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 syndes- motic 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 ± 0.4 cm, 3.4 ± 0.5 cm, 1.9 ± 0.4 cm, and 5 ± 1 cm (mean ± SD), respectively. Distance from the most distal part of the fibula to lateral malleolus is 1.6 ± 0.4 cm (mean ± 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.