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Fibular Strut Graft: Comprehensive Research & Literature Review
What Is a Fibular Strut Graft?
A fibular strut graft uses a segment of the fibula - either as a free non-vascularized graft, a vascularized free flap with its peroneal artery pedicle, or a pedicled/local graft - as a structural bone support ("strut") across a defect, nonunion, or mechanically compromised skeletal site. The fibula is favored because it is long, tubular, cortical, and expendable without major functional loss, and when vascularized, it retains osteogenic capacity and the ability to hypertrophy under load.
I. Anatomical Basis & Biomechanical Rationale
The fibula offers:
- Cortical tubular geometry ideal for intramedullary or extramedullary strut positioning
- Length up to 25-30 cm harvestable
- Peroneal artery pedicle (when vascularized): allows microvascular anastomosis and living bone transfer
- Hypertrophy potential: vascularized grafts remodel and strengthen over time under mechanical loading
- Expendability: the tibia bears ~85% of lower leg load; fibula removal causes minimal functional deficit if the distal 6 cm are preserved
II. Major Clinical Applications
1. Proximal Humerus Fractures (Medial Column Support)
Campbell's Operative Orthopaedics (15th Ed., 2026) describes fibular strut graft use in proximal humerus ORIF as providing medial column support, particularly in:
- Osteoporotic bone
- Posteromedial calcar comminution
- Metadiaphyseal extension
- 3- and 4-part fractures at risk of varus collapse
"Use of a fibular strut graft to provide medial column support has proven efficacious particularly in patients with osteoporosis, demonstrating improved radiographic outcomes and reduced complications compared with locked plating alone." - Campbell's Operative Orthopaedics 15th Ed.
The graft is inserted endosteally (intramedullary), acting as an internal scaffold to support the humeral head and prevent varus malunion or screw cut-out.
Key literature:
| Study | Design | Key Finding |
|---|---|---|
| Tang et al. (2022) - PMID 35191274 | Meta-analysis, 749 patients, 10 cohort studies | Locking plate + fibular strut allograft superior to locking plate alone for humeral head height preservation, neck-shaft angle, Constant-Murley score, ASES score, VAS, varus malunion rate (RR 0.22), and screw penetration rate (RR 0.26) |
| Cheng et al. (2025) - PMID 40676439 | Systematic review + meta-analysis, 37,494 patients, 35 studies incl. 6 RCTs | Augmentation (including fibular strut) improves pain, function, and radiographic outcomes but did not significantly reduce overall complication risk vs. locking plate alone; no significant difference between strut fibular and non-fibular grafts |
| Myers et al. (2020) - PMID 32745228 | Comparative series | Lower complication incidence (coronal collapse 5%, AVN 6.5%, screw breakage/loosening 6.6%, revision surgery 1.7%) with fibular strut vs. without |
| Tuerxun et al. (2020) - PMID 32882053 | Comparative | Complication rate 7.3% (fibular allograft group) vs. 27.3% (locking plate alone) |
| Matassi et al. (2012) - PMID 22921382 | Evaluation study | 100% radiographic healing without AVN, head collapse, or screw cut-out in 17 patients |
| Das SP et al. (2025) - PMID 40450630 | Four-part fractures | Clinico-radiological outcomes of fibular strut augmentation in four-part proximal humerus fractures |
Technique (Willis et al., as described in Campbell's 15th Ed.):
- Expose and mobilize the nonunion site
- Debride devitalized bone; shorten as needed for contact
- Open the medullary canal both proximally and distally
- Fashion fibular allograft with high-speed burr - length should be 3-4x the humerus diameter at the nonunion site
- Insert graft into one fragment, then slide across the nonunion site
- Stabilize with DCP/LC-DCP/LCP; at least one screw on each side through the allograft
2. Femoral Neck Fractures
Fibular strut grafting is used in both fresh and neglected femoral neck fractures, typically in combination with cannulated screws or a dynamic hip screw (DHS). The graft serves to:
- Fill the medullary canal, providing structural support and preventing collapse
- Provide biological stimulus to union
- Support the posterior calcar in comminuted fractures
Key literature:
| Study | PMID | Focus |
|---|---|---|
| Zahid et al. (2012) | 22933677 | Cannulated screws + fibular strut for fresh fractures with posterior comminution |
| Pal et al. (2014) | 25163951 | Cancellous screws + fibular strut for neglected femoral neck fractures |
| Elgeidi & El Negery (2017) | 28730395 | DHS + fibular strut for fresh femoral neck fractures with posterior comminution |
| Mehraj et al. (2022) | 36524782 | Fibular strut + cannulated screws for fresh femoral neck fractures |
| Azam et al. (2009) | 19753182 | Free fibular strut graft in neglected femoral neck fractures in adults |
| Elgeidi & El-Negery (2017) | 28439306 | Fibular strut for nonunited femoral neck fractures in children |
| Velmurugesan et al. (2025) | 40511348 | DHS + fibular strut vs. Femoral Neck System for comminuted femoral neck fractures |
3. Avascular Necrosis (AVN) of the Femoral Head - Vascularized Fibular Graft
This is one of the most technically sophisticated applications. As described in Miller's Review of Orthopaedics (9th Ed.):
"Vascularized fibular strut is placed up against subchondral plate of femoral head to prevent collapse. Microvascular anastomosis with lateral femoral circumflex artery."
