Nutrient Foramina of the Fibula: A Systematic Review and Meta-Analysis with Narrative Context on Lower-Limb Long Bones

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Background: The nutrient arteries reach the diaphysis by passing through the nutrient foramina, and where these openings lie carries clinical weight for fracture healing, for cortical blood supply, and for the safe lifting of vascularized bone grafts. Reported values for the count, the location, and the foraminal index of these foramina in the long bones of the lower limb differ from one population and one methodology to the next. Objective: To pool the accessible evidence on the nutrient-foramen anatomy of the fibula and to set what emerges alongside the corresponding patterns reported for the femur and the tibia. Methods: A PubMed/MEDLINE search was carried out through 17 July 2026 and was widened with Google Scholar, PubMed Central/DOAJ-style channels, publisher and journal sites, and checks of reference lists. A study qualified when it was an osteometric or imaging report of adult human fibulae from which a nutrient-foramen count or a foraminal-index value could be extracted. Reports on the femur and tibia served as narrative lower-limb background. Pooling used random-effects models, with Freeman-Tukey transformed proportions and inverse-variance models for the means; logit-based sensitivity analyses of the proportions were run in addition. Results: Twenty-four studies fed into at least one quantitative fibula outcome. The foramen-count analysis drew on 23 studies and 2,398 fibulae. A single nutrient foramen was found in a pooled 90.7% of fibulae (95% CI 87.2-93.8; I2=86%), whereas the foramen was altogether missing in a pooled 3.2% (95% CI 1.5-5.5; I2=84%). Once the high-absence Parmar 2019 outlier was set aside, these figures shifted to 91.7% and 2.5%. The pooled foraminal index for the fibula came to 44.2% (95% CI 42.1-46.4; prediction interval 36.9-51.5; I2=94%), consistent with a customary middle-third position. For the femur, most reports noted one or more posterior foramina tracking the linea aspera, while for the tibia a solitary posterior foramen in the upper-to-middle third was the usual finding. Conclusion: The typical fibular arrangement is one nutrient foramen sited in the middle third, though absent and multiple foramina remain noteworthy variants. Because heterogeneity was high, the pooled figures are best treated as descriptive summaries of the evidence at hand rather than as fixed population constants. Keywords: nutrient foramen; foraminal index; fibula; femur; tibia; vascularized bone graft; anatomical variation; meta-analysis.

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