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Approach to the Fibula

 Approach to the Fibula


Approach to the Fibula indications:

The approach to the fibula employs a classic extensile exposure and offers access to all parts of the fibula.

The approach to the fibula includes the following:

  1. Partial resection of the fibula during tibial osteotomy or as part of the treatment of tibial nonunion.
  2. Resection of the fibula for decompression of all four compartments of the leg.
  3. Tumors Resection.
  4. Osteomyelitis Resection.
  5. Open reduction and internal fixation of fractures of the fibula
  6. Removal of bone graft, cortico-cancellous strut grafts.

Position of the Patient

  • Place the patient on his or her side on the operating table with the affected side uppermost.

If fibula approach is used in conjunction with a surgical approach to the tibia, place the patient supine on the operating table. A sandbag placed underneath the affected buttock will rotate the leg internally. Tilting the table away from the operative side will further increase internal rotation and allow adequate exposure of the lateral aspect of the leg. Subsequently, if the sandbag is removed and the table is leveled, the leg will naturally rotate externally, providing access to the tibia.

Landmarks and Incision

  • Landmarks:
    1. Head of the fibula.
    2. The lower fourth of the fibula.
  • Incision:
    • Make a linear incision just posterior to the fibula, beginning behind the lateral malleolus and extending to the level of the fibular head.
    • Continue the incision up and back, a handbreadth above the head of the fibula and in line with the biceps femoris tendon. Watch out for the common peroneal nerve, which runs subcutaneously over the neck of the fibula and can be cut if the skin incision is too bold.
    • The length of the incision depends on the amount of exposure needed

Internervous plane

The internervous plane for the approach to the fibula lies between:

  • Peroneal muscles: it’s innervated by the superficial peroneal nerve.
  • Muscles of the posterior compartment: it’s innervated by the tibial nerve.

Superficial dissection

  • To expose the fibular head and neck, begin proximally by incising the deep fascia in line with the incision, taking great care not to cut the underlying common peroneal nerve.
  • Find the posterior border of the biceps femoris tendon as it sweeps down past the knee before inserting into the head of the fibula.
  • Identify and isolate the common peroneal nerve in its course behind the biceps tendon; trace it as it winds
    around the fibular neck.
  • Mobilize the nerve from the groove on the back of the neck by cutting the fibers of the peroneus longus that cover the nerve and gently pulling the nerve forward over the fibular head with a strip of corrugated rubber drain.
  • Identify and preserve all branches of the nerve.
  • Develop a plane between the peroneal and the soleus; with the common peroneal nerve retracted anteriorly, incise the periosteum of the fibula longitudinally in the line with this plane of cleavage.
  • Continue the incision down to bone.

Deep dissection

  • Strip the muscle off the fibula by dissection. All muscles that originate from the fibula have fibers that run distally toward the foot and ankle.
  • Therefore, to strip them off cleanly, you must elevate them from distal to proximal. Most muscles originate from periosteum or fascia; they can be stripped.
  • Muscles attached directly to bone are difficult to strip; they usually must be cut The other structure attached to the fibula, the interosseous membrane, has fibers that run obliquely upward.
  • To complete the dissection, strip the interosseous membrane subperiosteally from proximal to distal.

Approach Extension

The approach to the fibula can be extended distally:

  • Extend the skin incision distally by curving it over the lateral side of the tarsus.
  • To gain access to the sinus tarsi and the talocalcaneal, talonavicular, and calcaneocuboid joints, reflect the underlying extensor digitorum brevis muscle.
  • This extension is used frequently for lateral operations on the leg and foot.

Dangers

The structures at risk during the approach to the fibula include:

  1. Common peroneal nerve: Avoid injury by isolating proximally.
  2. Superficial peroneal nerve: It’s susceptible to injury at junction of middle and distal third of leg, if injured will cause numbness on the dorsum of the foot.

References

  • Surgical Exposures in Orthopaedics book – 4th Edition
  • Campbel’s Operative Orthopaedics book 12th

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