Principles:
- Surgical removal of the necrotic segment through a large core hole
- VFG placed up against the subchondral plate to mechanically prevent femoral head collapse
- Anastomosis to the lateral femoral circumflex artery
- Particulate autogenous bone grafting of adjacent resected bone
Indications: Medium (B) and large (C) lesions; no crescent sign preferred; reasonable success even with crescent sign and minimal head collapse
Complications: Flexor hallucis longus contracture is the most common donor-site complication
| Study | PMID | Key Contribution |
|---|---|---|
| Eward et al. (2012) | 22733182 | Long-term hip preservation with VFG in precollapse osteonecrosis |
| Richard et al. (2021) | 34016425 | Outcomes of VFG for post-traumatic osteonecrosis |
| Gaskill et al. (2009) | 19651942 | Donor and graft site morbidity with free vascularized fibular transfer |
| Davis et al. (2006) | 17079376 | THA after failed VFG - technical considerations |
| Dean et al. (2001) | 11347822 | Pediatric femoral head osteonecrosis treated with free VFG |
| Khan et al. (2025) | 41116936 | Core decompression vs. fibular strut graft in early AVN of the hip |
4. Spine - Anterior Column Reconstruction
Fibular strut grafts have a long history in anterior spinal surgery. Campbell's 15th Ed. notes that the anterior retropharyngeal approach (McAfee modification) provides adequate exposure for insertion of iliac or fibular strut grafts without posterior carotid dissection or oral cavity entry.
Applications include:
- Anterior cervical corpectomy reconstruction
- Cervicothoracic junction reconstruction
- Tumor resection (chordoma, chondrosarcoma)
- Spondylolisthesis salvage
- Craniocervical junction instability
| Study | PMID | Contribution |
|---|---|---|
| Minami et al. (1997) | 9020443 | Free vascularized fibular strut graft for anterior spinal fusion |
| Yanamadala et al. (2017) | 28327915 | Vascularized fibular strut autografts in spinal reconstruction after chordoma/chondrosarcoma resection |
| Addosooki et al. (2016) | 27099811 | Anterior cervical reconstruction using free vascularized fibular graft after corpectomy |
| Goldman et al. (2020) | 32795683 | Cervical spine and craniocervical junction reconstruction with vascularized fibula free flap |
| Thongtrangan et al. (2003) | 15347222 | Management of strut graft failure in anterior cervical spine surgery |
| Meyers et al. (2001) | 11493859 | Salvage reconstruction with vascularized fibular strut fusion for severe spondylolisthesis |
5. Ankle Arthrodesis - Transfibular (Transmalleolar) Approach
Campbell's Operative Orthopaedics (15th Ed.) describes the transfibular arthrodesis technique incorporating a vascularized fibular strut graft as a modification of the Mann technique:
"The original technique of Mann has been modified to incorporate, if possible, a vascularized fibular strut graft. This graft brings an added measure of stability and vascular supply to the fusion site. Colman and Pomeroy reported a 96% fusion rate in 48 patients, with an average time to fusion of 82 days."
