Free Vascularized Fibular Graft for Distal Tibial and Ankle Arthrodesis

Abstract

Background The use of free vascularized fibular graft (FVFG) for proximal and mid-shaft tibial reconstruction is well documented in the literature. However, literature documenting distal tibial and proximal ankle reconstruction using this technique is lacking. The purpose of this case report is to demonstrate the osteocutaneous fibular free flap as a viable limb-sparing option to patients who previously required amputation in similar circumstances.

Methods The patient is a 39-year-old man who sustained a traumatic distal tibial pilon fracture. He underwent open reduction and internal fixation, which was complicated by osteomyelitis requiring multiple debridements and ultimately, resection of necrotic tissue. The resulting distal tibial defect measured 12 cm, including the talus. In an attempt to salvage the extremity, an FVFG was performed using the contralateral fibula. The harvested fibula was inserted proximally into the intramedullary canal of the tibia and impacted distally into the talar dome.

Results To date, the patient's postoperative course was notable for minor wound healing issues which resolved. Postoperative computed tomography confirmed fusion, allowing for weight-bearing and removal of the external fixator.

Conclusion Reconstruction of distal tibial defects with ankle involvement is a challenging operation for orthopedic and plastic surgeons. We describe a case in which a 12 cm tibial defect in conjunction with a talar defect was successfully reconstructed with a free vascularized fibular graft. We believe that this is a safe and viable option for those wishing to avoid amputation.

Keywords

free vascularized fibular graft - ankle reconstruction - limb salvage

• References

• 1 Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg 1975; 55 (5) 533-544
• 2 Chen ZW, Yan W. The study and clinical application of the osteocutaneous flap of fibula. Microsurgery 1983; 4 (1) 11-16
• 3 Lee KS, Park JW. Free vascularized osteocutaneous fibular graft to the tibia. Microsurgery 1999; 19 (3) 141-147
• 4 Santarelli Di Pompeo F. Tibia reconstruction. Medscape Web site. Available online at emedicine.medscape.com/article/1291028-overview . Accessed January 25, 2016
• 5 Tomita Y, Murota K, Takahashi F, Moriyama M, Beppu M. Postoperative results of vascularized double fibula grafts for femoral pseudoarthrosis with large bony defect. Microsurgery 1994; 15 (5) 316-321
• 6 Korompilias AV, Paschos NK, Lykissas MG, Kostas-Agnantis I, Vekris MD, Beris AE. Recent updates of surgical techniques and applications of free vascularized fibular graft in extremity and trunk reconstruction. Microsurgery 2011; 31 (3) 171-175
• 7 Innocenti M, Delcroix L, Manfrini M, Ceruso M, Capanna R. Vascularized proximal fibular epiphyseal transfer for distal radial reconstruction. J Bone Joint Surg Am 2004; 86-A (7) 1504-1511
• 8 Manfrini M, Innocenti M, Ceruso M, Mercuri M. Original biological reconstruction of the hip in a 4-year-old girl. Lancet 2003; 361 (9352) 140-142
• 9 Capanna R, Bufalini C, Campanacci C. A new technique for reconstructions of large metadiaphyseal bone defects: a combine graft (allograft shell plus vascularized fibula). Orthop Traumatol 1993; 2: 159-177
• 10 Bakri K, Stans AA, Mardini S, Moran SL. Combined massive allograft and intramedullary vascularized fibula transfer: the capanna technique for lower-limb reconstruction. Semin Plast Surg 2008; 22 (3) 234-241
• 11 Davis AM, Devlin M, Griffin AM, Wunder JS, Bell RS. Functional outcome in amputation versus limb sparing of patients with lower extremity sarcoma: a matched case-control study. Arch Phys Med Rehabil 1999; 80 (6) 615-618
• 12 Abudu A, Grimer RJ, Tillman RM, Carter SR. Endoprosthetic replacement of the distal tibia and ankle joint for aggressive bone tumours. Int Orthop 1999; 23 (5) 291-294
• 13 Green SA, Roesler S. Salvage of the infected pilon fracture. Tech Orthop 1987; 2: 37-44
• 14 Roukis TS, Kang RB. Vascularized pedicled fibula onlay bone graft augmentation for complicated tibiotalocalcaneal arthrodesis with retrograde intramedullary nail fixation: a case series. J Foot Ankle Surg 2016; ; pii: S1067-2516(15)00575-X