Vascularized Fibula Transfer Research Articles

Optimizing bone fixation in vascularized fibula graft in the upper extremity

The free vascularized fibula transfer has become a widely utilized method in reconstructive surgery, with successful applications across various anatomical areas. The biological properties of the graft, including its ability to fuse with recipient bone, repair fractures, and remodel in new biomechanical environments, have been key to its efficacy. However, stable bone fixation is crucial for successful fusion and to prevent complications like non-union. While early approaches focused on minimally invasive techniques to preserve the fibula's vascular network, stable internal fixation has become favored in preventing complications. This article aims to systematically describe bone fixation options for vascularized fibula grafts in the upper limb based on extensive experience, recommending internal fixation over external methods, such as long plates for humerus reconstruction. Different osteotomy techniques are discussed, including intramedullary, transverse, and step cut, with considerations for biomechanics and patient demographics. The discussion emphasizes the importance of stable osteosynthesis for successful outcomes, particularly in early rehabilitation. Additionally, advancements in 3D printing offer personalized solutions in osteosynthesis device design, further enhancing surgical outcomes.

The Vascularized Fibula as Salvage Procedure in Extremity Reconstruction: A Retrospective Analysis of Time to Heal and Possible Confounders.

The vascularized fibula transfer is a well-established technique for extremity reconstruction, but operative planning and patient selection remains crucial. Although recently developed techniques for bone reconstruction, such as bone segment transfer, are becoming increasingly popular, bone defects may still require vascularized bone grafts under certain circumstances. In this study, 41 cases, 28 (68%) men and 13 (32%) women (median age: 40 years), were retrospectively analyzed. Therapy-specific data (flap vascularity [free vs. pedicled] size in cm and configuration [single- vs. double-barrel], mode of fixation [internal/external]) and potential risk factors were ascertained. Indications for reconstruction were osteomyelitis at host site (n = 23, 55%), pseudarthrosis (n = 8, 20%), congenital deformity (n = 6, 15%), traumatic defect, and giant cell tumor of the bone (n = 2, 5% each). Complete healing occurred in 34 (83%) patients after a median time of 6 months. Confounders for prolonged healing were female gender (p = 0.002), reconstruction in the lower limb (p = 0.011), smoking (p = 0.049), and the use of an external fixator (p = 0.009). Six (15%) patients required secondary limb amputation due to reconstruction failure, and one patient had persistent pseudarthrosis at last follow-up. The only risk factor for amputation assessed via logistic regression analysis was preexisting PAOD (peripheral artery occlusive disease; p = 0.008) The free fibula is a reliable tool for extremity reconstruction in various cases, but time to full osseous integration may exceed six months. Patients should be encouraged to cease smoking as it is a modifiable risk factor.

The Use of Free Fibula Flap in Different Extremities and Our Clinical Results.

Background and objectives Plastic, orthopedic, otolaryngology, and oromaxillofacial surgery specialists rely on fibula grafts to solve reconstructive problems. The aim of this study is to discuss the use and results of vascular fibula flaps in the treatment of bone and soft tissue defects in various regions with different etiologies. Materials and methods In our clinic, we treated 32 patients with osteocutaneous fibular flaps due to bone and soft tissue defects of different etiologies and varying anatomical regions. In our study, age, gender, side, cause of injury, surgical technique, treatment results, and complications were evaluated for each patient. Results Of the 32 patients, 25 were male, and 7 were female. The average age is 37.2 (27-56). The mean bone defect size was 10.45 cm. Bone defect occurred in eight patients due to osteomyelitis, eleven patients due to gunshot wounds, nine patients due to pseudoarthrosis, and four patients due to a giant cell tumor. We applied osteocutaneous fibula flap in 27 patients and vascularized fibular flap in five patients. Bone union could not be achieved in four patients, and bone grafting was performed as a secondary surgery. Local infection occurred in five patients, and their treatment was completed with debridement and antibiotic administration. Wound complications occurred in three patients at the donor site, which were treated with debridement and skin grafting. The mean duration of radiological union was three months, and complete union was achieved in the seventh month. Conclusions We have shown in our case series that free vascularized fibula transfer has gained an important place in the field of skeletal reconstruction and is a reliable method for various bone reconstructions.