Additional ankle applications:
- Tibiotalocalcaneal (TTC) arthrodesis: Fibular strut graft used as intramedullary bone scaffold, especially in revision cases and Charcot neuroarthropathy
- Sankey et al. (2023) - PMID 38274151: TTC arthrodesis with intramedullary fibular strut graft and adjuvant hardware fixation
- Monaco et al. (2016) - PMID 27009078: Fibular strut graft for revisional TTC arthrodesis
- Desnantyo et al. (2023) - PMID 37399591: Fibular strut graft for primary ankle arthrodesis in diabetic Charcot neuroarthropathy
6. Humerus Nonunion / Gap Nonunion
The fibular strut graft acts as a "biological intramedullary nail" (JBJS) in complex nonunions:
- Gap nonunions of the humeral shaft
- Oligotrophic nonunions refractory to revision ORIF
- Provides both structural support and biological stimulus
| Study | PMID / Source | Key Finding |
|---|---|---|
| Kale et al. (2024) | 39253680 | Gap nonunion humerus: fibular strut graft + iliac crest + LCP functional outcomes |
| Fink Barnes et al. (2020) | - | Non-vascularized fibular strut allograft for humeral shaft nonunions: postoperative outcomes and surgical technique review |
| Badman et al. (cited in Campbell's) | - | Achieved radiographic union in 17/18 (94%) of surgical neck nonunions |
7. Elbow, Forearm & Long Bone Defects
Campbell's also documents fibular strut allograft use in revision elbow surgery and free vascularized fibular graft (VFG) for long bone defects >6 cm in the forearm, tibia, and femur. An updated techniques review (Park, Archives of Hand and Microsurgery 2024) summarizes expanded VFG indications:
- Mid-tibial, humeral, forearm, distal femur, proximal tibia defects
- Shoulder and knee joint arthrodesis
- Tumor resection reconstruction
8. Osteoperiosteal Fibular Strut Grafting
A recent technique modification:
- Venkatadass et al. (2024) - PMID 39066905: Osteoperiosteal fibular strut grafting to improve union rates - preserving the periosteum maximizes the osteogenic potential of the graft
III. Vascularized vs. Non-Vascularized Fibular Strut
| Feature | Non-Vascularized (Free Graft) | Vascularized (VFG/Free Flap) |
|---|---|---|
| Mechanism | Osteoconductive scaffold; incorporation by creeping substitution | Living bone; immediate osteogenesis; remodels and hypertrophies |
| Best for | Short defects (<6 cm), medullary canal support, adjunct fixation | Defects >6 cm, AVN of femoral head, irradiated fields, tumor resection |
| Revascularization time | Months; full strength restored late | Immediate vascular supply |
| Technical complexity | Moderate | High (microsurgery required) |
| Donor site morbidity | Low (FHL contracture uncommon) | Low but requires microsurgical expertise |
| Hypertrophy | Minimal | Yes - can double in diameter over years |
| Key complication | Graft resorption or fracture before incorporation | Vascular thrombosis, FHL contracture |
IV. High-Level Evidence Summary (Meta-Analyses & Systematic Reviews)
-
Tang et al. (2022) [PMID 35191274] - Meta-analysis: Locking plate + fibular strut allograft vs. locking plate alone for proximal humerus fractures (749 patients). Fibular strut significantly superior in humeral head height, neck-shaft angle, Constant-Murley, ASES, VAS, varus malunion (RR 0.22), and screw penetration (RR 0.26). No difference in osteonecrosis rate.
-
Cheng et al. (2025) [PMID 40676439] - Systematic review + meta-analysis: 37,494 patients across 35 studies (6 RCTs). Augmentation (bone grafts + cement) improves pain, function, and radiographic outcomes but does not convincingly reduce complication or screw protrusion risk vs. locking plate alone. No significant difference between fibular and non-fibular strut grafts.
-
Dasari et al. (2022) (cited in web sources): Improved outcomes for proximal humerus ORIF augmented with fibular allograft in elderly patients - systematic review and meta-analysis (J Shoulder Elbow Surg).
V. Donor Site Considerations
- Harvest typically from the ipsilateral or contralateral leg, 10-15 cm proximal to the lateral malleolus
- Distal 6 cm of fibula must be preserved to maintain ankle syndesmosis stability
- Peroneal nerve at risk proximally
- For VFG: peroneal artery and venae comitantes harvested with the graft
- Most common donor morbidity: ankle instability (if too much distal fibula removed), FHL tightness/contracture, peroneal nerve injury
VI. Current Research Gaps & Trends (2024-2026)
- Osteoperiosteal technique (Venkatadass et al., 2024): Preserving periosteum to enhance biology
- Optimal insertion angle for proximal humerus: Finite element analysis (MDPI Bioengineering 2025) comparing vertical vs. oblique insertion
- DHS + fibular strut vs. newer implants (Femoral Neck System) for comminuted femoral neck fractures (Velmurugesan et al., 2025 - PMID 40511348)
- Fibula strut allograft + biological augmentation (tibial autograft, BMP, PRP) for oligotrophic nonunions
- TTC arthrodesis outcomes in Charcot neuroarthropathy
Key References
Textbooks:
- Campbell's Operative Orthopaedics, 15th Ed. (2026) - Chapters on humerus fractures/nonunion, ankle arthrodesis, cervical spine approaches
- Miller's Review of Orthopaedics, 9th Ed. - Hip osteonecrosis chapter
PubMed - Highest Evidence:
- Tang et al. 2022 (Meta-analysis, proximal humerus) - PMID 35191274
- Cheng et al. 2025 (Syst. review + meta-analysis, proximal humerus) - PMID 40676439
- Eward et al. 2012 (VFG for hip AVN) - PMID 22733182
- Yanamadala et al. 2017 (VFG for spinal chordoma) - PMID 28327915
- Venkatadass et al. 2024 (Osteoperiosteal technique) - PMID 39066905
- Velmurugesan et al. 2025 (DHS+fibular strut vs. FNS) - PMID 40511348
Web Resources:
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