Surgical Anatomy for Fibular Free Flap Focusing on the Inferior Tibiofibular Syndesmotic System: A Cadaveric Study and Case Series of 3-Dimensional Prefabricate Cutting Guided Fibular Free Flap

Abstract

Even though there are many options for mandibular reconstruction, a free fibula osteocutaneous flap is regarded as the most frequently used flap. Despite having some previous anatomical studies pertaining to syndesmotic ligaments, there is no study pointing out that surgical landmarks can be used while free fibula osteocutaneous flaps are performed and used for surgical landmarks in order to avoid syndesmotic ligament injuries. Therefore, this study investigates the characteristics and relationship between inferior syndesmotic ligaments and fibula in cadavers. A total of 140 legs were obtained from 83 embalmed cadavers as well as other soft ones, which were donated for the inferior tibiofibular syndesmotic system's study. Detailed dissection and measurement of each ligament's distance to the end of the fibula and lateral malleolus were performed. Distances from the distal end of the fibula to anterior inferior tibiofibular ligament, posterior inferior tibiofibular, and inferior transverse ligament, and the lower border of the interosseous membrane are 3.5 AE 0.4 cm, 3.4 AE 0.5 cm, 1.9 AE 0.4 cm, and 5 AE 1 cm (mean AE SD), respectively. Distance from the most distal part of the fibula to lateral malleolus is 1.6 AE 0.4 cm (mean AE SD). Thus, the remaining distance of the fibular should be left at least 4 cm without disrupting the syndesmotic ligament complex. It is argued that the lateral malleolus can be applied as a surgical landmark while harvesting fibula.

Radiological landmark of syndesmotic ligament complex by magnetic resonance imaging correlate with fibula free flap harvesting procedure

“…For instance, Pacelli et al discovered that maintaining syndesmotic ligament stability and preventing ankle instability required leaving 10% of the fibular shaft (3.9 cm) preserved 11 . Additionally, Ongsiriporn et al reported comparable distances between the distal end of the fibula and the AITFL and PITFL, suggesting that the lateral malleolus could function as a surgical landmark for fibula harvesting 7 .…”

“…Additionally, we can inform CT-guided surgical planning by examining the ligament-bone relationship in MRI scans. The previous study 7 suggests that CT scans and the surgical landmark 2 cm above the lateral malleolus can be used for a safe osteotomy without syndesmotic ligament injury. Despite poor ligament visualization on CT scans, surgeons can use this knowledge to choose the best osteotomy site.…”

“…Few studies have investigated the distal tibiofibular complex's anatomy, particularly in relation to FFF surgery, whereas the majority of ankle MRI studies have focused on evaluating ligament injuries 6 . On the basis of our previous cadaveric study, a surgical landmark 2 cm above the lateral malleolus can be used intraoperatively for safe osteotomy without the potential of syndesmotic ligament injury 7 . This study aims to investigate the characteristics and relationship between the inferior syndesmotic ligaments and the fibula bone, that can be utilized for preoperative planning in FFF procedures, specifically virtual surgical planning.…”