Free vascularized fibula graft for staged reconstruction of infected humerus nonunions.

To evaluate the union rate and rate of post-operative complications in patients with septic nonunions of the humerus following a two-stage reconstruction using a free vascularized fibula graft. Retrospective case series. Academic, tertiary referral center. Adult patients with staged reconstruction for infected nonunion of the humerus with at least 2 years follow up after vascularized fibula graft transfer. First, infected nonunion debridement with antibiotic spacer and external fixator placement. After antimicrobial treatment, free vascularized fibula transfer with internal fixation. Time to union, pain, affected extremity range of motion and function. 10 patients with septic humerus nonunion treated with staged reconstruction using a free vascularized fibula graft, with a mean follow-up of 32.3 months were included. Following the two-stage reconstruction using a free fibula, radiographic union was achieved in 6/10 patients, with a mean time to union of 19.9 weeks. The remaining four patients required an additional procedure with graft augmentation and/or implant revision. After the revision procedure, union was noted in 3/4 patients, 21 weeks post-operatively. Mean patient visual analog scale pain scores improved from 5.8 pre-operatively to 0.9 at final follow up (p=0.02). Post-operatively mean elbow flexion was 110±20 degrees and extension 15±7.5 degrees. A two-stage reconstruction using a free fibula graft can be used in patients with septic nonunions of the humerus in the setting of multiple failed prior surgeries and compromised local biology. Additional procedures may be needed in some to achieve final union. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Establishment of a rabbit's model for modified Capanna technique

Massive bone allograft with an intramedullary vascularized fibula (Capanna technique) represents one of the most widely used methods for the reconstruction of massive bone defect. However, the mechanisms, healing process, and underlying influential factors were poorly understood due to the lack of suitable experimental animal models. Critical-sized defects (CSD) in bone were constructed in the proximal tibia of 24 rabbits and randomly divided into two groups. Allogeneic bone segments of the same size as CSDs were obtained from another 12 rabbits and then inactivated. In group Ⅰ, an ipsilateral pedicled vascularized fibula was dissociated and transferred into the intramedullary cavity of allograft to assemble a composite for CSD reconstruction (Capanna technique), while group Ⅱ received a reconstruction with allogeneic bone alone. Radiographic evaluation was performed every week after the operation to assess union status. All animals were sacrificed at 16th week, and the specimens were histologically analyzed. All animals survived without severe intraoperative complications. There was one rabbit (8.33%) in group Ⅰ developed a postoperative infection and died, while three rabbits (25%) had postoperative complications in group Ⅱ (two died of infection and one died of internal fixation fracture). Radiographically, the mean time to union at the allograft-host junction in group Ⅰ was 12.8±1.80 weeks, significantly shorter than in group II (>15.18±1.12 weeks; p<0.001). The grade of graft union of group Ⅰ was significantly higher than that of group Ⅱ both at 8th and 16th week (8th week: p=0.035; 16th week: p=0.033). Fully bone union at the junctions was histologically confirmed in all specimens in group Ⅰ and 66.67% (8/12) in group Ⅱ. Combined allograft and intramedullary vascularized fibula transfer in rabbit's tibia represent an ideal model that accurately simulates the Capanna technique for CSD reconstruction.

Utility of Ipsilateral Medial Fibular Transport Using the Ilizarov Frame in the Treatment for Non-elderly Patients Sustaining Massive Tibial Bone Defects as a Sequela of Trauma and Infection: A Systematic Review

