Fibular Segments Research Articles

Raising the Osteocutaneous Fibular Flap for Oral Reconstruction With Reduced Tissue Alteration

Raising the osteocutaneous fibular flap offers excellent possibilities for oral reconstructive surgery but is associated with specific donor-site risks. Moreover, with inadequate surgical technique, flap-specific complications can occur, such as loss of the skin paddle or inadequate pedicle length. A flap-raising technique has been used to decrease surgical damage but provide maximal pedicle length. Sixty-six osteocutaneous fibular flaps were raised by the lateral approach with the following modifications: 1) flap-raising was carried out without a tourniquet, 2) only the amount of bone needed was removed, leaving the rest of the fibula intact, 3) only a minimal muscle cuff was included, and 4) the complete pedicle was dissected along the posterior intermuscular septum without opening the interosseous membrane and without touching the deep flexor muscles proximal to the osteotomized fibular segment. The skin paddle was placed distally in the leg, perfused by only 1 perforator in most cases. Medical records were analyzed and patients were examined postoperatively for up to 32 months to evaluate the above-mentioned complications. Of the 66 reconstructions, 44 were performed in a previously operated or irradiated neck. Three flaps and 1 skin paddle were lost. The most common donor-site complications were temporary wound-healing disturbances of the skin graft (n = 17) and transient pain or sensory alterations (n = 12). No compartment syndrome, ankle instability, or need for walking aids was recorded. A hammertoe deformity developed in 1 patient. On average, pedicle length was 9 cm and flap-raising took 130 minutes. In conclusion, maximal pedicle length and minimal bone and muscle resections can be achieved with a small number of donor-site complications. The skin paddle is highly reliable based on only 1 perforator. Perforators can be precisely controlled when raising the flap in the perfused leg.

Application of the free double-skin paddle string-type composite fibular flap in the reconstruction of the combined defects of ulna and radium

Objective To investigate the outcome of the free double-skin paddle string-type composite fibular flap in the reconstruction of the combined defects of ulna and radium. Methods From June 2005 to July 2009, 5 cases with combined defects of ulna and radium were reconstructed using the free double-skin paddle string-type composite fibular flap. The length of fibular segment for the reconstruction of ulnar defect ranges from 4.5 to 7.5 cm. The length of fibular segment for the reconstruction of radial defect ranges from 5.5 to 7.0 cm. The size of the flap varies from 5.0 cm × 3.0 cm to 8.0 cm × 5.5 cm. At the 12 month follow-up, the function of reconstructed forearm was evaluated based upon Enneking scoring system.Results Ten flaps in the 5 cases all survived. The time for the transplanted fibula healed on the radium and ulna was 4-6 months. The 5 patients were followed up from 14 months to 2 years. The forearm rotation functions were excellent in 2 cases, good in 2 cases and poor in 1 case. The eligible rate was 80%. The average Enneking score was 24.8, which indicated an average of 81.3% recovery of limb function. Conclusion Bone graft with blood supply can ensure the activity of osteocytes, which facilitates the fracture union.Whilst, the procedure can reconstruct multi-location and multi-tissue defects in the forearm. Therefore, the double-skin paddle string-type composite fibular flap is an ideal alternative for the reconstruction of the combined defects of ulna and radium and the skin. Key words: Ulna; Radium; Bone defect; Fibular flap; Transplantation

Employing Rapid Prototyping to Assist Free Fibular Flap Reconstructive Surgery of Mandibular Defects

Patients suffering from mandible tumors often require a reconstructive surgery to repair the defects caused by large tumors. The particular type of reconstructive surgery studied in this paper is called free fibular flap reconstruction, which uses fibular segments to replace removed sections of the mandible and a titanium plate to provide strength. In order to decrease the dependence on design experience, decrease surgery time, and enhance the participation of surgeons in the design process, Rapid Prototyping (RP) biomedical models were employed to enable good visualization of the original and reconstructed geometry and for use as forming guides for the customized titanium plates. This study reports on one male and one female patients who underwent mandibular reconstruction. In one case, the operation time was reduced 2 hours and the other one was reduced 1.8 hours. The customized titanium plate shapes conformed to the patients’ mandible anatomy and were thick enough to provide the strength and stiffness needed to fix the mandible until the bone grafts and soft tissues heal.

