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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 37-40

Fibular osteotomy strategies and techniques: A survey of the limb lengthening and reconstruction society membership


1 Department of Orthopaedics, Scottish Rite Hospital, Dallas, TX, USA
2 Department of Orthopedic Surgery, Nationwide Children's Hospital, Columbus, OH, USA

Date of Web Publication23-Aug-2019

Correspondence Address:
Dr. Christopher A Iobst
Department of Orthopedic Surgery, Center for Limb Lengthening and Reconstruction, The Ohio State University, College of Medicine, Nationwide Children's Hospital, 700 Children's Drive, Suite T2E-A2700, Columbus, OH 43205
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jllr.jllr_8_19

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  Abstract 

Context: Fibular osteotomy is a necessary element of most tibial procedures, but there is no consensus on the ideal location, orientation, or technique for the procedure. Aims: We surveyed limb reconstruction surgeons to learn how often a fibular osteotomy was performed, details of surgical technique, and varying intraoperative parameters. Settings and Design: A cross-sectional survey was sent to all members of the Limb Lengthening and Reconstruction Society – North America, as well as experienced international limb reconstruction surgeons. Subjects and Methods: The survey contained 12 questions regarding fibular osteotomies in the setting of limb reconstruction surgery. Responses were not specific to any particular procedure. Data were collected on how often a fibular osteotomy was performed, details of surgical technique, and varying intraoperative parameters. Statistical Analysis Used: Statistical tests employed include Kruskal–Wallis, Mann–Whitney U, Chi-square, and Fisher's exact tests where appropriate. Results: A total of 149 surveys were returned. Most surgeons perform fibular osteotomy at the junction of middle and distal thirds or in middle third, 36.9% and 31.5%, respectively. The least common location for osteotomy was in the proximal third of fibula (4%). The most common method for creating fibular osteotomy was with an oscillating saw (48.3%), followed by drilling holes and using an osteotome (45.0%). The average reported time for the completion of osteotomy was 13 ± 7.2 min, with shortest average time reported for surgeons who perform osteotomy in the distal third (11.3 ± 6.4 min) and longest for those at proximal third (14.6 ± 10.3 min). The most common closure technique was that of layered closure (97%). Conclusions: Most surgeons perform a transverse osteotomy occurring at the junction of the middle and distal thirds of the fibula. The osteotomy is most commonly performed at the beginning of the case using either an oscillating saw or multiple drill holes and osteotome. Continued research is needed to determine the specific indications for performing a fibular osteotomy, if the anatomic location of the fibula osteotomy is important, and when a segment of the fibula should be removed.

Keywords: Fibular osteotomy, limb lengthening, osteotome, transverse osteotomy


How to cite this article:
Johnson D, Singh S, Samchukov M, Cherkashin A, Iobst CA. Fibular osteotomy strategies and techniques: A survey of the limb lengthening and reconstruction society membership. J Limb Lengthen Reconstr 2019;5:37-40

How to cite this URL:
Johnson D, Singh S, Samchukov M, Cherkashin A, Iobst CA. Fibular osteotomy strategies and techniques: A survey of the limb lengthening and reconstruction society membership. J Limb Lengthen Reconstr [serial online] 2019 [cited 2019 Sep 15];5:37-40. Available from: http://www.jlimblengthrecon.org/text.asp?2019/5/1/37/265361


  Introduction Top


Fibular osteotomies are an essential component of tibial lengthening and tibial reconstruction surgeries. A review of the tibial reconstruction literature demonstrates that most authors either ignore discussion of the fibular osteotomy or provide only a cursory description of the surgical technique.[1],[2],[3] Despite being a necessary element of most tibial procedures, there is no consensus on the ideal location, orientation, or technique of the fibular osteotomy.

The purpose of this study was to review the most common management strategies and surgical techniques for performing a fibular osteotomy during a typical reconstruction surgery by surveying an international group of experienced limb reconstruction surgeons.


