Vascularized Fibular Graft Research Articles

Should fractures in massive intercalary bone allografts of the lower limb be treated with ORIF or with a new allograft?

Massive bone allografts have been used for limb salvage of bone tumor resections as an alternative to endoprostheses, although they have different outcomes and risks. There is no general consensus about when to use these alternatives, but when it is possible to save the native joints after the resection of a long bone tumor, intercalary allografts offer some advantages despite complications, such as fracture. The management and outcomes of this complication deserve more study. The purposes of this study were to (1) analyze the fracture frequency in a group of patients treated with massive intercalary bone allografts of the femur and tibia; (2) compare the results of allografts treated with open reduction and internal fixation (ORIF) with those treated with resection and repeat allograft reconstruction; and (3) determine the likelihood that treatment of a fracture resulted in a healed intercalary reconstruction. We reviewed patients treated with intercalary bone allografts between 1991 and 2011. During this period, patients were generally treated with intercalary allografts when after tumor resection at least 1 cm of residual epiphysis remained to allow fixation of the osteotomy junction. To obtain a homogeneous group of patients, we excluded allograft-prosthesis composites and osteoarticular and hemicylindrical intercalary allografts from this study. We analyzed the fracture rate of 135 patients reconstructed with segmental intercalary bone allografts of the lower extremities (98 femurs and 37 tibias). In patients whose grafts fractured were treated either by internal fixation or a second allograft, ORIF generally was attempted but after early failures in femur fractures, these fractures were treated with a second allograft. Using a chart review, we ascertained the frequency of osseous union, complications, and reoperations after the treatment of fractured intercalary allografts. Followup was at a mean of 101 months (range, 24-260 months); of the original 135 patients, no patient was lost to followup. At latest followup, 19 patients (14%) had an allograft fracture (16 femurs [16%] and three tibias [8%]). Six patients were treated with internal fixation and addition of autologous graft (three femurs and three tibias) and 13 patients were treated with a second intercalary allograft (13 femurs). The three patients with femoral allograft fractures treated with internal fixation and autologous grafts failed and were treated with a second allograft, whereas those patients with tibia allograft fractures treated by the same procedure healed without secondary complications. When we analyzed the 16 patients with a second intercalary allograft (13 as primary treatment of the fracture and three as secondary treatment of the fracture), five failed (31%) and were treated with resection of the allograft and reconstructed with an endoprosthesis (four patients) or an osteoarticular allograft (one patient). Fractures of intercalary allografts of the tibia could successfully be treated with internal fixation and autologous iliac crest bone graft; however, this treatment failed when used for femur allograft fractures. Femoral fractures could be treated with resection and repeat allograft reconstruction, however, with a higher refracture frequency. The addition of a vascularized fibular graft in the second attempt should be considered. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Vascularised fibula osteocutaneous flap for mandibular reconstruction and multiple implant retained fixed prosthetic rehabilitation of a patient with mandibular ameloblastoma

Ameloblastomas are rare, benign dental tumours representing 1% of the oral tumours and cysts.1 The most common site for ameloblastoma is mandibular molar region. It is an aggressive benign tumour of epithelial origin that has generally been treated surgically for metastases. Treatment by wide excision is curative in up to 95% of cases. Chana et al2 proposed a 1–2 cm normal margin, and the large defect left after resection warrants reconstruction preferably with the fibula osteocutaneous flap. Taylor in 19753 first described vascularised fibula graft for composite reconstruction of the bone and soft tissue defect. After demonstrating that osteotomies can be performed in vascularised fibula grafts without compromising the viability of the bone segment, these grafts became the state of art reconstruction method after mandible ablation. The free fibula flap provides the greatest bone length and is suitable to accept dental implants. Osseointegrated implants have become generally accepted for prosthodontic management.4 The application of endosseous implants in combination with bone grafting for jaw reconstruction has allowed for improved results. Different types of osseointegrated implants have been placed either simultaneously with bone grafts5, 6 or at a later stage after the bone grafts have healed. In this case report a 23-year-old female patient underwent left hemimandibulectomy because of ameloblastoma. Fibula was osteotomised and reconstructed to resemble mandible shape and fixed to reconstruction plate with intact pedicle. Implants were placed four months after surgery and prosthetic rehabilitation of the edentulous site was accomplished.