The survival and functional outcome of primary bone sarcomas in distal lower extremity

To analyze the oncological and functional outcome of limb salvage in this location. From November 2003 to January 2010, 20 patients with primary malignant bone tumors of the distal lower extremity were treated. There were 15 male and 5 female, the mean age was 20 years. Among 14 patients with malignant distal tibial sarcoma, 11 patients had ankle arthrodesis reconstructed by using allograft (7 patients) or autografts (4 patients), the other 3 patients underwent below-knee amputation. Three patients with osteosarcoma of distal fibula reconstructed with ipsilateral fibular head, 3 patients with calcaneus osteosarcoma underwent total calcanectomy and reconstructed with fibular segment and iliac crest. The mean follow-up was 36.4 months. Five of 7 (71.4%) patients with allograft reconstruction were associated with delayed wound healing, however, only 1 of 10 patients with autograft had this problem (P = 0.036). One local recurrence was observed, 2 osteosarcoma patients died of disseminated disease. The estimated 2-year and 5-year overall survival for the patients with malignant tibial sarcomas were 92.9% and 79.6% respectively, for the patients with distal tibial high-grade osteosarcoma were 87.5% and 70.0% respectively. The mean functional MSTS score was 82% for limb salvage patients. The survival of patients with primary malignant bone tumor of distal lower extremity seems to be better than that of other sites. Limb salvage can provide satisfactory local control and functional results.

The Accuracy of Virtual Surgical Planning in Free Fibula Mandibular Reconstruction: Comparison of Planned and Final Results

The concept of virtual surgery uses surgical simulation rather than relying exclusively on intraoperative manual approximation of facial reconstruction. The purpose of this study was to evaluate the degree to which surgical outcomes in free fibula mandibular reconstructions planned with virtual surgery and carried out with prefabricated surgical plate templates and cutting guides correlated to the virtual surgical plan in a series of 11 patients. This retrospective study evaluated 11 consecutive patients (6 males and 5 females) with an average age of 50.73 years (range, 23-72 years) who required mandibular reconstruction for aggressive benign or malignant disease with a free fibula osseomyocutaneous flap at Emory University Hospital (Atlanta, GA) between January 1, 2009 and December 31, 2009. In each case, a high-resolution helical computed tomography (CT) scan of the maxillofacial region and mandible was obtained prior to surgery. The CT data was sent on a CD to a modeling company (Medical Modeling Inc, Golden, CO). The scans were then converted into 3-dimensional models of the maxillofacial skeleton utilizing both automatic and manual segmentation techniques in the SurgiCase CMF software (Materialise NV, Leuven, Belgium). A virtual surgery planning session was held via a Web meeting between the surgeons and the modeling company, at which the resection planes of the mandible, positioning of the plate, and fibula lengths/osteotomy angles were established. The surgery was then carried out using prefabricated cutting guides and manual bending of a reconstruction plate using a prefabricated plate template. A postoperative CT scan of each patient was obtained within the first 7 postoperative days on the same scanner. Three-dimensional computer models of the final reconstruction were obtained for comparison with the preoperative virtual plan. To make the desired comparisons, the 3-dimensional objects representing the postoperative surgical outcome were superimposed onto the preoperative virtual plan using manual alignment techniques. These objects were then compared by 1-to-1 magnification for measurements of fibular bone volume, location of mandibular osteotomies, location of fibular osteotomies, plate contour, plate position on fibula, and plate position on mandible. Comparison was made between the virtual and final plates with regard to contour and position through superimposition overlays of the 3-dimensional models that are registered in the same coordinate system. A total of 19 mandibular osteotomies were carried out. The mean distance of the actual mandibular osteotomy when compared to the virtual mandibular osteotomy was 2.00 ± 1.12 mm. The mean volume determined by the software program of the 11 virtual fibulas was 13,669.45 ± 3,874.15 mm(3) (range, 9,568 to 22,860 mm(3)), and the mean volume of the 11 actual postoperative fibulas was 12,361.09 ± 4,161.80 mm(3) (range, 7,142 to 22,294 mm(3)). The mean percentage volumes of the actual postoperative fibula compared to the planned fibula were 90.93 ± 18.03%. A total of 22 fibular segments were involved in the study created by 44 separate fibula osteotomies. The mean distance of the actual fibula osteotomy when compared to the virtual fibula osteotomy was 1.30 ± 0.59 mm. The mean percentage overlap of the actual plate to the virtual plate was 58.73% ± 8.96%. Virtual surgical planning appears to have a positive impact on the reconstruction of major mandibular defects through the provision of accuracy difficult to achieve through manual placement of the graft, even in the hands of experienced surgeons. Although a reasonably high level of accuracy was achieved in the mandibular and fibula osteotomies through use of the surgical cutting guides, the limited ability to correctly contour the plate by hand to replicate the plate template is reflected in our findings.

