Free Vascularized Fibula Flap Reconstruction of the Clavicle Combined with Biceps Tendon Repair of the Conoid Ligament and Customized Plate Stabilization of the Acromioclavicular Joint

Abstract

Sir: We report a new application of the free vascularized fibula1 for clavicular reconstruction, using a biceps tendon transfer to reconstruct the coracoclavicular ligament and a customized clavicular plate to prevent acromioclavicular joint dislocation. Two of three previous reports of vascularized fibula for clavicular reconstruction2,3 were for malunion and involved normal clavicular joints. The other describes whole clavicle reconstruction after oncologic resection of the clavicle.4 Although aesthetically satisfactory, wire fixation resulted in limited functional shoulder abduction. Our case epitomizes translational research collaboration between surgical and engineering specialties to produce an optimal outcome tailored to the patient. A 42-year-old man presented with a 5-cm recurrent dermatofibrosarcoma adherent to the periosteum of the lateral third of the left clavicle on magnetic resonance imaging, 9 years after his original resection. In operation 1, in October of 2006, wide tumor excision, with 3-cm skin margins and 9.5 cm (lateral two-thirds) of the clavicle, was performed, sparing adjacent neurovascular structures and a ligamentous acromioclavicular joint cuff (Fig. 1, left). A left osseocutaneous fibular flap was raised on the peroneal vessels and transferred (Fig. 1, center). The fibula was inset with reciprocal step-osteotomies in the clavicle and secured with a plate and unicortical screws. Laterally, the fibula was fixed in the acromioclavicular joint using a Kirschner wire threaded transversely through the acromion into the medulla of the fibula and by suturing the acromioclavicular joint capsule to a cuff of fibula periosteum. The coronoid (coracoclavicular) ligament was reconstructed using the short head of the biceps tendon. Left attached proximally, the tendon was split longitudinally toward the muscle belly and the medial half looped around the fibula and sutured to itself to reconstruct this ligament, critical for neoclavicular stabilization. End-to-end anastomosis of peroneal vessels to the transverse cervical artery and external jugular vein was performed to revascularize the flap. Despite satisfactory early postoperative recovery and appropriate splinting for 4 weeks, the Kirschner wire extruded, resulting in acromioclavicular joint subluxation. To resolve this, the curved Richardson clavicular dislocation hook-plate5 was customized by an engineer (Fevzi Alakus) to match the straight shape of the fibula.Fig. 1.: Diagram of the procedure. (Left) The site of bone section (arrow). (Center) The free flap and (right) in the split biceps tendon flap, the clavicular hook plate in position to prevent dislocation of the acromioclavicular joint, and revascularization of the composite flap to vessels in the neck.In operation 2, the acromioclavicular joint dislocation was reduced and held by fixing the modified clavicular plate with unicortical screws and positioning the hook beneath the acromion laterally (Fig. 1, right). The previously reconstructed coracoclavicular ligament (divided for access) was repaired and tightened. The wound healed uneventfully and the patient underwent precautionary postoperative radiotherapy. After initial stiffness, excellent shoulder contour and movement were achieved (Fig. 2), with radiographic union at 3 months and no resulting shoulder dislocation or tumor recurrence at 12 months. Although traditional teaching suggests that endosteal blood supply is critical for fibula bone flap survival, our experience suggests that this bone will survive on the periosteal supply alone, verified in this case, by sound claviculofibular union at 3 months, despite postoperative radiotherapy.Fig. 2.: The result at 6 months.The immediate clavicular reconstruction with conoid ligament repair and customized clavicular plating for acromioclavicular joint stabilization highlights the importance of multidisciplinary collaboration in optimizing outcomes for the individual patient. G. Ian Taylor, A.O., M.D. S. Seneviratne, F.R.A.C.S. I. Jones, F.R.A.C.S. D. White, F.R.A.C.S. E. Mah, M.B.B.S. R. Shayan, M.B.B.S. Department of Anatomy and Cell BiologyUniversity of MelbourneParkville, Victoria, Australia