Long Term Follow Up Results of Dynamic Functional Abdominal Wall + Perineal and Peri Anal Reconstruction + Fecal / Urinary Incontinence

Introduction: Managing complex abdominal wall / perineal + peri anal injuries acutely or at the time of reconstruction is challenging. Contaminated surgical fields, life threatening sepsis, devitalized tissue, intestinal / urinary fistula and tissues under tension contribute to clinical scenarios where closure is not possible or morbidity is unacceptable. Successful functional rehabilitation following high velocity, extensive post-traumatic, complex life threatening injuries including loss of the anterior abdominal wall, anterior wall of the urinary bladder, pubic symphysis and pubic ramus and / or phallus, scrotum, testes using vascularized fibula graft + innervated Latissimus dorsi to achieve the pelvic area stability and strength + gracillis muscle flaps to achieve the anal / urinary sphincter control.

Gastrocnemius-Fibular Flap. A New Pedicled Vascularized Bone Graft Alternative for Femur Pseudarthrosis. Review of 7 Consecutive Clinical Cases

Introduction: In 2009, SAINT-CYR defined the perforasome theory in which flow from linking vessels are maximum in parallel to the axis of limb. According to this principle, we've modified PANDE flap 2002 to a gastrocnemius fibular flap. We've merged skin territories from MCRAW's lateral gastrocnemius musculo-cutaneous flap and YOSHIMURA'S fibular flap, communicating perforators from lateral sural and fibular arteries providing a vascularized fibular bone graft that reaches diaphysis of femur.

Surgical Correction of Clawtoe Deformity Following Harvesting of Vascularized Fibula Graft

Surgical Correction of Clawtoe Deformity Following Harvesting of Vascularized Fibula Graft

Severe forearm deformity and instability after Monteggia fracture-dislocation

A 16-year-old boy presented with a painful deformity of the forearm. At the age of 11 years, he had sustained a Monteggia fracture-dislocation. Radiographs indicated nonunion of the ulna, radial head dislocation, and degenerative changes of the radiocapitellar joint. The longstanding nonunion of the ulna had caused very severe growth disturbance. Despite severe deformity, the patient had had relatively good motion. To regain forearm stability with maintaining motion, we corrected the deformity and stabilized the ulna with a vascularized fibular graft. Two years after surgery, the patient had a good range of motion without pain and grip strength was increased.

Combined composite osteofasciocutaneous fibular free flap and radial head arthroplasty for reconstruction of the elbow joint

Reconstruction of the radial head can be complicated in cases of wide resection, particularly in those cases including the proximal radial shaft. In such cases, radial head replacement may not be possible because of lack of adequate bone stock. Here, we report the use of a radial head prosthesis incorporated with a vascularized fibula for immediate anatomic restoration of the forearm and elbow. We present a case of a pathologic fracture non-union in the proximal radius in a 57-year-old female with a history of multiple myeloma. Non-operative management of the fracture was unsuccessful after chemotherapy and radiation. The proximal radius and radial head were resected and reconstructed with vascularized fibula graft in conjunction with immediate radial head prosthesis. The osteotomy site healed at 6-weeks and follow-up at 1 year showed good functional outcome. We feel that the use of this construct has definite promise and may be considered for reconstruction following resection of the proximal radius.

Creation of false pedicles and a neo-pelvis for lumbopelvic reconstruction following en bloc resection of an iliosacral chondrosarcoma with lumbar spine extension

En bloc resection with negative tumor margins remains the principal treatment option for control or cure of primary pelvic chondrosarcomas, as current adjuvant therapies remain ineffective. Iliosacral chondrosarcomas with involvement of the sciatic notch are sufficiently challenging tumors. However, when there is concomitant lumbar extension requiring resection of the pedicles to maintain negative surgical margins, transpedicular screw fixation is not possible, making reconstruction of the lumbopelvic junction extremely challenging. A patient with an iliosacral chondrosarcoma with lumbar spine extension is presented in this report to illustrate a novel lumbopelvic spinal construct. Following combined external pelvectomy and hemisacrectomy with contralateral L3-5 hemilaminectomy and ipsilateral pediculotomy, bicortical transvertebral body screws were substituted for the missing pedicles, resulting in the creation of "false pedicles," which were further supplemented with an autologous vascularized fibular strut graft from the amputated lower limb and applied to the lateral aspect of the vertebral bodies. The creation of false pedicles allowed for a robust reconstruction of the lumbopelvic junction, including maintaining pelvic ring integrity with a "neo-pelvis", creating a functional load-bearing construct adequate for early mobilization and ambulation. The biomechanical dynamics of this unique construct are also discussed.

