The use of fibula flaps for complex reconstructions: indications and outcomes

Chapter 1 In the general introduction several aspects of microvascular reconstructive surgery, with emphasis on the use of the free vascularized fibula flap, are described, followed by the ouline and aim of this thesis. Chapter 2 In Chapter 2 we performed a systematic review of the literature on the outcome of the so-called Capanna technique. We found that combining a massive allograft and an intramedullary vascularized fibula as a method for the primary reconstruction of segmental bone defects in the lower extremity provides a single step reconstruction with good functional long-term outcomes. Chapter 3 Congenital pseudarthrosis of the tibia is a rare disease affecting the development of the diaphysis of the tibia. In summary, the Capanna technique for ipsilateral vascularized fibular transplantation needed only 1.2 interventions to achieve union in 6 out of 7 tibias with a relative short time to full weight bearing and seems therefore to be a more patient-friendly treatment than the conventional methods of bone transport with ring frames or vascularized fibula transfers that do not use the addition of a massive allograft in the reconstruction. Chapter 4 We present four illustrative case histories of patients with a pedicled fibular graft for a salvage arthrodesis of the knee. The case histories of these patients do illustrate that a pedicled vascularized fibula is a good option in knee arthrodesis and sometimes the only alternative to amputation. On the basis of our case studies, we recommend some technical modifications when using a pedicled fibular graft for knee arthodesis. We believe that an ipsilateral pedicled fibula flap is a good solution for salvage arthrodesis of the knee. Chapter 5 The free vascularized fibula graft is the first choice in most cases of spinal reconstruction. We describe long-term follow up and complications as well as patient- reported outcomes on spinal reconstructive surgery utilizing a FVFG. The quality of life after this complex and extensive reconstructive surgery is good and demonstrates the viability and durability of FVFG’s in spinal reconstruction. Chapter 6 Osteoradionecrosis of the jaw is a severe complication of radiotherapy in head and neck cancer patients. If conservative treatment and surgical debridement have been unsuccessful, the preferred treatment for symptomatic mandibular osteoradionecrosis is radical resection of the affected bone and subsequent reconstruction with a free vascularized flap. The fibula is the preferred free flap for mandibular reconstruction, also in mORN cases, albeit with a higher risk of complications. Patients need to be informed that these complications may require surgical re-intervention or even revision of the reconstruction. Chapter 7 There are several studies describing the donor leg morbidity after removal of osseous and osteo-cutaneous fibula flaps, but the effect of the flexor hallucis longus harvest on remaining function is unknown. In this study, there was no difference in loss of function between these two methods of fibula free flap harvesting. Isolated flexor hallucis longus flexion contracture has been reported in the literature. However we did not find clawtoe deformity following ipsilateral harvest of a free vascularized fibula graft. Thus, it looks like the surgeon’s choice to use either technique can be made without considering donor site morbidity of the hallux. Chapter 8 When a skin paddle is harvested together with the free vascularized fibula flap, the donor site can be either closed primarily or be covered with a split skin graft. Our findings do not strongly support the use of skin grafting for donor site wounds that can be closed with modest tension. We recommend primary closure for wounds amenable to modest tension, taking into account patient-specific factors like defect size versus leg circumference, skin laxity, and tissue quality.