Use of a Retrograde Pedicled Double-Barreled Osteocutaneous Fibula Flap for Reconstruction of Distal Tibia and Soft-Tissue Defects

Abstract

Sir: After trauma or oncologic surgery, distal lower extremity reconstruction is often challenging. Although microsurgery allows composite transfer of bone, muscle, and skin, free tissue transfer to the lower extremity is marred by high failure rates.1 Traditionally, free osteocutaneous fibula flaps have been the workhorse flaps for reconstructing dual bone and soft-tissue defects.2,3 In 1986, Chen et al. described a pedicled, osteocutaneous fibula flap for distal femur reconstruction.4 Later, Minami et al. described the retrograde fibula flap based on communicating branches between the peroneal and posterior tibial vessels for reconstruction of distal tibia defects.5 To our knowledge, no retrograde, pedicled fibula flap has been harvested with an overlying soft-tissue component supplied by underlying peroneal septocutaneous perforators. Such a skin paddle allows reconstruction of accompanying soft-tissue defects and serves as a marker for total flap viability. Furthermore, cutaneous harvest has not been reported in a retrograde, pedicled fibula flap in which the fibula is osteotomized. A patient suffered an open tibia-fibula fracture complicated by osteomyelitis and nonunion. After débridement, she had a 7-cm distal tibia and soft-tissue defect (Fig. 1). We used a retrograde, pedicled, osteocutaneous fibula flap for reconstruction.Fig. 1.: (Above, left) A 7-cm distal tibia defect (filled with antibiotic bone spacer) had loss of overlying soft tissue following surgical débridement. Intraoperative marking of the tunnel site for skin paddle was marked with a checkerboard pattern. (Above, left) A retrograde osteocutaneous fibula flap was mobilized on the distal pedicle after ligation of the peroneal vessels at their takeoff. (Below, left) After contouring osteotomy, a double-barreled vascularized fibula and a single strut of nonvascularized fibula were cerclage-wired together to fill the distal tibial defect. (Below, right) After final inset, the skin paddle appeared viable.Intraoperatively, the fibula was traced from the lateral condyle of the knee to the lateral malleolus. The area between the defect and harvest sites (checkerboard pattern) marks where the flap would be tunneled. We used Doppler ultrasonography to identify peroneal perforators and accordingly designed a 12 × 6-cm skin paddle. Using both anterior and posterior approaches, the osteocutaneous fibula flap was harvested in situ in the standard fashion.3 Next, we dissected cephalad to the tibial-peroneal trunk, ligating the peroneal vessels at their takeoff. This converted the in situ flap into a retrograde flap mobilized on its distal pedicle (Fig. 1). The recipient site was prepared by elevating fasciocutaneous edges and the previously marked tunnel. A reconstruction plate was presecured in the anteromedial tibia (spanning the defect) with five proximal and four distal screws, and then removed. The fibula was osteotomized into thirds: the distal segment was used as the main bony bridge and was telescoped into the proximal and distal ends of the tibia, the middle third was buttressed alongside this segment, and the proximal portion was osteotomized off at the original fibula fracture site and used as a nonvascularized bone graft. This left a vascularized double-barreled fibula and a nonvascularized third strut acting as a fibula graft. These three struts were cerclage-wired together using 16-gauge wires and the reconstruction plate was resecured (Fig. 1). A drain was placed in the recipient bed. The proximal donor site was closed primarily and a meshed split-thickness skin graft was used distally. The skin paddle was inset in layers (Fig. 1). A posterior resting splint was fashioned to maintain the ankle at 90 degrees. At 12-month follow-up, the patient could bear weight, had radiographic evidence of good bony union, and had an acceptable final soft-tissue contour (Fig. 2). The retrograde, pedicled fibula osteocutaneous flap advances previously described variations of the fibula free flap to safely provide autogenous reconstruction of distal tibia and soft-tissue defects.Fig. 2.: (Left) Lateral radiograph shows the reconstructed tibia at 20-month follow-up. (Right) At 12-month follow-up, the patient was able to bear weight and had stable soft-tissue coverage and acceptable final contour.DISCLOSURE The authors have no financial interests in or commercial associations with any product or technique advocated in this article. Raj M. Vyas, M.D. Division of Plastic Surgery John E. Ready, M.D. Department of Orthopedic Surgery Lifei Guo, M.D., Ph.D. Division of Plastic Surgery Brigham and Women's Hospital Harvard Medical School Boston, Mass.