Free vascularised fibular graft to be used in the treatment of avascular necrosis of femur head; a more practical, new modification in the preparation of the graft

Objectives: During the dissection of some blind areas for vascularized fibular graft, some failures may be seen due to prolonged surgical procedure. Our aim was to discuss a new modification developed to resolve the dissection problems encountered during the preparation of the graft on our subjects with avascular necrosis of the femoral head. Methods: Between 2011, 2012, a vascularized fibular grafting was applied on 6 cases (4 male, 2 female) using the modified technique. In the lateralization stage of the harvesting of the fibula, extra distal (15 mm) and proximal (25mm) fibular resections were included to facilitate the procedure and overcome getting a longer pedicle. Harvesting of the extra fibular grafts was performed at the fixation of the vascularized fibular graft at the femoral tunnel. Mean age was 37.8 (32- 40) and mean monitoring time was 16 (12-24) months. Results: All fibular grafts at the femoral head have been consolidated, and 5 cases were very good and 1 was good according to Merle d’Augbigne analyzing method at the control time. There were no complications during and after the preparation of the graft. Conclusion: We think that this modified technique is a useful method for getting grafts, and it ensures a shorter time for the preparation of the vascularized fibular graft.

Precise Resection and Biological Reconstruction Under Navigation Guidance for Young Patients With Juxta-articular Bone Sarcoma in Lower Extremity

It is a challenge to perform a joint-preserving resection for young patients with juxta-articular bone sarcomas. We determined whether osteotomy under image-guided navigation make joint-saving resection possible for juxta-articular lesions while adhering oncological principles. Between June 2008 and July 2010, joint-preserving limb salvage surgeries were performed on 9 patients with juxta-articular bone sarcomas under navigation guidance. Computed tomography/magnetic resonance imaging fusion images were used for real-time navigation. Eight lesions located around the knee and 1 in hip. Six tumors extend to and 3 beyond the epiphyseal line. Planned osteotomy under image-guided navigation was employed for achieving clear surgical margin while maximizing host tissue preservation. All tumors were en bloc removed and intercalary defect were reconstructed by combination of allograft with vascularized fibula graft. All specimens were examined for resection margin. Patients were followed up for an average of 25.2 months for evaluating of functional and oncology outcomes. Entire joint were preserved in 6 patients and part of joint were saved in another 3 patients. The mean registration error for navigation was 0.40 mm (range, 0.31 to 0.62 mm). Clear surgical margin was obtained in all specimens. The average closest distance between the osteotomy line and tumor edge was 9.6 mm (range, 6 to 14 mm). Entire joint cartilage was preserved in 6 patients and portion of joint were saved in 3 patients (2 in proximal tibia, 1 in distal femur). No patient experienced local recurrence. Two patients developed lung metastasis. One died of disease and the other underwent metastasectomy and had no evidence of disease at the most recent follow-up. All reconstruction was in situ with the Musculoskeletal Tumor Society average score of 26.7 at final follow-up. With careful patient selection, image navigation-assisted surgery made it possible to resect the bone exactly as planned in length and orientation in the magnetic resonance imaging image, yielding a clear margin and preserving the entire or part of the articular cartilage in joint-sparing limb salvage procedures for treating skeletally immature patients with juxta-articular bone sarcomas. Level IV--therapeutic study.

腓骨皮弁による下顎再建（総説）

血管柄付き腓骨皮弁は，長い骨が得られる，しなやかな皮弁が得られる，複数の骨切りが可能などの利点から，下顎再建に最も好まれる術式である。本稿では術式の詳細とそのキーポイントについて報告する。術前の計画として腓骨は下顎欠損と同側の下腿から採取する。腓骨と同時に適切な量の長母趾屈筋を同時に採取する。採取した筋肉は頸部郭清後の顎下部の死腔を充填するために用いる。手術は仰臥位でターニケット駆血下に行い，十分な大きさの皮島と骨を採取するように注意する。下顎骨形態の再現のための骨切りは，皮弁採取部の下腿で血流を保持して行う。骨形態の加工が終了したら腓骨皮弁を採取して頸部に移動する。頸部に移動した骨はミニプレートまたは下顎再建プレートを用いて残存する下顎骨に固定する。その際，中の一時的な顎間固定により，正しい咬合位を得ることが重要である。骨の固定が終了したら皮弁の血管と頸部の毛環吻合を行う。最後に腓骨皮弁の皮島を口腔内の粘膜欠損部に縫合，頸部皮膚を閉鎖して手術を終了する。

