Discovering and designing the free fibula flap—how we did it

The first successful free vascularised bone flap in a human was performed on 1 June 1974 (reported in 1975) using the fibula diaphysis supplied by the peroneal artery and vein to repair a tibial defect. This was followed by us with the iliac crest based on the superficial circumflex iliac artery in 1975 and then the deep circumflex iliac artery in 1978. On 29 November 1983, the fibula was transplanted for the first time on the anterior tibial vessels in a child to repair the tibia following tumour ablation. Finally on 7 May 1984 the growth plate in the proximal epiphysis of the fibula was transplanted successfully on the anterior tibial vessels, and especially its recurrent genicular branch, to repair the distal radius after a traumatic hand injury. The growth rate of this epiphysis matched that of the fibula in the opposite leg and fused at the same time. Fourteen cases of free vascularised fibula transfer are presented from a series of 397, including three unique transfers of the fibula diaphysis and epiphysis to repair the jaw, clavicle and long bones of the extremities. The blood supply to and within the fibula plus vascular anomalies are detailed following fresh cadaver India ink injection, bone histology and lead oxide radiography. Preoperative planning using angiography, computer-generated bone models of the donor and recipient bones to plan osteotomies for jaw reconstruction, trial runs in cadavers, Doppler perforator mapping for skin flaps and incision-marking before theatre are all prerequisites for success. Operative technique is outlined for each approach to the fibula and potential pitfalls are highlighted. The importance of protected stress on the fibula, especially in the lower extremity, is paramount. The fibula should be placed within the medullary cavity of the femur or tibia in the line of weight bearing and protected from rotational or angular stress by an external cast, a fixateur with pins placed before and beyond the fibula or, now it is becoming clear, transfixed with an intramedullary nail or rod. With large series worldwide, some in the thousands and with success rates in the high 90 per cents, the free vascularised fibula flap, especially when combined with skin and soft tissue, has emerged as the gold standard for reconstructing major congenital or acquired defects in the jaw and long bones of the extremities, facilitated by the large calibre of its supplying vessels. Now with the ability to transfer the fibula with the associated skin and deep tissues of its peroneal or anterior tibial angiosome, we have the ability in one day to replace the months and years of the multi-staged reconstructions that were endured by those that suffered the ravages of the two world wars.