• Hypothermia

Intra-operative Complications

During surgery, different complications may occur.

• Bleeding
• A discrepancy of the graft if not previously properly planned
• Iatrogenic bone fracture
• Damage to the neurovascular bundle

Post-operative Complications

• Hematoma
• Pin migration
• LLD (leg length discrepancy)
• Valgus malalignment
• Equinus deformity of the ankle[18]
• Graft fracture was the most common complication
• Infection (is the second most common complication[14]
• Great-toe contracture, flexion contracture of the great toe is the most frequent complication after fibular graft harvest. (Flexor hallucis longus lengthening might be needed to correct this contracture)
• Motor weakness at the early follow-up visits appeared to be largely attributable to pain inhibition[19]
• Peroneal nerve palsy
• Low hematocrit or hemoglobin levels requiring transfusion in the immediate postoperative period[20]
• Delayed nonunion
• Growth deformities due to physeal abnormalities or asymmetrical growing[15]
• Inadequate soft-tissue coverage (might need soft tissue flaps)
• Early postoperative wound dehiscence
• Amputation due to failed treatment of the initial source of bone defect or failure of grafting union[21]
• Thrombosis of the anastomosed vessels, stress fracture, and variable donor-site morbidity, including sensory abnormalities, motor weakness, and ankle pain[7]

An autogenous vascularized/non-vascularized fibular graft is used frequently and for many major reconstructive purposes as it provides structural stability and reliable vascular supply. The fibular graft is versatile and advantageous compared to other graft, and this has been well documented in the literature. Bone lengthening by the Ilizarov technique is time-consuming and has much morbidity. Non-union is a frequent complication of posttraumatic open fractures, osteomyelitis, and also in post tumoral bone resections. Fibular grafts not only allow to cover mechanical and structural defects but also have a high capability of enhancing bone remodeling and provides an adequate blood supply to overcome bony infections. The fibular head is also being used in distal radius and lateral malleolus reconstruction. Another method of fibula transfer is the medicalization of fibula in large tibial defects, providing promising outcomes.[22]

Complications always follow surgical procedures and this reconstructive procedure also has limitations and complications. The advantages of these procedures outweigh the side effects. This novel idea has decreased the amputation rates, morbidity, and mortality of patients.

Preoperative and postoperative patient care is crucial in order to improve the outcomes of a free fibular graft transfer. General practitioners, nurses, and pharmacists should advise the patient to change lifestyle, such as weight control and stop smoking. Making referrals to other professionals is important when concomitant and associated pathologies could be present.

Patients are usually followed by the primary care provider, nurse practitioner, and physiotherapist. This procedure has shown promising long term results. Orthopedic surgeons, radiology technicians, and nursing staff together form an interprofessional team for accurate deployment and post-procedural clinical monitoring. On each follow-up patient’s subjective complaints and objects, findings are noted and addressed properly. As a team workload is not only divided but efficiently carried out minimizing human error.

Complete comprehensive preoperative planning should be assessed. It is important to carefully document neurological status before surgery and develop correct and complete operative consent describing the magnitude, scope, and detailed complications of the surgery, as well as detailed alternatives considering nonoperative management. 

Even when the benefits of bone reconstruction vs conservative management vs amputation for the treatment of large bone defects has not been proved, fibular bone graft transfer remains an effective surgical technique for the treatment of large skeletal bone defects in pathologies such as tumors, posttraumatic bone defects, pseudoarthrosis, and long bone length discrepancy. [Level 1]

Nurse postoperative care should include finite management of intravenous fluids, foley catheter care until ambulating, antibiotics, pain control, wound, and dressing care, and an advanced diet when appropriate.

Postoperative patient monitoring is important for recognizing some early complications, especially the failure of vascular anastomosis in the case of vascularized grafts, it is important to evaluate the wound looking for some suggestive signs such as skin color changes, or lack of doppler sounds while monitoring the skin paddle at the recipient site. In addition, clinical signs such as hypotension, dizziness, excessive pain not possible to manage it with proper analgesia, or fever, should raise alert from a possible complication.