The Muscular and the New Osteomuscular Composite Peroneus Brevis Flap: Experiences from 109 Cases

Pedicled peroneus brevis muscles are proven flaps for defect coverage around the ankle, foot, and distal lower leg. Some of these defects--such as postosteitic hollowed out calcaneal bones--may profit from a simultaneous vascularized bone transplantation. The authors' experiences with 109 successive muscular and newly developed osteomuscular peroneus flaps are outlined for small to medium combined defects in this region. One hundred nine patients with various soft-tissue and skeletal defects underwent reconstruction with proximally (n = 10) or distally pedicled (n = 98) or free microvascular transplanted (n = 1) peroneus brevis flaps. Eight patients received a composite flap of the peroneus brevis muscle with an attached lateral split fibula segment. In 72.5 percent of the cases, a stable defect closure was achieved without significant secondary procedures. In 16.5 percent, further operations such as secondary wound closure or flaps were necessary, most often because of the avascular loss of the 1 to 3 cm of the distal flap tip. Nine flaps (8.3 percent) were lost completely. Seven of eight osteomuscular flaps demonstrated stable bony healing, and full weight bearing was achieved. No relevant donor-site complications were seen. The peroneus brevis is a valuable flap for defect closure around the ankle and lower leg. It can be harvested together with a vascularized split fibula segment, representing a simple alternative to several free composite flaps. Its complication rate can be lowered significantly if the proximal 3 cm of the muscle origin (i.e., the flap tip in distally pedicled flaps) is discarded during dissection and delicate hemostasis is performed.

Fixation and reconstruction of severe tibial shaft fractures with vascularized fibular grafting

Based on the considerable experience for management of combined bone and composite soft-tissue defects in the limbs by free vascularized fibula or osteocutaneous fibular flap grafting, the authors present the effective alternative for management of the severe comminuted tibial shaft fractures in one-stage reconstructive technique. Twenty-six patients were male and 12 were female, and their mean age was 32 years (range 15-57 years). Ten tibial shaft fractures were closed and 28 were open. Based on the AO classification, there were 12 group C1 fractures and 24 group C3 fractures according to the fracture pattern and degree of comminution. With the exception of eight cases that were delayed for 3-5 days for primary treatment in another hospital, 30 cases were treated on an emergency basis within an average of 12 h since the initial injury (range 6-22). Normal healing occurred in 31 fractures with a mean healing time of 21 weeks (range 18-24 weeks). Delayed union in 7 with a mean of 32 weeks (range 28-41 weeks), and there were no nonunion and infections. The vascularized fibula allows for fast bone fusion. In this context, the grafted fibula segment appeared to be a valuable reconstructive tool that offered good fracture stabilization and vascularised bone graft. The attached fibular flap can also provide a large piece of mobile skin to cover the soft-tissue defect in grade III open-tibial fractures. It demonstrates that this early free vascularized fibula graft is a useful and effective option for treating the severe comminuted tibial shaft fractures.

