Utilization of the Pedicled and Free Fibula Flap for Ankle Arthrodesis

Abstract

Ankle arthrodesis has become a common surgical procedure for individuals with end-stage ankle arthritis, chronic infection, and bony misalignment. Although arthrodesis is typically managed with arthrodesis in situ or realignment, reconstruction may be utilized for patients with more complicated cases that involve metatarsal defects. Our institution utilizes both the pedicled and free fibula flaps for surgical management pertaining to ankle arthrodesis. Our study looks to evaluate the work of a single plastic surgeon and identify patient postoperative outcomes.

Methods: A retrospective chart review was conducted at Beaumont Health System, Royal Oak, for patients who underwent ankle arthrodesis with a pedicled fibula flap for nonunion or avascular necrosis of the talus between the years 2014 and 2022. Demographic data, operative details, complications, medical comorbidities, and patient outcomes were retrospectively gathered and analyzed.

Results: A total of six patients were isolated, with three patients undergoing a free fibula approach and three patients undergoing the pedicled fibula approach. All patients were found to have tolerated the procedure well and had no intraoperative complications. In addition, all patients had clinically viable flaps and were satisfied with their surgical result.

Conclusions: Both free and pedicled free fibula flaps may be used effectively in the management of ankle arthrodesis in patients who have failed prior therapy. In our study, free fibula flaps were utilized in a medial approach, while the pedicled fibula flap was utilized in a lateral approach. With the right expertise and patient population, the free and pedicled fibula flaps can be highly successful in the repair of ankle defects.

Fig. 1.

Case 1. Preoperative image of a patient with prior right ankle reconstruction presenting with chronic right lower extremity pain due to avascular necrosis of the talus.

Fig. 2.

Case 1. Intraoperative image demonstrates right osteocutaneous free flap utilized for ankle arthrodesis.

Fig. 3.

Case 1. Intraoperative image of right ankle revision and tarsal arthrodesis with right fibula osteocutaneous free flap and hardware removal before external fixator placement.

Fig. 4.

Case 2. Preoperative image of a patient with prior right ankle fracture status after ORIF with subsequent development of medial malleolar nonunion.

Fig. 5.

Case 2. Intraoperative image demonstrates preparation of the recipient site by creation of a bone slot for free fibula flap to be placed.

Fig. 6.

Case 2. One-year follow-up demonstrates that the flap has healed without complications and that the patient is able to successfully bear weight on her right lower extremity.

Fig. 7.

Case 3. Preoperative image of a patient who presents with initial right open pilon fracture before surgical intervention with ORIF. He subsequently developed infected hardware and osteomyelitis, which led to hardware removal, bone debridement, and placement of antibiotic spacer.

Fig. 8.

Case 3. Intraoperative image demonstrates removal of the antibiotic bone spacer and preparation of the recipient site for free fibula flap.

Fig. 9.

Case 3. Intraoperative image of the chimeric medial femoral condyle free flap.

Fig. 10.

Case 3. Intraoperative image demonstrates creation of an arteriovenous loop.

Fig. 11.

Case 4. Intraoperative image of the harvested left fibula rotational bone flap that would be utilized for ankle arthrodesis.

Fig. 12.

Case 4. Postoperative three-dimensional CT scan demonstrates placement of the fibula flap in the bone slot for ankylosis.

Fig. 13.

Case 5. Intraoperative image of the harvested left fibula rotational bone flap that would be utilized for ankle arthrodesis.

Fig. 14.

Case 5. Postoperative three-dimensional CT scan demonstrates placement of the fibula flap in the bone slot for ankylosis.

Fig. 15.

Case 6. Intraoperative image of the harvested left fibula rotational bone flap that would be utilized for ankle arthrodesis.

Fig. 16.

Flowchart demonstrating our indications on when a fibula or pedicled fibula flap should be utilized for ankle arthrodesis.