Introduction and Objectives. Segmental tibial bone loss from tumor, trauma, or infection is a debilitating, limb-threatening scenario where treatment principles involve aggressive resection of infected tissues usually leading to large defects requiring reconstruction. A systematic review was conducted to determine the best available evidence related to the ipsilateral medial fibular transport using the Ilizarov frame in the management of these massive tibial bone defects.&#x0D; Methods. Multiple medical online database search for articles containing the keywords: ipsilateral medial fibular transport, medial fibula transport, medialization of the fibula using the Ilizarov fixator, ring external fixator, vascularized free fibula, vascularized fibula transfer, and other related MeSH terms was done. Data was summarized to describethe mean age, bone defect, external fixator time, external fixator index, and bone and functional results using the ASAMI criteria.&#x0D; Results. Eight studies with a total of 43 patients with massive tibial bone defects treated by fibular transport using the Ilizarov methods were identified. The mean age was 25.27 years (6.5-44.4) with a mean bone defect of 13.57 cm (9.52-17). The mean length of follow-up was 37.67 months (18-70.2). The bone union rate was 100%. Mean external fixation time was 9.59 months (8.31-10.88) and external fixation index was 0.61 months/cm (0.52-0.70). The majority of patients have an excellent bone (84%) and functional (52%) results. The average rate of complication was determined at 0.74/patient (95% CI, 0.60-0.89). The most common complications include pin-tract infection (37%), residual loss of motion/stiffness of knee and ankle (35%), and pain on the transport site (21%).&#x0D; Conclusion. Ipsilateral medial fibular transport using the Ilizarov frame provides a viable alternative treatment option for the treatment of massive tibial bone defects.

Masquelet’s induced membrane technique for the reconstruction of post-traumatic, open-grade distal femur fracture with bone defect

Introduction: Reconstruction of complex, open-grade distal femur fracture with bone defect presents an orthopaedic surgeon with a distinctive challenge as they are often associated with contaminated, compromised soft tissue and poor host condition. Conventional techniques like vascularized fibula transfer, autologous bone grafting or distraction osteogenesis focus mainly over bone union without taking infection control into consideration. The aim of this study is to evaluate the outcome of induced membrane technique in the reconstruction of open distal femur fracture with bone defect. Methods: 10 such patients were retrospectively evaluated. Union was considered when a minimum of two cortices were seen on a radiograph. Knee Society Score was used to evaluate the functional outcome. Results: The average length of the defect was 5.7cm (3–10 cm) with mean interval period between the two stages being 42.7 days (34–51 days). Internal fixation was carried out in all cases. In 7 patients we used a mixture of cancellous autograft and cancellous allograft mixed in a ratio of 3:1. In the remaining 3 patients we used only cancellous autograft. Radiological union was achieved in all patients with mean union time of 8.5 months (7–11 months). Mean knee score was 79 (69–86) and mean function score was 71.5 (60–80). Conclusion: The induced membrane technique is an economical, technically less demanding technique for reconstruction of distal femur fracture with bone defects. The results are reproducible with a high success rate and without the need of any special instrumentation. It bestows infection control and prevents graft resorption. Long reconstructive period and donor site morbidity are matters of concern.

Combined massive allograft and intramedullary vascularized fibula transfer: the Capanna technique for treatment of congenital pseudarthrosis of the tibia

Background and purpose — Congenital pseudarthrosis of the tibia (CPT) is caused by local periosteal disease that can lead to bowing, fracturing, and pseudarthrosis. Current most successful treatment methods are segmental bone transport and vascularized and non-vascularized bone grafting. These methods are commonly hampered by discomfort, reoperations, and long-term complications. We report a combination of a vascularized fibula graft and large bone segment allograft, to improve patient comfort with similar outcomes.Patients and methods — 7 limbs that were operated on in 6 patients between November 2007 and July 2018 with resection of the CPT and reconstruction with a vascularized fibula graft in combination with a bone allograft were retrospectively studied. The mean follow-up time was 5.4 years (0.9–9.6). Postoperative endpoints: time to discharge, time to unrestricted weight bearing, complications within 30 days, consolidation, number of fractures, and secondary deformities.Results — The average time to unrestricted weight bearing with removable orthosis was 3.5 months (1.2–7.8). All proximal anastomoses consolidated within 10 months (2–10). 4 of the 7 grafts fractured at the distal anastomosis between 6 and 14 months postoperatively. After reoperation, consolidation of the distal anastomosis was seen after 2.8 months (2–4). 1 patient required a below-knee amputation.Interpretation — This case series showed favorable results of the treatment of CPT through a combination of a vascularized fibula graft and large bone segment allograft, avoiding the higher reintervention rate and discomfort with ring frame bone transport, and the prolonged non-weight bearing with vascularized fibula transfer without reinforcement with a massive large bone segment allograft.

