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Management of Fibula in HTO

- Discussion:
    - proximal tibiofibular joint will prevent valgus correction unless fibula is shortened or tibiofibular ligaments are removed;
    - transection if tibiofibular ligamets: (preferred technique)
           - performed thru same incision as for osteotomy;
           - proximal tibiofibular joint capsule is disrupted (may also remove inner 1/3 of fibular head), allowing the fibula to migrate
           - tibiofibular ligaments can be sectioned or portion of fibula to which they attach can be removed;
           - if large correction is needed, however, fibular head, if retained, may impact on proximal tibial fragment as wedge is closed;
           - in the study by Billings A, et al. (2000), not one of 64 knees that underwent high tibial osteotomy (using transection of the
                   tibio-fibular capsule) developed peroneal nerve palsy;

    - fibular head transection:
         - gives clear access to lateral tibial condyle, removes tibiofibular joint and ligaments, and allows for
                  reattachment of biceps tendon & fibular collateral ligament to neck of fibula under
                  physiological tension;
         - w/ this technique, peroneal nerve can be visualized directly;
         - the distal cut can be made directly thru the center of the fibular head;
                 - care is taken to protect the peroneal nerve;
                 - often the proximal fibular head fragment will fuse to the proximal tibia, as well as healing to the distal
                            fibular fragment;
    - fibular transection:
         - oblique transection in its prox 1/3 to allow overlap as osteotomy is closed;
         - be aware of the danger zone of fibular osteotomy which lies between 70 mm and 150 mm from the
                 fibular head (which endangers nerve  branches to the EHL)

The fate of fibular osteotomies performed during high tibial osteotomy

Danger Zones Associated with Fibular Osteotomy.

Palsy of the deep peroneal nerve after proximal tibial osteotomy. An anatomical study.

High Tibial Osteotomy with a Calibrated Osteotomy Guide, Rigid Internal Fixation, and Early Motion. Long-Term Follow-up.

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