Interosseous Nerve Transfers for Tibialis Anterior Muscle Paralysis (Foot Drop): A Human Cadaver-Based Feasibility Study

This study explored the anatomical feasibility of using an interosseous nerve transfer (routed between the tibia and fibula) to restore motor function to the tibialis anterior (TA) muscle, following injury to the common peroneal nerve (resulting in a foot drop). The specific nerve branches evaluated as possible donor nerves included the nerves to the medial gastrocnemius, the lateral gastrocnemius, and the soleus muscles. All nerve transfers were accomplished using a direct interosseous route and a direct repair (one medial gastrocnemius transfer did require interpositional grafting). The distance from the repair site to the TA muscle was shortest for the transfer using the nerve branch to the soleus. Histologically, the nerve branch to the soleus was most similar to the branch to the TA for both axonal count and cross-sectional area. A two-incision surgical approach using a fibular window (mobilizing a fibular segment after double osteotomy) and interosseous routing of the transfer is proposed.

Successful Transfer of a Vascularized Fibular Osteocutaneous Bone Graft Harvested Distal to a Previously Fractured Fibula

A literature search revealed one published case report in which a previously fractured fibula was used as a free vascularized fibular bone graft. The segment of fibula used was 3 cm proximal to the previous fracture site and was hypothesized to be within the “zone of injury.”1 Our case study, however, is the first report of a free vascularized fibular osteocutaneous transfer in which the fibula was harvested distal to a previous fracture and was therefore completely dependent on its periosteal, and not endosteal, blood supply. A 17-year-old boy sustained a grade IIIB open fracture of the left tibia and fibula (Fig. 1) and a closed fracture of the right tibia and fibula. After serial debridement, a 13-cm segmental tibial defect and a 15 × 8-cm soft-tissue defect (covered with a split-thickness skin graft) remained over the anteromedial aspect of the distal third of the lower leg.Fig. 1.: Grade IIIB open comminuted fracture of the left tibia and fibula.Eight months later, a vascularized free fibular osteocutaneous transfer, using the previously fractured right fibula, was performed. A portion of the flexor hallucis longus was left attached to the fibula to help preserve the periosteal circulation and fill the soft-tissue defect. A distal osteotomy was performed 6 cm proximal to the lateral malleolus, and the proximal osteotomy was made proximal to the fracture site. A 13-cm segment of fibula was harvested 3 cm distal to the previous, now-healed fibular fracture (Fig. 2). Examination of the proximal peroneal artery under the operating microscope showed no evidence of vascular intimal injury.Fig. 2.: Previously fractured, vascularized free fibular osteocutaneous graft.The fibula was then dowelled into the tibia and fixed with two cortical screws. End-to-side anastomosis of the peroneal artery to the recipient posterior tibial artery and end-to-end anastomosis of the peroneal venae comitantes to a posterior tibial vein were performed. Excellent blood flow was re-established to the fibula, flexor hallucis longus, and skin flap. The remaining soft-tissue defect was closed with a split-thickness skin graft. The skin flap showed excellent color and capillary refill and a strong Doppler signal throughout the postoperative course. The flap and split-thickness skin graft healed completely. Two years postoperatively, radiographs confirmed a solidly united tibia and the patient was ambulating pain-free (Fig. 3).Fig. 3.: Radiographs of the left tibia and fibula 2 years postoperatively (left, anteroposterior view; right, lateral view).This is the first report of successful transfer of a free vascularized fibular osteocutaneous bone graft in which the entire segment of fibula was harvested distal to a previous fracture. Previous fracture of the fibula may be associated with damage to its vascular supply and may jeopardize the viability of a vascularized free fibular bone graft. Normally, 70 percent of the cortex is supplied by the longitudinal endosteal circulation, which would become completely disrupted by a fracture of the fibula. The remaining 30 percent of cortical blood supply originates from the periosteum.2 When a free fibular transfer is performed several months after the initial injury, the fracture in the donor fibula will have healed, and it might be assumed that the cortical blood supply has been reconstituted. On the basis of this one case, we believe that, in rare circumstances, a free vascularized fibular osteocutaneous bone graft may be harvested distal to a healed previous fracture of the fibula without compromising its viability. ACKNOWLEDGMENT The authors thank Ryan Karlstad, M.D., clinical fellow, at the UCLA Medical Center, Los Angeles, California. Ruby Grewal, M.D. Hand and Upper Limb Center London, Ontario, Canada Norman Y. Otsuka, M.D. Department of Orthopedic Surgery UCLA School of Medicine Shriners Hospital for Children Los Angeles, Calif. Neil F. Jones, M.D. Division of Plastic and Reconstructive Surgery Department of Orthopedic Surgery UCLA School of Medicine Hand Surgery UCLA Medical Center Los Angeles, Calif.