Evaluation of the Efficacy of Pasteurized Autograft and Intramedullary Vascularized Fibular Transfer for Osteosarcoma of the Femoral Diaphysis.

ObjectiveTo assess the treatment of osteosarcomas of the femoral diaphysis through wide en bloc excision and reconstruction of the defect by pasteurized autograft combined with vascularized fibular transfer.MethodsA single‐center, retrospective study was performed of 15 selected patients (six females, nine males) whose lesion in the middle diaphysis of the femur were treated by en bloc excision and reconstruction of the bone defect with recycled pasteurized autograft combined with vascularized fibular graft between January 2000 and December 2011. The primary diagnoses of the patients were osteosarcoma (15 patients), and one of these patients had a pathological fracture. The mean patient age at the time of surgery was 22.3 years (range, 10–40 years). All these cases of bone tumors were staged according to Ennekingʼs criteria with three stage IIA cases, and 12 stage IIB cases. The patients were examined clinically and radiologically every month during the first 6 months after surgery to exclude the evidence of infection and local recurrence, then at 3‐monthly intervals for 2 years and then at 6‐monthly intervals for life. Function was assessed using the Musculoskeletal Tumor Society Scoring system (MSTS).ResultsAt a mean follow‐up of 65.1 months (range, 31–131 months), all the patients had achieved bony union at the final follow‐up. The mean time to bone union of the proximal junctions of vascularized fibula was 8.7 months (range, 6.0–13.0 months) and that of the distal junctions was 9.2 months (range, 6.0–12.0 months). Mean union time of the proximal junctions of the pasteurized autogenous bone was 14.3 months (range, 10.0–25.0 months) and that of the distal junctions was 15.6 months (range, 10.0–27.0 months). There were two fractures of the pasteurized bone during the operation. One patient, in whom the plate had been removed after union at 3 years postoperatively, sustained a fracture in a fall. This was treated with external fixation and united uneventfully. One patient, in whom two of the proximal screws had been broken, developed coxa vara. There was no infection. There were three pulmonary metastases and no local recurrence. The mean function score was 81.8%. Five patients died of their underlying disease, and the disease‐specific survival of patients was 69.1%.ConclusionsPasteurized autogenous bone graft combined with a vascularized fibula graft is a useful reconstruction method for large bone defects after resection of osteosarcoma in the femur.

Surgical treatment of congenital pseudarthrosis of the forearm: Review and quantitative analysis of individual patient data

There is little scientific evidence on the best surgical treatment for congenital pseudarthrosis of the forearm due to the rarity of this condition (less than 100 cases described in the literature) and the lack of comparative studies. Our aim was to provide evidence in favor of a certain surgical technique. A comprehensive review of the literature was performed using case series and case reports. The statistical analysis was based on individual patient data to mimic a case-control study. A multiple logistic regression was used to assess the effect of each independent variable (neurofibromatosis status, location of the pseudarthrosis, age at first surgery and type of treatment) on bone union at last follow-up (yes/no). The database searches yielded 1112 articles; 55 articles were selected, reporting on 94 cases. Seventy patients had healed completely at the last follow-up (74%). Neither the age at surgery nor the location of the pseudarthrosis was related to union (P>0.7). The patients’ neurofibromatosis type 1 status was weakly related to healing (P=0.06). Vascularized fibula transfer had a higher rate of healing (100%) than did non-vascularized bone graft (70%) (P=$0.002). Level of evidence4 (case-control study of data from case series and case reports).

Treatment of Complex Infected Non-union of Bone of the Upper Extremity by a Staged Approach: Debridement and Antibiotic Cement Followed by a Vascularized Free Fibula Flap