Long-Term Follow-Up of Microsurgical Reconstruction for Pelvic Tumor Focusing on Spinal Deformity and Quality of Life

Background: To provide patients with a superior quality of life (QOL) after their pelvic tumor resection, ensuring the stability of the trunk as well as satisfactory lower extremity function is important. Although microsurgical reconstructions for the pelvic ring and hip are used clinically, the details of postoperative long-term spinal deformity and QOL remain unclear. Methods: The patients were 66- and 43-year-old men and a 43-year-old woman. The mean postoperative follow-up period was 134 months. The surgical procedures performed on these patients were: pelvic ring reconstruction using a double-barreled free vascularized fibular graft (FVFG) in Patient 1; simultaneous pelvic ring reconstruction using FVFG and hip arthrodesis in Patient 2; and latissimus dorsi free flap without pelvic ring reconstruction in Patient 3. As indicators of spinal deformity, we measured the Cobb angle, thoracic kyphosis angle, lumbar lordosis angle, pelvic angle on the sagittal plane, and sagittal plane balance using whole spine radiography. To assess the patients’ QOL, we examined the International Society of Limb Salvage (ISOLS) score, the Roland-Morris Disability Questionnaire (RDQ), activities of daily living (ADL) satisfaction using a visual analogue scale (VAS), and the SF-36. Results: Spinal alignment in the frontal plane worsened in order from Patient 1 to 3. Spinal alignment and pelvic tilt in the sagittal plane were at appropriate levels in Patients 1 and 2. The trunk tilt in the sagittal plane was at an appropriate level only in Patient 1. In the QOL assessment, the function of the affected limb worsened in order from Patient 1 to 3. RDQ scores were lower than the national norm in Patients 2 and 3. With respect to ADL satisfaction and the SF-36, Patient 3 had a markedly low VAS, physical functioning, role-physical, and role-emotional scores. Conclusion: In the long-term clinical course after pelvic tumor resection, in order to obtain satisfactory spinal alignment and QOL, pelvic ring reconstruction and hip arthrodesis are important.

구강악안면재건을 위한 비골복합유리피판의 해부학적 고찰

The fibula is one of the most useful sources for harvest of a vascularized bone graft. The fibula is a straight, long, tubed bone, much stronger than any other available bone that can currently be used for a vascularized graft. It has a reliable peroneal vascular pedicle with a large diameter and moderate length. There is a definite nutrient artery that enters the medullary cavity, as well as multiple arcade vessels, which add to the supply of the bone through periosteal circulation. The vascularized fibula graft is used mainly for long segment defects of the long tubed bone of the upper and lower extremities. It can provide a long, straight length up to 25 cm in an adult. The fibula can be easily osteotomized and can be used in reconstruction of the curved mandible. Since the first description as a vascularized free fibula bone graft by Taylor in 1975 and as a mandibular reconstruction by Hidalgo in 1989, the fibula has continued to replace the bone and soft tissue reconstruction options in the field of maxillofacial reconstruction. For the better understanding of a fibular free flap, the constant anatomical findings must be learned and memorized by young doctors during the specialized training course for the Korean National Board of Oral and Maxillofacial Surgery. This article reviews the anatomical basis of a fibular free flap with Korean language.

Management of Upper Limb Bone Defects Using Free Vascularized Osteoseptocutaneous Fibular Bone Graft

Sixteen patients (11 men and 5 women), who formed the basis of the study, underwent surgery in the Hand and Reconstruction Microsurgical Unit, Orthopedic Department, Sohag Faculty of Medicine, from January 2001 to January 2009.The right side was involved in 7 cases and the left side in 9 cases. Average age was 35.2 years. The causes of bone defects were infected nonunion of both bone forearms in 5 cases, infected nonunion of the middle part of radius in 4 cases, posttraumatic bone loss of distal radius in 4 cases, and tumor of shaft humerus in 3 cases (aneurysmal bone cyst in 1 and osteosarcoma in 2 patients).The principle of treatment was debridement and excision of either infected unhealthy bone or tumor tissues with wide safety margin.The average bone defect was 8 cm (range, 6-14 cm). The defect was bridged by osteoseptocutaneous vascularized fibular bone graft. The donor bone was the right fibula in 7 cases and the left fibula in 10 cases. Two grafts were used in 1 patient because of soft tissue injuries, which included the peroneal vessels during osteotomy. The vascularized fibula was fixed by small dynamic compression plate. The operative time ranged between 7 and 11 hours. Blood transfusion was indicated in all the cases and its average transfusion was 1000 mL. The average follow-up was 84 months. Bone union was ultimately obtained in 15 patients except 1 who had failure of the graft. Arthrodesis of the distal ulna with the wrist joint was done during the follow-up. Arthrodesis of the wrist joint was also performed for 1 patient who had loss of carpal bones, distal radius, and wrist and finger extensors. The average time for union was 3.5 months. The hand function was normal in all cases. Stress fracture and fibular donor-site morbidity did not occur in this series. Neither shoulders nor elbows were affected postoperatively. There was no recurrence for either infection or tumor.

