Danger zones associated with fibular osteotomy.

Anatomic dissections were performed on five cadaveric lower extremities. Measurements of important neurovascular structures in relation to the fibula were obtained at 1-cm intervals along the length of the fibula with the tip of the fibular head as the reference point. Neurovascular structures adjacent to the fibula in danger of injury with fibular osteotomy were identified. At the proximal one-third of the fibula, the peroneal nerves and their muscular branches are at primary risk. The anterior tibial artery is vulnerable where it penetrates the interosseous membrane and where it runs adjacent to the fibula with the deep peroneal nerve. In the middle one-third of the fibula, the peroneal artery and vein are the major structures at risk. In the distal one-third of the fibula the peroneal vessels are at less risk because they branch and enter the region of the syndesmosis curving anteriorly. The other neurovascular structures are not adjacent to the fibula. Based on these data, general recommendations for fibular osteotomy include (a) placement of the osteotomy as distally along the shaft as is feasible, commensurate with the surgical goal; (b) direction of the osteotomy blade along a line connecting the axis of the fibula with the midpoint of the subcutaneous tibial surface in the proximal and middle one-third of the fibula; and (c) direction of the osteotomy blade from the axis of fibula to the anterior subcutaneous border of the tibia in the distal one-third of the fibula.