present the case of a 6-year-old boy who was struck by
a vehicle. He suffered from close femoral fracture AO 32 A1.2
and open tibial fracture AO 42 C3.3 with extensive soft tissue injury
on the ipsilateral anterolateral calf (Fig. 1a, 1b, 3, 4).
femoral fracture AO 32 A1.2 was stabilized by open reduction and
plate osteosynthesis. Subsequently consistent debridement of the open
tibial fracture was carried out. After removal of necrotic tissues
and devascularised bone particles, the tibial defect extended to a
length of 8 cm (Fig. 1c, 1d). The tibial fracture was stabilized
by unilateral external fixator. Remaining skin defects were covered
with free skin graft. Early mobilization of knee and ankle joint was
fibular transfer was chosen as a treatment of choice for this large
tibial defect. First stage of transfer was realized 3 weeks after
injury. The fibula was approached with a straight lateral approach.
The peroneal fascia was incised and the peroneal nerve was visualized
and protected before osteotomy. Osteotomy was performed with an
oscillating saw 4 cm below the fibular head. The fibula was then
gently transposed to the slot in the proximal tibia. The notch in
tibia was approximately 2 x 0.5 cm in size. We were not able to make
the fibular transposition using one approach. Also anterior approach
was needed to fully expose the tibia. The vicinity of the physeal
plate forced us to remove the external fixator. The graft was
decorticated on the surface adjacent to the tibia, and
subsequently screwed to the tibia. An iliac crest cancellous graft
was also packed around the proximal anastomosis. External
immobilization of the lower limb in a long plaster cast was continued
for six weeks. The patient was mobilized on crutches, avoiding
weight-bearing. After six weeks the second stage of the procedure was
performed. Analogously the distal fibular remnant was transposed to
the distal tibia slot. Distal fibular osteotomy was carried out
approximately 8 cm above the spike of the lateral malleolus. Fixation
was secured with two cortical screws. We wrapped the distal
anastomosis with bone chips.
of the lower limb continued for another six weeks. Subsequently only
short fixation with full weight-bearing was allowed. The fracture
completely healed after 5.5 months (Fig. 2a, 2b). X–ray scans
revealed progressive hypertrophyof the graftwithout resorption up to twice its
original size eight months after fibular transfer. At the 24-month
follow up the patient had a tibial lengthening of 2 cm, no varus
deformity and a recurvatum deformity of about 20 degrees (Fig. 5, 6).
The range of ankle and knee motion is without any restriction.
of the most difficult problems confronting the reconstructive surgery
is the reconstruction of large tibial post-traumatic defects (3).
Optimal treatment should permit early mobilisation with
weight-bearing, and minimize leg length discrepancy and/or axial
deformity (5). These injuries are usually high-energy in nature and
are invariably associated with severe soft-tissue damage (4).
defects measuring up to 5 cm can be treated with either bone
transport or corticocancellous bone grafting. For defects longer than
6 cm, most surgeons will use either a free vascularized
fibula graft or bone-lengthening techniques (5). The idea of
substitution of the tibia with the fibula is based on its function in
lower animals, in which the fibula is considered an important support
of the leg. In humans due to plantigrade walking it has a less
important function. The fibula carries one sixth of the static load
of the leg. The fibula undergoes hypertrophy under more than
physiological stress and becomes a static supporting element of the
main principle of the ipsilateral fibular transfer lies in fulfilling
the gap between the proximal and distal tibial ends by achieving
tibiofibular synostosis. The procedure uses a vascularized
fibular graft, which evidently speeds up the time of bone healing.
The main blood supply to the fibula must remain intact during the
procedure. The fibula shaft is supplied by a branch of the peroneal
artery, which usually enters the posterior surface of the fibula in
the middle third of its shaft, normally 7 cm below its origin, and
gives off multiple branches to the periosteum (8).
vascularized fibula transfer technique has many advantages. It
retains periosteal and endosteal vasculature and the main arteries in
the leg are left undamaged. No microsurgical skills are required. It
offers only minimal donor morbidity and shortens operation time. The
technique does not affect growth, so it can be used in children and
adolescents. A vascular graft also has greater resistance to
infection. Earlier weight-bearing is permitted by the transfer of a
large graft of the fibula into a biomechanically advantageous
position. It is not very suitable for too proximal or distal tibial
defects. This limitation is given by the fact that the main blood
supply of the fibula is a branch of the peroneal artery which enters
the posterior middle third of the bone 6–7 cm below its origin. The
pedicle may be too short for transfer and due to the size of graft,
stress fracture may also occur (5).
disadvantages include valgus deformity of the donor site ankle (6,
7), development of angular deformity about the knee (2).
stiffness of the ankle after fibular transfer is usually not directly
related to the fibular transfer itself. Removal of the fibula does
not seem to have any detectable disadvantage in terms of function
are only a few available references in the literature about the
application of ipsilateral fibular transfer in children as a
treatment modality for massive traumatic tibial bone loss (2). This
option is usually used for treatment of congenital infected
non-unions, and as a solution for bone defects after resections of
bone tumors in children.
fibular transfer is a relatively old technique which is probably
underutilized today. In comparison to other modern techniques, mainly
free fibular transfer, it provides comparable results. It seems to be
appropriate especially for children and adolescents. We suppose that
this method should be still remembered as a valuable option for
treatment of large tibial bone defects.
of Trauma Surgery, Faculty Hospital of Louis Pasteur
1. Agiza AR. Treatment of tibial osteomyelitic defects and infected pseudarthroses by the Huntington fibular transference operation. J. Bone Joint Surg. Am., 63, 1981, p. 814–819.
2. Agus H., Kalenderer O., Eryanilmaz G., Omeroglu H. Biological internal fixation of comminuted femur shaft fractures by bridge plating in children. J. Pediatr. Orthop., 23, 2003, p. 184–189.
3. Hatori M., Ayoub KS., Grimer RJ., Carter SR., Tillman RM. The two stage ipsilateral fibular transfer for tibial defect following tumour excision. Sarcoma, 4, 30, 2000, p. 27–30.
4. Khan MZ., Downing ND., Henry AP. Tibial reconstruction by ipsilateral vascularized fibular transfer. Injury, 27, 1996, p. 651–654.
5. Koulouvaris P., Theos C., Kottakis S., Demertzis N. A simple treatment for a 15-cm tibia bone defect: a case report of an ipsilateral vascularized fibula transfer. J. Orthop. Trauma, 21, 2007, p. 215–218.
6. Ozaki T., Hillmann A., Wuisman P., Winkelmann W. Reconstruction of tibia by ipsilateral vascularized fibula and allograft. 12 cases with malignant bone tumors. Acta Orthop. Scand., 68, 1997, p. 298–301.
7. Pho RW., Levack B., Satku K., Patradul A. Free vascularised fibular graft in the treatment of congenital pseudarthrosis of the tibia. J. Bone Joint Surg. Br., 67, 1985, p. 64–70.
8. Ruch, DS., Koman LA. The fibula-flexor hallucis longus osteomuscular flap. J. Bone Joint Surg. Br., 79, 1997, p. 964–968.