  Subjects and Methods Top


A cross-sectional survey was sent to all members of the Limb Lengthening and Reconstruction Society – North America, as well as experienced international limb reconstruction surgeons. A total of 149 surveys were returned. The survey contained 12 questions [Figure 1] regarding fibular osteotomies in the setting of limb reconstruction surgery. Responses were not specific to any particular procedure (i.e., lengthening vs. reconstruction). All responses were collected and managed using REDCap data capture tools. Specifically, data were collected on how often a fibular osteotomy was performed, details of surgical technique, and varying intraoperative parameters. Free text responses were individually read by the authors and categorized for analysis. Statistical tests employed include Kruskal–Wallis, Mann–Whitney U, Chi-square, and Fisher's exact tests where appropriate. All analyses were completed using SPSS Statistics 24 (IBM, Armonk, NY, USA).
Figure 1: Survey questions

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  Results Top


A total of 149 surveys were completed and returned. Based on the responses, most surgeons perform the fibular osteotomy at the junction of the middle and distal thirds or in the middle third, 36.9% and 31.5%, respectively. The least common location for osteotomy was in the proximal third of the fibula (4%). Forty-nine percent of surgeons always perform a fibular osteotomy, whereas 51% only do so sometimes. The decision to perform an osteotomy did not vary significantly with the anatomic location of the fibular osteotomy (P = 0.868).

Performing the fibular osteotomy at the beginning of the external fixation case (75%) before frame attachment was preferred, rather than in the middle (11%) or at the end of the case (14%). Those who favor proximal fibular osteotomies appeared to have a higher incidence (33%) of performing the osteotomy after the frame was attached and the tibia was osteotomized; however, this was not significant (P = 0.758). The average overall incision length reported was 3.38 ± 1.5 cm. The length of the incision was not affected by the location of the osteotomy (P = 0.882).

The most common method for creating the fibular osteotomy was with an oscillating saw (48.3%), followed by drilling holes and using an osteotome (45.0%). The oscillating saw method was reported to be used 38.3% of the time for surgeons who chose the middle third and 56.4% for those who preferred the junction of the middle and distal thirds. For the drill hole and osteotome technique, the most common drill sizes used were 2.0–2.9 mm (42%), 1.8 mm or smaller (27%), and 3.0–3.9 mm (23%). The most common osteotome size was 6 mm (¼ inch) at 37% followed by 9 mm (3/8 inch) and 12 mm (½ inch) at 20% each. The majority of surgeons (77.7%) orient their osteotomy transversely, regardless of if an oscillating saw or multiple drill holes techniques were utilized. Approximately one-third of the respondents (36.3%) recommended excising a section of fibula during the procedure. This excised fragment was reported to be an average of 1.1 ± 0.5 cm. When removing a segment, the preferred method was an oscillating saw (64%) compared to drill holes and osteotome (32%).

The most common closure technique was that of layered closure (97%). In addition, 59% of surgeons report closing the fascia following the fibular osteotomy. Monocryl was the most common suture material followed by nylon and staples; v-lock, vicryl, and skin glue were the less frequently used.


  Discussion Top


Fibular osteotomies are a necessary component of many tibial lengthening and reconstruction procedures.[4] However, detailed descriptions of the surgical technique and the decision-making process surrounding this procedure are rarely included in the tibial literature. In addition, while the fibula osteotomy appears to be a straightforward task, it can often be a frustrating portion of the procedure. The purpose of the present study was to review the management strategies and technical details pertaining to fibular osteotomies as performed by experienced limb lengthening and reconstructive surgeons.