Background: Infected non-union of bone of the upper extremity remains a difficult problem to treat with limited options. Management must address chronic osteomyelitis and skeletal instability caused by the non-union. We present our experience with a staged approach in five patients. Methods: The study cohort consisted of five males with an average age of 38 years and 4 prior procedures for infected non-union of the humerus (1) radius(1), ulna(1), ulna and radius(1) and metacarpal(1). The first stage consisted of aggressive debridement of all infected devitalized bone, bone cultures, removal of hardware, placement of antibiotic impregnated cement and stabilization with an external fixator (4 of 5 patients) followed by culture specific antibiotics. This was followed by definitive reconstruction using a free vascularized fibular flap and a course of post-operative antibiotics. Results: The average bony defect measured 8.6 cm. All flaps survived, one required re-exploration for venous thrombosis 72 hrs post-operatively and was successfully salvaged with a re-do anastomosis using a vein graft. The average time to bony union was 14 weeks. There was one hypertrophic non-union from proximal hardware failure which required repeat surgical intervention. At an average of 5.1 years follow-up all patients remain infection free and were working. Conclusions: A stage approach to the treatment of infected non-union of bone consisting of aggressive debridement, antibiotic cement, culture specific antibiotic followed by a vascularized fibular transfer is an effective treatment to a complex problem with limited alternatives. Keywords: Infected non-union of bone, Osteomyelitis, Microsurgery, Antibiotic cement, Free vascularized fibula flap.

Black pigmentation of both forearm bones after chronic minocycline antibiotic therapy for septic nonunion. A case report and literature review

We report the case of a 28-year-old man with a septic forearm non-union treated with minocycline for 3 months. At the time of reconstructive surgery, the radius and ulna were entirely black. Surgical debridement until bleeding of both bone extremities resulted in a 5-cm defect that was filled with a cement spacer. Histology confirmed poorly vascularized bone with focal areas of acute inflammatory infiltrate at the non-union sites (highly suggestive of infection) and normal structure of the remaining diaphyseal bones, although black in color. Reconstruction with free vascularized fibula transfer was successful leading to complete bone healing. An incidental finding of minocycline-induced black bone discoloration should not change the surgeon's decision because there is no evidence of adverse effects on bone healing in the literature. Surgery can be performed safely at sites of minocycline-induced black bone pigmentation.

Vascularized fibular graft for chronic osteomyelitis of humerus in a 10 years child

Introduction: Reconstruction of large skeletal defects secondary to osteomyelitis remains a challenging problem. Free vascularized bone can be used to reconstruct large skeletal defects greater than 6 cm or bone defects of smaller size that failed to heal with nonvascularized bone grafting. There are only few case reports which describe it in such a young age group. Case report: We report a case of a 9 years male child with a right proximal humerus osteomyelitic defect treated with a vascularized fibular graft and plating with a 6 months follow up having a satisfactory functional outcome. Conclusion: free vascularized fibula transfer is an efficient technique for exceptional cases of multi-operated and aseptic resistant non-union with bone defect of the humerus. The indications for vascularized bone grafting are skeletal defects greater than 6 cm or smaller defects that have failed to heal with nonvascular bone graft with a reported success rate of 77%-90%.

Aesthetic and Functional Mandibular Reconstruction With Immediate Dental Implants in a Free Fibular Flap and a Low-Profile Reconstruction Plate

Aesthetic and functional mandibular reconstruction can be achieved in 1-stage. It involves simultaneous dental implant placement in a free vascularized fibula transfer with a low-profile reconstruction plate. The aim of this study was to assess the postoperative aesthetic profile and oral functional result. Ten patients with a mean age of 31.6 years and an average follow-up time of 83.7 months underwent 1-staged mandibular reconstructions after segmental mandibulectomies. Simultaneous dental implantation was placed at the fibular segment according to the maxillary dentition. The fibula-implant construct was stabilized superiorly with miniplates and an additional low-profile reconstruction plate recreated the inferior mandibular contour. Any remaining vascularized soft tissue was used for augmentation. Palatal mucosa grafts were placed around the dental implant healing abutment at the uncovering stage surface. Aesthetic profile and oral function were evaluated postoperatively for 5 years. All microsurgical transplantations were successful. None of the patients required subsequent revisions. All patients completed prosthodontic rehabilitation. All patients had palatal mucosal grafts placed around the dental implants. The mean probing pocket depths were shallower around the implants, 3.09 ± 0.82 mm at mesial, 3.33 ± 1.05 mm at distal, 3.02 ± 1.13 mm at buccal, and 3.23 ± 1.17 mm at lingual surfaces. Radiographs revealed no statistical differences in mean of the mesial [0.27 ± 0.26 mm] and distal [0.33 ± 0.25 mm] of peri-implant bone loss. The prosthetic load mean follow-up time was 71.7 months with a satisfactory implant-supported prosthesis. Two slender female patients palpated the reconstruction plate beneath the soft tissue envelope. This approach is selectively fashioned for patients with benign disease when the overlying soft tissue drape is adequate. The technique described results in improved appearance and function through definition of the lower third of the face and simultaneous dental implant replacement.

