TIPS AND PEARLS

Prevention of Complications During Fibular Osteotomy

Mark Eidelman, MD and Pavel Kotlarsky, MD
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Key Words: fibular osteotomy—fibula—deformity correction—limb

lengthening—leg deformity.
(Tech Orthop 2024;00: 000–000)

F ibular osteotomy is a standard procedure, frequently per-

formed as part of deformity correction surgery of the leg.
Complications related to fibular osteotomy are well
described.1–5 The most feared complication related to fibular
osteotomy is peroneal nerve palsy.2–5 The incidence of peroneal
nerve palsy is related to the level where the osteotomy is per-
formed. Nevertheless, even when performed between the distal
and middle third of the fibula, an area that is considered to be
relatively safe, injury to the extensor hallucis longus (EHL) was
still described.2 Another potential complication is nonunion.
In our opinion, these complications are mostly related to
technical errors and bone thermal injury. During the last
15 years, to avoid complications related to fibular osteotomy,
we developed a specialized technique.
The aim of this study was to describe our technique
developed to diminish complications related to fibular osteotomy.

TECHNIQUE
After receiving approval from the Institutional Review
Board, we retrospectively reviewed the medical records of all
patients who underwent fibular osteotomy as part of leg
deformity correction and/or leg lengthening surgery between
FIGURE 1. First, drill holes are created in line with planned
the years 2006 and 2019. We found 168 patients who under- osteotomy (black arrow pointing to a magnified view).
went 210 fibular osteotomies at the level of the middle third of
the fibula. There were 102 males and 66 females with a mean
age of 14 years (range: 3 to 66 y).

Operative Technique
Fibular osteotomy is performed as the initial step of
deformity correction surgery. The patient is positioned supine
with a bump under the buttock on the operated side to prevent
the foot from rolling outwards. After preparation and draping,
a sterile tourniquet is applied. The preferred area for osteot-
omy is between the middle and distal third of the fibula,
which is the safest region. At this level, the fibula is quite
superficial and usually can be easily palpated. A roughly 3 cm
skin incision is done, followed by deeper dissection between

From the Pediatric Orthopedics, Ruth Rappaport Children’s Hospital,

Rambam Health Care Campus, Haifa, Israel.
M.E.: study design, data analysis, and manuscript preparation. P.K.: study
design, data collection, data analysis, and manuscript preparation.
The authors declare that they have nothing to disclose.
For reprint requests, or additional information and guidance on the
techniques described in the article, please contact Pavel Kotlarsky, MD,
at spavelko@gmail.com or by mail at Pediatric Orthopedics, Ruth
Rappaport Childrens’ Hospital, Rambam Health Care Campus, 8 Haaliya
Hashniya Street, Haifa 3525408, Israel. You may inquire whether the
author(s) will agree to phone conferences and/or visits regarding these FIGURE 2. Next, osteotomy is completed using osteotome in
techniques. anterior to posterior direction (black arrow pointing to diagram
Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved. that clarifies the direction of the osteotome).

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 Eidelman and Kotlarsky Techniques in Orthopaedics$  Volume 00, Number 00, ’’ 2024

posterior. The drill holes are positioned in a line of anticipated

osteotomy (Fig. 1). The number of drill holes depends on the
size of the fibula, though, we aim to place a drill hole every 2
to 3 mm. The osteotomy is completed with an osteotome
directed from anterior to posterior (Figs. 2, 3). The choice of
this direction reduces the likelihood of peroneal artery injury,
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which is located just medial to the fibula, next to the tibio-

fibular interosseous membrane. In addition, this course avoids
injuring the peroneal nerve branch that innervates the EHL,
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which is another serious complication occasionally associated

with fibular osteotomy.3 The tourniquet can be released at this
stage, if not required for further surgical steps. The skin is
closed in layers (subcutaneous layer and skin).

FIGURE 3. A magnified view of the osteotomy site after drill holes
were placed showing again the position of the osteotome.
peroneal muscles at the front and gastrocnemius-soleus
muscle at the back. Sharp dissection using scissors reveals
the fibula. Two small Hohmann retractors are inserted sub-
periosteally anterior and posterior to the fibula. To prevent
thermal necrosis, we predrill the fibula with an Ilizarov 1.8
wire from lateral to medial, as well as from anterior to
EXPECTED OUTCOMES
There were no complications related to fibular osteotomy;
no peroneal nerve injury, as well as no EHL branch injury, and
no intraoperative bleeding after completion of the osteotomy
and tourniquet removal. Healing time of the osteotomy was
somewhat variable based on the additional procedures that were
performed. Union rates were up to 8 weeks in patients who did
not have concomitant lengthening procedures (average 5.5
wk). In patients who had lengthening, fibular union was seen no
later than 8 weeks after the end of lengthening (average 5 wk).
No delayed unions or nonunions have been observed. A clinical
example of fibular osteotomy as part of a leg-lengthening
procedure is shown in Figure 4.

FIGURE 4. Clinical example. An 11-year-old patient who had fibular osteotomy as part of a tibial lengthening procedure. A, completed
osteotomy at surgery. B, One month after surgery distraction at the fibular osteotomy site can be seen. C, One year after surgery, there is
complete remodeling at the osteotomy site.

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 Techniques in Orthopaedics$  Volume 00, Number 00, ’’ 2024
COMPLICATIONS AND DISCUSSION
Osteotomy of the fibula is a common procedure in
deformity correction surgery and leg lengthening. The osteot-
omy can be performed in different regions of the fibula.
Complication rates are directly related to the level of the
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osteotomy. Wootton et al3 recommended not to perform fibular
osteotomy in zones II to III (from just below the fibular head to
15 cm distal to this level) due to a high incidence of neuro-
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logical complications (21 out of 105 patients, 20% incidence).
We routinely perform osteotomy of the fibula between the
middle and distal third; however, even at this level, complica-
tions are not uncommon, and primarily related to injury to the
peroneal artery and the peroneal nerve.
Low-heat osteotomy using predrilling, followed by com-
pletion of the osteotomy of the fibula by an osteotome in the
anterior to posterior direction, is a safe, simple, and straight-
forward procedure. This method has become the standard
technique in our practice for the last 15 years. Since applying
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Safe Fibular Osteotomy
this technique, no complications related to the fibular osteotomy
have been observed in our practice.
REFERENCES
1. Sachs O, Katzman A, Abu-Johar E, et al. Treatment of adolescent Blount
disease using the Taylor spatial frame with and without fibular
osteotomy: is there any difference? J Pediatr Orthop. 2015;35:501–506.
2. Dilawaiz NR, Quick TJ, Eastwood DM. Focal dome osteotomy for correction
of tibial deformity in children. J Pediatr Orthop B. 2005;14:340–346.
3. Wootton JR, Asworth MJ, McLaren CA. Neurological complications of
high tibial osteotomy as causative factor: a clinical and anatomical study.
Ann R Coll Surg Engl. 1995;77:31–34.
4. Gibson M, Barnes M, Allen M, et al. Weakness of foot dorsiflexion and
changes in compartment pressures after tibial osteotomy. J Bone Joint
Surg Br. 1986;68-B:471–475.
5. Curley P, Eyres K, Brezinova V, et al. Common peroneal nerve dysfunction
after high tibial osteotomy. J Bone Joint Surg. 1990;72:405–408.
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