Vascularized Bone Flaps for Salvage Ankle Fusion

Abstract

Objective: The ankle is a critical load-bearing joint for the lower extremity that is prone to damage from a variety of causes. Achieving stable bony fixation is paramount to restoring function after ankle injury. Initial attempts at fixation with hardware may fail, or large bone deficits may make primary fixation impossible. Vascularized bone grafts can be used to create stable and functional reconstruction of the ankle. Methods: We reviewed our experience using vascularized bone flaps to achieve bony ankle fusion in patients with unstable ankle joints. We then developed indications for whether the use of pedicled flaps versus free tissue transfer will best accomplish successful fusion. Results: At our institution, a single surgeon has performed 6 cases of vascularized bone grafts for ankle fusion. Three of these were pedicled fibula flaps and three were free fibula flaps. One of the free fibula flaps had persistent non-union and was salvaged with a medial femoral condyle free flap to achieve bony fusion. All patients had improved pain and were able to bear weight on the ankle joint post-operatively. Pedicled fibula flaps can be used when there is avascular necrosis of the talus or distal tibia, non-union after ankle fusion, failed total ankle replacement, or for large bony defects. Free fibula flaps are required when there is non-union of the distal fibula, if there is need for tibiotalocalcaneal fusion, and therefore need to extend the fibula to the calcaneus, or if the lateral malleolus has been already taken down during prior ankle fusion. Conclusion: Ankle reconstruction presents a challenging problem, but vascularized bone grafts can provide stable and functional results for patients. Using the indications we have developed for the use of pedicled flaps versus free tissue transfers can help other surgeons tackle these difficult cases. Corresponding Author: Gretchen Stieg MD, Department of Plastic & Reconstructive Surgery Detroit Medical Center/Wayne State University, 4160 John R, Suite 400, Detroit, MI 48201, Email: [email protected], Phone: (407) 252-0909