Two-Stage Distraction Lengthening of the Forearm

Single-stage lengthening of the forearm using callus distraction is well described; however, forearm lengthening using a 2-stage technique of distraction followed by bone grafting has received less attention. A 2-staged technique can be a better alternative in cases where the surgeon desires extensive lengthening. A retrospective review was undertaken of eleven 2-stage forearm lengthening procedures performed by 1 surgeon over a 15-year period. Indications were radial longitudinal deficiency (8 patients), neonatal ischemic contractures (2 patients), and septic growth arrest (1 patient). Average follow-up was 2.8 years. Distraction was performed on patients an average of 82 mm over an average duration of 24 weeks. Average time to union from the time of distractor removal and grafting was 87 days. Average healing index was 32.1 d/cm. Distraction problems were common and related to the length of time that the distractor was in place; they included pain, pin-related infections, and multiple mechanical device difficulties. Three patients had nonunion, and another had delayed union; however, additional procedures resulted in ultimate bony union in all patients. Demineralized bone matrix and autologous corticocancellous bone grafts yielded predictable healing and good functional results in short-distance distractions. For longer distractions, free vascularized fibula transfer produced the best outcomes. Intercalary cortical allografts did not heal well. Patients with neonatal Volkmann contractures had the most difficulty with distraction and healing, ultimately obtaining little to no lengthening and poor functional outcomes.

Intérêt de la conservation d’un lambeau insulaire de peau comme index de vitalité d’un transplant libre fibulaire dans les reconstructions diaphysaire étendues

To evaluate the feasibility and reliability of free vascularized fibular graft with skin island flap for reconstruction of large diaphyseal bone defect. The clinical results of vascularized fibular graft and experiences related to the importance and reliability of a monitoring island flap for the reconstruction of various long bone defects were reviewed in 87 patients. Bony reconstruction was achieved in 82 of the 87 patients. Arterial thrombosis of anastomosed vessel in two patients and venous congestion of monitoring flap in nine patients occurred in the early postoperative periods. All of them were managed by immediate thrombectomy and reanastomosis; alternatively the thrombotic veins were replaced by new veins to anastomose with the superficial veins in five patients. Partial flap necrosis was noted in six patients, but additional surgical intervention was not required. The vascularized fibula survived and bony fusion was achieved in all patients. Postoperative stress fractures of the fibula graft occurred in 19 (21.8%) patients (once in seven patients, twice in five patients, three or more times in seven) as the mechanical stress to the graft increased. Included fracture on the tibia in 12 patients, humerus in one and femur in six. Treatments included casting in 11 patients, percutaneous pinning in one case, and adjustment of external fixator in seven patients. Bony union was finally achieved an average of 9.6 months after fracture. Correct alignment between the recipient bone and the external fixator is a prerequisite to preventing graft fracture. Vascularized fibula transfer is a valuable procedure for long bone defects, and a skin island monitoring flap is a simple, extremely useful, and reliable method for assessing the vascular status of vascularized fibula. Level IV. Retrospective study.

Value of a skin island flap as a postoperative predictor of vascularized fibula graft viability in extensive diaphyseal bone defect reconstruction