Double barrel vascularized fibula graft in mandibular reconstruction: a 10-year experience with an algorithm

Double barrel vascularized fibula graft in mandibular reconstruction: a 10-year experience with an algorithm

Total 3D planned mandibular reconstructions using CAD–CAM reconstruction plates and guided implant placement in free vascularized fibula grafts

Background and objectives: New developments in 3D computerized planning now allow for the inclusion of precise dental implant placement in the fibula as well as pre-operatively CAD–CAM produced reconstruction plates. In the research phase for the development of a new commercially available CAD CAM produced reconstruction plate a cadaver and clinical study was performed. Several items were studied: (1) The development of a new design of a 3D printed guide allowing implant insertion, pre drilling of screw holes as well as segmentation of the fibula.

Preexisting Deep Venous Thrombosis in the Peroneal Vein of a Free Vascularized Fibular Graft

Sir: The reported prevalence of preoperative deep venous thrombosis in patients with advanced malignancy ranges from 8 to 16 percent.1,2 The peroneal vein is a common site for deep venous thrombosis to develop3; however, we have rarely encountered deep venous thrombosis when harvesting free vascularized fibular grafts. However, we recently found a preexisting deep venous thrombosis in the peroneal vein of a free vascularized fibular graft harvested to reconstruct the distal femur. A 68-year-old man with spindle-cell sarcoma of the left distal femur underwent wide resection of the femur and immediate reconstruction with liquid nitrogen–treated autograft and a free vascularized fibular graft. Forty days earlier, an excisional biopsy had been performed under general anesthesia. Before resection, the left leg had been asymptomatic, and the D-dimer level had been normal (0.6 µg/ml). The free vascularized fibular graft was harvested without a tourniquet from the ipsilateral leg. The peroneal artery and two accompanying veins were transected just distal to the bifurcation of the posterior tibial vessels. After transection, we found a firm thrombus in the lumen of the larger peroneal vein (Fig. 1). The smaller peroneal vein was patent and without thrombus. After bone fixation at the recipient site, the peroneal artery was anastomosed to the deep femoral artery, and the patent peroneal vein was anastomosed with a venous coupler to a branch of the deep femoral vein. After revascularization, we attempted to remove the thrombus of the larger peroneal vein under an operating microscope; however, the thrombus was partially organized and could not be removed from the lumen (Fig. 2). Therefore, we trimmed the peroneal vein back to the bifurcation of the soleus branches to leave only healthy lumen. This peroneal vein was then anastomosed by hand to the deep femoral vein. Vigorous venous return through the vein was observed. The postoperative course was uneventful. The patient was treated with heparin until the seventh postoperative day.Fig. 1: Harvested vascular pedicle of the fibula. There was a partially organized thrombus (arrowhead) in one of the peroneal veins.Fig. 2: Appearance of the thrombus (arrow) under an operating microscope.To our knowledge, only a few cases of preexisting deep venous thrombosis in the peroneal vein of a free vascularized fibular graft have been reported.4,5 Taghinia et al. reported a similar case at the time of mandibular reconstruction but successfully transferred the flap by using the soleus branch as an alternative drainage route.4 Jacobson et al. reported two similar cases at the time of head and neck reconstruction; however, the flaps could not be transplanted because the peroneal veins were diffusely occluded.5 The cause of the deep venous thrombosis in the present case could not be definitively determined; however, we suspect the deep venous thrombosis developed after the excisional biopsy, when the patient was restricted to bed rest with the knee immobilized for 5 days. The nature of the thrombus, which was incompletely organized, is consistent with the time course. We believe that preoperative examination for possible deep venous thromboses in the peroneal veins is advisable when the free vascularized fibular graft is harvested from a limb with a history of surgery or trauma. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Shimpei Miyamoto, M.D. Division of Plastic and Reconstructive Surgery National Cancer Center Hospital Tokyo, Japan Masahide Fujiki, M.D. Minoru Sakuraba, M.D. Division of Plastic and Reconstructive Surgery National Cancer Center Hospital East Kashiwa, Japan