Once the surgeon determines if the fibula requires an osteotomy, the location and the timing of the osteotomy need to be chosen. In this survey, 75% of the surgeons preferred to perform the fibula osteotomy at the beginning of the case before the frame application. This allows the osteotomy to be completed without frame components obstructing access to the fibula. The most common locations for fibular osteotomies in our study were at the junction of the middle and distal thirds (36.9%) and in the middle third (31.5%). Most surgeons cited ease of procedure, reliable anatomy, avoiding the syndesmosis, and lower risk of disrupting the peroneal nerves as reasons for choosing these locations. Previous studies have highlighted the relationship between the site of osteotomy and the incidence of peroneal nerve palsies.[4],[5],[6],[7],[8] A higher complication rate is observed with osteotomies performed within 15 cm of the fibular head. Specifically, those existing 7–15 cm distal to the fibular head place the nerve to extensor hallucis longus at risk and can result in isolated weakness in great toe extension.[4],[9] Neurologic complications such as weakness in foot dorsiflexion, with or without sensory deficits, are reported to occur between 0% and 20% of the time.[4],[8],[10] While an osteotomy of the proximal fibula carries more risk, it may be warranted when performed in conjunction with peroneal nerve decompression, as a means to avoid additional skin incisions. Interestingly, there were conflicting responses regarding the distance from the tibial osteotomy site when selecting the location of the fibular osteotomy. Surgeons responded in nearly equal frequency for choosing an anatomic location because it was near the site of the tibial osteotomy as they did for choosing that the same location for being far away from it. Further investigation to define the indications for the fibular osteotomy location will need to be undertaken.

There are several techniques available for cutting the fibula. In our survey, the oscillating saw was the most common (48%) followed closely by the multiple drill hole and osteotome technique (45%). The Gigli saw and the Rongeur were also mentioned as methods of cutting the fibula. The oscillating saw was favored for osteotomy at the junction of the middle and distal thirds of the fibula, while the osteotome was favored for middle third osteotomies. For the drill hole and osteotome technique, a drill diameter between 2.0 and 3.0 mm and a ¼-inch osteotome were the most common sizes used among our respondents. Our results indicate that there does not appear to be any consensus regarding the most effective method for performing the fibula osteotomy, and there are no data in the literature comparing rates of healing between the various techniques. Surgeon preference seems to be the most compelling reason to use one technique over another.

The next decision regarding the fibula osteotomy is the orientation of the bone cut. According to our survey results, the majority of surgeons (77.7%) orient their osteotomy transversely, regardless of whether an oscillating saw or multiple drill holes technique was utilized. The location of the osteotomy also did not seem to influence whether a transverse or oblique osteotomy was chosen. Several advantages of the oblique osteotomy were mentioned in the responses, including: the fibula can be lengthened while still maintaining bony contact and the surface area available for healing is increased compared to a transverse osteotomy.

Once the fibula has been cut, the surgeon needs to decide whether a second osteotomy to remove a segment of the fibula is needed. The surgeon must weigh the risk of premature fibular consolidation against the risk of nonunion when fibular excision is performed. The incidence of premature consolidation varies in the literature, with some reports being as high as 8% when 0.5 cm of fibula is excised.[11] When the excised segment is increased to 1 cm, this rate decreases to 3%.[12] Conversely, the rate of nonunion increases when larger amounts of fibular bone are removed. A 10% nonunion rate associated with removing a 0.5 cm segment and a 40% nonunion rate with 1 cm of excision have been reported.[11],[12] Nonunion can also lead to distal fibular migration.[11] If the surgeon feels that a segment of fibula needs to be removed, the oscillating saw appears to be the most preferred method. The results from our study demonstrate that 36.3% of surgeons excise a portion of the fibula, at an average length of 1.1 ± 0.5 cm. A hybrid osteotomy method using the saw to start the bone cut and the osteotome used to complete the cut was also described by several surgeons. One technique tip mentioned was to make the second bone cut before finishing the first bone cut.

From a technical standpoint, the survey found the average overall incision length necessary to perform the osteotomy was 3 cm. This length was consistent regardless of the location for the osteotomy. At a minimum, the length of the incision should be long enough to avoid injuring the skin with retractors. Finally, 97% of surgeons preferred a layered closure with a 4.0 monocryl stitch in the skin. Leaving the incision open until the end of the procedure may help avoid hematoma formation.

This study has several limitations. First, even though experienced limb reconstruction surgeons were surveyed, the evidence is only anecdotal in nature. Second, the data were collected via survey and rely on the surgeon's ability to recall previous surgeries. Thus, measurements such as incisional length are only estimates and based on surgeon recall. Finally, the open-ended form of some of the questions made it difficult to objectively measure their answers. For example, we tried to determine the frequency that fibular osteotomy is utilized by asking, “When do you cut the fibula?” This was a poorly constructed question because we did not specify the exact case scenario (lengthening vs. reconstruction) and it was open ended. Therefore, it was difficult to determine whether the answers were referring to a tibial lengthening case or a tibial reconstruction case. Ultimately, the data for this question had to be omitted.


