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.

Methodology and Material: Between December 2008 and December 2013 we have operated 7 patients with the technique. There were 4 men and 3 women. Age ranged from 18 to 54 years old. All patients had at least 10 previous surgeries. Pre-operative femur fragments osteoporosis were found in 5/7 patients. Active infection was present 3/7 patients.

Patients were positioned supine. A cushion was placed under stricken lower limb gluteus. Technique includes desbridement of femur. A monoplanar assembly external fixator was installed. Lateral gastrocnemius musculo-cutaneous flap with a huge skin island was harvested with care on isolation of fibular nerve. Flap raising must preserve fibular perforators of the septum between soleus and fibular longus muscle. Fibula was harvested as usual. Fibular vessels were ligated on both ends of fibula. In patient 2 additional soleus muscle has harvested to fill cavity. In patient 5 screws were also applied and in patient 6: 2 TENs nail were placed in femur.

Results: Cutaneous flaps were viable in all 7 cases. Patient 5 lost fibula and decided for amputation. Post-operative bone scintigraphy with tecneciun was performed in 6 patients. 5 of them graft was considered viable. Of the 7 patients operated with technique 3 are consolidated, one lost fibula and decided for amputation, 3 are in evolution (3 last patients of series). Soft tissue GRAM negative bacillus infection was most common complication.

Conclusions: This is the first clinical application of perforasome theory as a pedicle flap.

Technique is reliable, biologic and potentially reproducible in other centers and general hospitals.

Technique is promising however, prospective randomized study is demanded to assure it´s better than free fibula transplantation