Spinal Reconstruction with Free Vascularized Fibular Grafts

Spinal Reconstruction with Free Vascularized Fibular Grafts

Forearm post-traumatic deformities: Classification and treatment

IntroductionThere is no classification for acquired forearm deformities. A clinical-radiographic study was conducted to classify these deformities and evaluate the results. Materials and methodsThirteen patients with forearm deformities following traumas or their treatment were included (11 men and two women, from 2000 to 2010). Mean age was 31 years (range 10–75 years). Initial treatment was conservative in five patients and surgical in eight patients. One segment was affected in seven patients (the radius in four patients, the ulna in three), and both segments were affected in six patients. Location assessment: 2 projections X-rays, including wrist and elbow. Deformity location: proximal, diaphisary, distal, defined with the abbreviation, in distal sense, R1, R2, R3 for the radius, and U1, U2, U3 for the ulna. Primary and secondary deformities were distinguished: secondary deformities occurred later in a different location than the primary one. Six patients were treated with plate and screws. An external fixator was used in six patients. One patient was treated with bone resection. Iliac crest bone graft was used in 10 patients, and vascularised fibula graft in one patient. ResultsThe primary deformity affecting the radial diaphysis (R2) determined a secondary deformity in four patients: in the distal ulna (U3) with ulnocarpal dislocation in three patients and in the distal radius (R3) in one patient. Results of osteosynthesis treatment were excellent in one patient, satisfactory in four and unsatisfactory in one. External fixation was excellent in one patient and satisfactory in five. Bone resection was satisfactory in one patient. DiscussionSurgical treatments with osteosynthesis are the major cause of acquired forearm deformities in adults. Location and aetiology of the deformities are essential for the surgical indication and the result. It is important to restore the length of the deformed segment, realigning the anatomical axis. X-rays enable clinicians to distinguish between primary and secondary forearm deformities. ConclusionCharacteristics and locations of post-traumatic deformities were identified. The major location is diaphisary and distal, the elbow is rarely affected. The functional consequence is a limitation in the range of motion of the hand. The best results are achieved with short-term treatment.

One-Stage Reconstruction of Composite Extremity Defects with a Sural Neurocutaneous Flap and a Vascularized Fibular Graft

The fibula flap has been widely used for reconstruction of composite bone and soft-tissue defects. The skin paddle of the fibula flap has played a critical role in providing a cutaneous component and good monitor for the bone component. In this report, the authors designed a perforator-based sural neurocutaneous flap instead of a peroneal perforator flap to enlarge a skin paddle for wound coverage. A novel chimeric flap was harvested based on the peroneal artery, and consisted of a sural neurocutaneous flap and a fibular graft. The sural neurocutaneous flap was elevated based on a single peroneal perforator and connected with the bone component by means of the peroneal artery. Two patients with complex bone and soft-tissue defects were treated by using this chimeric flap. In case 1, the radius defect was 8 cm in length and the soft-tissue defect measured 23 × 10 cm. In case 2, the distal radius was injured and the defect was 16 cm in length. The area of soft-tissue defect was 23 × 8 cm. In this case, the fibula head was used for wrist reconstruction. The soft-tissue defects in the two cases stretched across the palmar and dorsal surfaces of the forearm. The lengths of the bone components were 10 and 16.5 cm, respectively, and the areas of the skin components were 24 × 12 cm and 25 × 10 cm, respectively. Both chimeric flaps survived completely without complications. The follow-up period was 42 months in case 1 and 16 months in case 2. Complete bone union was observed in both cases, and no remarkable degeneration of the fibular head occurred in case 2. The sural neurocutaneous flap showed good texture match and contour. No serious donor-site complications occurred. The two patients were satisfied with their daily lives relative to the severity of their injuries. The chimeric flap composed of a sural neurocutaneous flap and a fibular graft by means of the peroneal artery is a good candidate for reconstruction of long bone defects associated with extensive soft-tissue defects in the extremities.