  Conclusions Top


Osteotomies of the fibula are an essential part of many tibial lengthening and deformity correction surgeries. Despite being an integral part of the procedure, discussion of the technique in the literature is scarce. This study found that most surgeons perform a transverse osteotomy occurring at the junction of the middle and distal thirds of the fibula. This location is chosen because it is safe, easy to perform, and away from the peroneal nerve. The osteotomy is most commonly performed at the beginning of the case using either an oscillating saw or multiple drill holes and osteotome. For surgeons who excise a portion of the fibula, an average of 1.1 cm is removed. A layered closure utilizing monocryl suture is typically performed. While this report sheds light on the most commonly performed practices, many questions still exist. Continued research is needed to determine the specific indications for performing a fibular osteotomy, if the anatomic location of the fibula osteotomy is important, and when, if ever, should a segment of the fibula be removed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Marti RK, Verhagen RA, Kerkhoffs GM, Moojen TM. Proximal tibial varus osteotomy. Indications, technique, and five to twenty-one-year results. J Bone Joint Surg Am 2001;83:164-70.  Back to cited text no. 1
    
2.
Georgoulis AD, Makris CA, Papageorgiou CD, Moebius UG, Xenakis T, Soucacos PN. Nerve and vessel injuries during high tibial osteotomy combined with distal fibular osteotomy: A clinically relevant anatomic study. Knee Surg Sports Traumatol Arthrosc 1999;7:15-9.  Back to cited text no. 2
    
3.
Eidelman M, Bialik V, Katzman A. The use of the Taylor spatial frame in adolescent Blount's disease: Is fibular osteotomy necessary? J Child Orthop 2008;2:199-204.  Back to cited text no. 3
    
4.
Ogbemudia AO, Umebese PF, Bafor A, Igbinovia E, Ogbemudia PE. The level of fibula osteotomy and incidence of peroneal nerve palsy in proximal tibial osteotomy. J Surg Tech Case Rep 2010;2:17-9.  Back to cited text no. 4
    
5.
Rupp RE, Podeszwa D, Ebraheim NA. Danger zones associated with fibular osteotomy. J Orthop Trauma 1994;8:54-8.  Back to cited text no. 5
    
6.
Soejima O, Ogata K, Ishinishi T, Fukahori Y, Miyauchi R. Anatomic considerations of the peroneal nerve for division of the fibula during high tibial osteotomy. Orthop Rev 1994;23:244-7.  Back to cited text no. 6
    
7.
Kirgis A, Albrecht S. Palsy of the deep peroneal nerve after proximal tibial osteotomy. An anatomical study. J Bone Joint Surg Am 1992;74:1180-5.  Back to cited text no. 7
    
8.
Wootton JR, Ashworth MJ, MacLaren CA. Neurological complications of high tibial osteotomy – The fibular osteotomy as a causative factor: A clinical and anatomical study. Ann R Coll Surg Engl 1995;77:31-4.  Back to cited text no. 8
    
9.
Jokio PJ, Ragni P, Lindholm TS. Management of the fibula in high tibial osteotomy for arthritis of the knee. Union times and complications. Ital J Orthop Traumatol 1986;12:41-52.  Back to cited text no. 9
    
10.
Wright JM, Crockett HC, Slawski DP, Madsen MW, Windsor RE. High tibial osteotomy. J Am Acad Orthop Surg 2005;13:279-89.  Back to cited text no. 10
    
11.
Kim SJ, Agashe MV, Song SH, Song HR. Fibula-related complications during bilateral tibial lengthening: 60 patients followed for mean 5 years. Acta Orthop 2012;83:271-5.  Back to cited text no. 11
    
12.
Hatzokos I, Drakou A, Christodoulou A, Terzidis I, Pournaras J. Inferior subluxation of the fibular head following tibial lengthening with a unilateral external fixator. J Bone Joint Surg Am 2004;86:1491-6.  Back to cited text no. 12
    


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