Refined Oro-Mandibular Reconstruction Using Free Fibular Flap and Dental Implants

Mandibular reconstruction of a long span defect with a free fibular flap is now the preferred procedure. However, the bone height of the neomandible reconstructed with the fibular flap is about half of the edentulous mandible. The resulting vertical discrepancy between the graft segment and the occlusal plane of the host interferes with ideal implant mechanics or adequate stability and retention for the conventional denture, when the fibular graft is placed only at the border of the previous mandibular position. To overcome these difficulties, we designed a refined two-strut type of mandibular reconstruction. In this technique, a vascularized fibular segment was used to reconstruct the inferior basal portion of the neomandible, while non-vascularized residual fibular was additionally placed to simulate the superior alveolar portion. Twenty-two consecutive cases were evaluated using this technique and followed for an average of 37.5 months. The clinical results including graft survival, graft resorption and the outcome of implant placement compared to the conventional one-strut type fibular flap were assessed. In three cases, the grafted fibular segment at the alveolar area was removed: one was for prophylactic reasons after intraoral wound dehiscence and the others were due to postoperative infection. All vascularized fibular flaps were successful. The resorption rate of the non-vascularized segment was 13.6% and that of the vascularized segment was 3.6%. Fifty-four fixtures were installed in 10 patients. Only one implant was removed due to non-osseo-integration. Peri-implant bone loss in the two-strut group was 1.03±0.03 mm at post-op one year and 1.37±0.11mm at two years, while with the conventional fibular flap it was 0.89±0.13mm and 1.2±0.16mm respectively. The crown-root ratio was largely improved to 1:1.7, compared to that of the conventional fibular flap (C:R ratio 1:1.21). The biting force was also increased by 231.1±39N (cf 187.3±41N in conventional fibular flap). In conclusion, the two strut concomitant fibular reconstructions of the mandibular defect, improved implant-prosthetic mechanics and lip/cheek support without additional significant marginal bone loss or implant failure.

Aneurysmal bone cyst of the third metatarsal treated by using free non-vascular transfer of the fibula segment

Here, we present a case of aneurysmal bone cyst of the third metatarsal that has been infrequently reported in the literature. Its characteristics can mimic various other bone tumors. While the radiographic appearance usually typifies this lesion, microscopic evaluation is paramount for a definitive diagnosis. There are various treatment alternatives for this lesion depending on size, patient's age and localization. In this report, we recommend total excision of the lesion and reconstruction of the defect by transfer of fibular seg- ment. We obtained satisfactory clinical and radiological results, after 3 years of postoperative evaluation.