To evaluate the feasibility and reliability of free vascularized fibular graft with skin island flap for reconstruction of large diaphyseal bone defect. The clinical results of vascularized fibular graft and experiences related to the importance and reliability of a monitoring island flap for the reconstruction of various long-bone defects were reviewed in 87 patients. Bony reconstruction was achieved in 82 of the 87 patients. Arterial thrombosis of anastomosed vessel in two patients and venous congestion of monitoring flap in nine patients occurred in the early postoperative periods. All of them were managed by immediate thrombectomy and reanastomosis, alternatively the thrombotic veins were replaced by new veins to anastomose with the superficial veins in five patients. Partial flap necrosis was noted in six patients, but additional surgical intervention was not required. The vascularized fibula survived and bony fusion was achieved in all patients. Postoperative stress fractures of the fibula graft occurred in 19 (21.8%) patients (once in seven patients, twice in five patients, three or more times in seven) as the mechanical stress to the graft increased. Included fracture on the tibia in 12 patients, humerus in one and femur in six. Treatments included casting in 11 patients, percutaneous pinning in one case, and adjustment of external fixator in seven patients. Bony union was finally achieved an average of 9.6 months after fracture. Correct alignment between the recipient bone and the external fixator is a prerequisite to preventing graft fracture. Vascularized fibula transfer is a valuable procedure for long-bone defects, and a skin island-monitoring flap is a simple, extremely useful, and reliable method for assessing the vascular status of vascularized fibula. Level IV. Retrospective study.

Vascularized fibula transfer for lower limb reconstruction

Massive bony defects of the lower extremity are usually the result of high-energy trauma, tumor resection, or severe sepsis. Vascularized fibular grafts are useful in the reconstruction of large skeletal defects, especially in cases of scarred and avascular recipient sites, or in patients with combined bone and soft-tissue defects. Microvascular free fibula transfer is considered the most suitable autograft for reconstruction of the middle tibia because of its long cylindrical straight shape, mechanical strength, predictable vascular pedicle, and hypertrophy potential. The ability to fold the free fibula into two segments or to combine it with massive allografts is a useful technique for reconstruction of massive bone defects of the femur or proximal tibia. It can also be transferred with skin, fascia, or muscle as a composite flap. Proximal epiphyseal fibula transfer has the potential for longitudinal growth and can be used in the hip joint remodeling procedures. Complications can be minimized by careful preoperative planning of the procedure, meticulous intraoperative microsurgical techniques, and strict postoperative rehabilitation protocols. This literature review highlights the different surgical techniques, indications, results, factors influencing the outcome, and major complications of free vascularized fibular graft for management of skeletal or composite defects of the lower limb.

Evaluation of the ankle function following reconstruction of the donor defect with a split fibular bone after a vascularized fibular flap transfer

To validate the hypothesis that the reconstruction of the missing segment of the fibula using a redundant split fibular graft after a vascularized fibular flap transfer may have a better effect on ankle function. Of the 24 head and neck cancer patients who received a free fibula flap for mandible reconstruction, 14 patients underwent the conventional method of donor site closure, in which the redundant fibular bone was discarded (Group I). Ten patients underwent longitudinal osteotomy of the redundant non-vascularized fibular portion to bridge the donor site defect (Group II). Postoperative subjective satisfaction level was evaluated with a self-constructed questionnaire in 10 parameters (ambulation with assistance, ankle instability, ankle stiffness, muscle weakness, leg edema, foot numbness, ankle pain, other sites of pain besides the ankle, and restriction to run) and the 4 voluntary motions (dorsiflexion, plantar flexion, eversion, and inversion) of both ankles were measured using a CYBEX II dynamometer. The muscle peak torque of the donor leg was significantly lower at ankle plantar flexion (P = 0.002), eversion (P = 0.002), and inversion (P = 0.0002) in Group I as well as at dorsiflexion (P = 0.031), plantar flexion (P = 0.016), and inversion (P = 0.002) in Group II against the contralateral non-operated leg. The muscle power was significantly greater when performing ankle eversion (P = 0.049) in those who underwent split fibular bone reconstruction. There was no difference in the subjective satisfaction score between these two groups. The reconstruction of the donor site with a split fibular bone graft led only a slight improvement in ankle eversion.

Simultaneous Radius and Ulna Reconstruction With Folded Free Vascularized Fibula Transfer: Case Report

We report 1 case of successful treatment of radius and ulna nonunion by a folded vascularized fibular graft, in which 2 parallel fibular struts remained connected by the periosteum and peroneal vessels, and another case of infected nonunion of the ulna and radius with osseous and soft tissue defects treated by a free fibular osteoseptocutaneous flap with folded fibular graft in a 1-stage procedure.