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

Abstract

Purpose: To evaluate the feasibility and reliability of free vascularized fibular graft with skin island flap for reconstruction of large diaphyseal bone defect.

Method: 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.

Results: 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.

Conclusions: 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 of evidence: Level IV. Retrospective study.