Fibular segment bone bridging in trans-tibial amputation

The purpose of this paper is to present an alternative method of achieving a synostosis between tibia and fibula in trans-tibial amputations by means of a fibular segment in place of tibial osteoperiosteal flaps as described by Ertl, in 1949. From May 1997 through to February 2003, 15 patients were submitted to the proposed procedure. As a result, all patients produced a solid synostosis between tibia and fibula and were rehabilitated with the use of prostheses. The capacity of these patients for distal weight-bearing on the stump was remarkable when compared to patients submitted to the conventional trans-tibial amputation technique.

Recombinant human bone morphogenetic protein-2 delivered in an injectable calcium phosphate paste accelerates osteotomy-site healing in a nonhuman primate model.

In recent clinical trials demonstrating the efficacy of recombinant human bone morphogenetic protein-2 (rhBMP-2) for the acceleration of bone-healing, investigators used carriers requiring open surgery for administration. In this study, we used a nonhuman primate fibular osteotomy model to evaluate injectable rhBMP-2/carrier formulations that can be administered in closed fractures. The fibular osteotomy model was first characterized by evaluating surgically harvested fibular segments containing untreated osteotomy sites (controls) from seventy adult male Cynomolgus monkeys at eight weeks (twenty-four monkeys), ten weeks (thirty-four), twelve weeks (six), and fourteen weeks (six). Fibular segments, from twenty-four animals, in which an osteotomy had not been performed served as normal controls (intact). The contralateral limb of twenty-four of the animals was then used to evaluate the effect of rhBMP-2 administered, three hours after the osteotomy, in eight carrier formulations (buffer, calcium phosphate paste, and hyaluronan gel, hyaluronan paste, and gelatin foam formulated with and without tricalcium phosphate granules). Each carrier was used in three monkeys. At ten weeks, the fibulae with the treated osteotomy sites were harvested and were compared with the contralateral, untreated osteotomized fibulae (paired control). The most promising carrier, calcium phosphate paste (alpha bone substitute material, or alpha-BSM), was then evaluated in eleven additional animals. The outcomes included the findings on radiographs made weekly until the time of fibular harvest, the callus area, the biomechanical properties, and the histologic findings. Radiographic and histologic studies confirmed complete bridging of the control osteotomy sites in most animals by fourteen weeks. The mean torsional stiffness and maximum torque of the control osteotomy sites were 42.7% and 53.7%, 55.2% and 60.4%, 66.7% and 66.4% of the mean torsional stiffness and maximum torque of the intact fibulae at eight, ten, and twelve weeks, respectively, but they were not substantially different from the mean torsional stiffness and maximum torque of the intact fibulae at fourteen weeks (82.3% and 79.8%). In the carrier screening study, outcome measures of healing were more consistently enhanced in the rhBMP-2/alpha-BSM-treated osteotomy sites. In the confirmatory study, the mean callus area, torsional stiffness, and maximum torque were 86%, 72%, and 68% greater in the rhBMP-2/alpha-BSM-treated osteotomy sites than in the paired-control osteotomy sites at ten weeks (p < 0.001). The torsional stiffness and maximum torque in the rhBMP-2/alpha-BSM-treated osteotomy sites were equal to those in the intact fibulae, whereas those parameters in the paired-control osteotomy sites were only 55% and 58%, respectively, of the torsional stiffness and maximum torque of the intact fibulae. Histologic analysis confirmed complete osseous bridging of the rhBMP-2/alpha-BSM-treated osteotomy sites but incomplete bridging of the paired-control osteotomy sites at ten weeks. A single percutaneous injection of rhBMP-2/alpha-BSM accelerates the healing of fibular osteotomy sites in nonhuman primates by approximately 40% compared with the healing of untreated osteotomy sites.

Repairing long-bone and skin defects by transplanting combined fibula segments with a periosteal vaso-nasa wraparound incoprating the overlying skin nourished with the consistent vascular pedicle

目的 探讨下肢粗骨长段缺损与皮肤缺损同时修复的可行方法.方法将腓血管制成1个或2个血管襻,该血管襻携带皮瓣,再将多段腓骨于骨膜内组合在一起,使成为一个骨膜包裹的粗骨修复骨与皮肤缺损.有丰富血运的骨膜,其骨膜下新生骨活跃,该新生骨充填骨膜内与腓骨段间隙、包绕腓骨,使移植腓骨增粗.结果临床应用5例,所携带的皮瓣血运良好,伤口一期愈合.1年后骨折愈合,2年后移植骨增粗,能负重行走,移植骨无骨折.供腓骨侧踝关节稳定,伸屈范围正常,功能恢复正常.结论血管襻骨膜内组合腓骨同蒂皮瓣移植是修复粗骨与皮肤缺损的一种可行方法。

Bone mass is preserved in a critical-sized osteotomy by low energy pulsed electromagnetic fields as quantitated by in vivo micro-computed tomography

The effectiveness of non-invasive pulsed electromagnetic fields (PEMF) on stimulating bone formation in vivo to augment fracture healing is still controversial, largely because of technical ambiguities in data interpretation within several previous studies. To address this uncertainty, we implemented a rigorously controlled, blinded protocol using a bilateral, mid-diaphyseal fibular osteotomy model in aged rats that achieved a non-union status within 3–4 weeks post-surgery. Bilateral osteotomies allowed delivery of a PEMF treatment protocol on one hind limb, with the contralateral limb representing a within-animal sham-treatment. Bone volumes in both PEMF-treated and sham-treated fibulae were assessed simultaneously in vivo using highly sensitive, high-resolution micro-computed tomography (μCT) over the course of treatment. We found a significant reduction in the amount of time-dependent bone volume loss in PEMF-treated, distal fibular segments as compared to their contralateral sham-treated bones. Osteotomy gap size was significantly smaller in hind limbs exposed to PEMF over sham-treatment. Therefore, our data demonstrate measurable biological consequences of PEMF exposure on in vivo bone tissue.

Concomitant reconstruction of mandibular basal and alveolar bone with a free fibular flap

Repair of long-span mandibular defects with a free fibular flap is now a routine procedure. However, the bone height of the neo-mandible after reconstruction with a fibular flap is about half that of the dentulous mandible. When a fibular graft is placed only at the inferior border of the mandible, the resulting vertical discrepancy between the graft segment and the occlusal plane can adversely affect implant mechanics or denture stability and retention.To overcome these problems, we developed a technique for two-strut type mandibular reconstruction. A vascularized fibular segment is used to reconstruct the inferior basal portion of the neo-mandible, while a non-vascularized residual fibular segment is used to simulate the superior alveolar portion.We used this technique in 22 patients. Graft survival, graft resorption, and the ability to place implants were assessed as compared with those after the conventional one-strut type technique. The fibular segment grafted to the alveolar region was removed in one patient with intraoral wound dehiscence and in two with postoperative infection. All vascularized fibular flaps were successful. The resorption rate was 13.6±7.2% for non-vascularized segments and 3.0±3.7% for vascularized segments. Dental implants were placed in five of our 22 patients. The crown:fixture length ratio was improved to 1:1.7, as compared with a ratio of 1:1.21 with use of a conventional fibular flap. We conclude that our technique is very easy and safe and provides substantially improved lower-lip and cheek support and implant–prosthetic mechanics than conventional procedures for the repair of long-span mandibular defects.

Functional development of the donor leg after vascularized fibula graft in childhood

Purpose: To evaluate the effect of free vascularized fibula grafts on developing donor leg function, the authors reviewed their experience of procedures performed in children. Methods: Over a 10-year period, 30 children (average age 7.2 years, without gender concern) underwent fibula harvest via an anterolateral approach. Graft length averaged 6.0 cm. Follow-up averaged 8 years. Results: No vascular injury or shank dysplasia ensued. Neural injury occurred in 8 patients: to the profound peroneal nerve in 1 and to the superficial peroneal nerve in 7. Symptoms resolved spontaneously at 3 to 5 months in 6, but persisted in 2 patients in the latter group at 8 years' follow-up. Of 24 children who underwent rapid walking (200 m) followed by immediate stair climbing (50 steps), 2 (whose grafts were longer than average) had slight and 1 had obvious ankle pain. However, muscle strength and range of motion in the donor ankle were no different from values in the recipient leg in the 24 cases. X-ray findings showed that, with growth, the remaining 2 fibular segments in the donor leg became longer, but the length of the gap between did not change. Thus, the gap left by harvest became relatively shorter long after operation, benefiting the stability of the ankle joint in adulthood. Conclusion: Unlike free vascularized fibula grafts performed in adulthood, from which serious complications to the donor leg have been reported, the procedure performed in childhood appears not to have an adverse effect on functional development. J Pediatr Surg 35:1226-1229. Copyright © 2000 by W.B. Saunders Company.

Monitoring of graft perfusion and osteoblast activity in revascularised fibula segments using [18F]-positron emission tomography: Schliephake H, Berding G, Knapp WH, et al. Int J Oral Maxillofac Surg 28:349, 1999

Monitoring of graft perfusion and osteoblast activity in revascularised fibula segments using [18F]-positron emission tomography: Schliephake H, Berding G, Knapp WH, et al. Int J Oral Maxillofac Surg 28:349, 1999

Ipsilateral vascularised fibular transport for massive defects of the tibia

The ipsilateral and contralateral fibulae have been used as a vascularised bone graft for loss of tibial bone usually by methods which have involved specialised microvascular techniques to preserve or re-establish the blood supply. We have developed a method of tibialisation of the fibula using the Ilizarov fixator system, ipsilateral vascularised fibular transport (IVFT), and have used it in five patients with massive loss of tibial bone after treatment of an open fracture, infected nonunion or chronic osteomyelitis. All had successful transport, proximal and distal union, and hypertrophy of the graft without fracture. One developed a squamous-cell carcinoma which ultimately required amputation of the limb. The advantage of IVFT is that the fibular segment retains its vascularity without the need for microvascular dissection or anastomoses. Superiosteal formation of new bone occurs if the tibial periosteal bed is retained. Other procedures such as corticotomy and lengthening can be carried out concurrently.

Monitoring of graft perfusion and osteoblast activity in revascularised fibula segments using [ 18F]-positron emission tomography

The aim of the present study was to evaluate healing of revascularised fibula grafts used for mandibular reconstruction using [ 18F]fluoride ion and positron emission tomography (PET). Sixteen PET studies in 11 fibula grafts were analysed to determine both blood flow and fluoride influx as a measure of vascularisation and osteogenic activity. Two graft failures and three non-unions were encountered and were compared to the succesfully healed grafts. In uneventful graft healing, early PET studies (on average 19 days after grafting) showed a significantly increased blood flow to the grafted bone and to the union between the grafts and the mandibles when compared to the reference region of the cervical spine. In contrast, fluoride influx was significantly lower in the grafts when compared to the plating area and the cervical spine. Six months after grafting, blood flow to the grafted bone and the mandibular bone had returned to a level comparable with the reference region. Fluoride influx remained significantly lower in the grafts than in the plating areas or cervical spines. Graft failures were associated with negligible fluoride influx near zero in early PET studies. These results suggest that revascularised fibula grafts provide a low osteogenic potential, presumably due to the pre-existing lack of cancellous bone. The relatively high frequency of non-unions makes meticulous adaptation of the graft and the mandible mandatory, particularly in patients with compromised viability of the recipient bone.