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One-stage reconstruction of extensive composite extremity defects with low donor site morbidity: A retrospective case series of combined transfer of a vascularized fibula flap and a perforator flap

Published:February 09, 2022DOI:https://doi.org/10.1016/j.injury.2022.02.028
      • Extensive composite extremity defects after high-energy trauma represent a significant challenge for plastic surgeons.
      • An ideal technique would allow one-stage reconstruction while causing minimal donor site morbidity.
      • In 14 patients, we avoided amputation using a combination of a vascularized fibula bone flap and a perforator flap in a one-stage surgery with a good functional and aesthetic outcome.

      Abstract

      Background

      Extensive composite extremity defects remain a challenge in plastic and reconstructive surgery. To preserve the extremity, we used combined transfer composed of the vascularized fibula flap and a perforator flap from various body parts to reconstruct extensive composite extremity defects.

      Patients and methods

      From January 2004 to December 2018, 14 male patients aged 9 to 55 years with extensive composite extremity defects (large soft-tissue and long bone defect) underwent reconstructive surgery in our institution. The combined transfer surgery consisted of the vascularized fibula bone flap and a perforator flap, such as anterolateral thigh flap, deep inferior epigastric perforator flap, or thoracodorsal artery perforator flap.

      Results

      All fourteen patients were treated successfully using the combined transfer method. The dimensions of the different perforator flaps ranged from 13 × 6 cm2 to 26 × 11 cm2, and the size of the skin paddle of the fibular osteocutaneous flap ranged from 9 × 3 cm2 to 21 × 7 cm2. The median length of the fibular graft was 15 cm. No serious donor site complications were observed. Only one patient developed venous congestion and was salvaged. Another patient had hematoma at the recipient site and underwent debridement. Though all patients achieved bone union (median time of 8 months), two developed a stress fracture of the transferred free fibula.

      Conclusion

      We were able to minimize donor site morbidity and avoid amputation in these patients using the combined transfer technique Our results show that the combined transfer of perforator flap and vascularized fibula flap with or without a skin paddle is a feasible reconstruction option for the treatment of the extensive composite extremity defects.

      Keywords

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      References

        • Lee K.S.
        • Han S.B.
        • Baek J.R.
        Free vascularized osteocutaneous fibular graft to the tibia in 51 consecutive cases.
        J Reconstr Microsurg. 2004; 20: 277-284
        • Zheng H.P.
        • Zhuang Y.H.
        • Zhang Z.M.
        • Zhang F.H.
        • Kang Q.L.
        Modified deep iliac circumflex osteocutaneous flap for extremity reconstruction: anatomical study and clinical application.
        JPRAS. 2013; 66: 1256-1262
        • Yazar S.
        • Lin C.H.
        • Wei F.C.
        One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities.
        Plast Reconstr Surg. 2004; 114: 1457-1466
        • Chim H.
        • Sontich J.K.
        • Kaufman B.R.
        Free tissue transfer with distraction osteogenesis is effective for limb salvage of the infected traumatized lower extremity.
        Plast Reconstr Surg. 2011; 127: 2364-2372
        • Kang Y.
        • Wu Y.
        • Ma Y.
        • Liu J.
        • Gu J.
        • Zhou M.
        • et al.
        Primary free-flap tibial open fracture reconstruction with the Masquelet technique" and internal fixation.
        Injury. 2020; 51: 2970-2974
        • Abdou S.A.
        • Stranix J.T.
        • Daar D.A.
        • Mehta D.D.
        • McLaurin T.
        • Tejwani N.
        • et al.
        Free tissue transfer with distraction osteogenesis and masquelet technique is effective for limb salvage in patients with gustilo type IIIB open fractures.
        Plast Reconstr Surg. 2020; 145: 1071-1076
        • Wang G.
        • Tang Y.
        • Wu X.
        • Yang H.
        Masquelet technique combined with microsurgical technique for treatment of Gustilo IIIC open distal tibial fractures: a retrospective single-center cohort study.
        J Int Med Res. 2020; 48 (300060520910024)
        • Ao M.
        • Asagoe K.
        • Maeta M.
        • Nakagawa F.
        • Saito R.
        • Nagase Y.
        Combined anterior thigh flaps and vascularised fibular graft for reconstruction of massive composite oromandibular defects.
        Br J Plast Surg. 1998; 51: 350-355
        • Koshima I.
        • Hosoda S.
        • Inagawa K.
        • Urushibara K.
        • Moriguchi T.
        Free combined anterolateral thigh flap and vascularized fibula for wide, through-and-through oromandibular defects.
        J Reconstr Microsurg. 1998; 14: 529-534
        • Wei F.C.
        • Celik N.
        • Chen H.C.
        • Cheng M.H.
        • Huang W.C.
        Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of extensive composite mandibular defects.
        Plast Reconstr Surg. 2002; 109: 45-52
        • Chang T.Y.
        • Lee J.S.
        • Lee Y.C.
        From “equal” to “unequal” combination of anterolateral thigh flap and fibula flap for extensive composite oromandibular defects.
        Microsurgery. 2017; 37: 839-840
        • Gong Z.J.
        • Zhang S.
        • Zhang S.
        • Liu J.
        • Xu Y.M.
        • Wu H.J.
        Reconstruction of through-and-through oromandibular defects with combined fibula flap and anterolateral thigh flap.
        J Oral Maxillofac Surg. 2017; 75: 1283-1292
        • Wang C.Y.
        • Chai Y.M.
        • Wen G.
        • Han P.
        One-stage reconstruction of composite extremity defects with a sural neurocutaneous flap and a vascularized fibular graft: a novel chimeric flap based on the peroneal artery.
        Plast Reconstr Surg. 2013; 132 (428e–437e)
        • Yu P.
        • Chang E.I.
        • Hanasono M.M.
        Design of a reliable skin paddle for the fibula osteocutaneous flap: perforator anatomy revisited.
        Plast Reconstr Surg. 2011; 128: 440-446
        • Chai Y.M.
        • Wang C.Y.
        • Zeng B.F.
        • Chen Z.G.
        • Cai P.H.
        • Kang Q.L.
        • et al.
        Peroneal artery perforator chimeric flap for reconstruction of composite defects in extremities.
        Microsurgery. 2010; 30: 199-206
        • Wei F.C.
        • Chen H.C.
        • Chuang C.C.
        • Noordhoff M.S.
        Fibular osteoseptocutaneous flap: anatomic study and clinical application.
        Plast Reconstr Surg. 1986; 78: 191-200
        • Guerra A.B.
        • Metzinger S.E.
        • Lund K.M.
        • Cooper M.M.
        • Allen R.J.
        • Dupin C.L.
        The thoracodorsal artery perforator flap: clinical experience and anatomic study with emphasis on harvest techniques.
        Plast Reconstr Surg. 2004; 114 (discussion 2-3): 32-41
        • Tang J.
        • Fang T.
        • Song D.
        • Liang J.
        • Yu F.
        • Wang C
        Free deep inferior epigastric artery perforator flap for reconstruction of soft-tissue defects in extremities of children.
        Microsurgery. 2013; 33: 612-619
        • He J.
        • Wu P.
        • Zhou Z.
        • Kalsi R.
        • Yu F.
        • Qing L.
        • et al.
        Versatile design of compound vastus lateralis muscle and anterolateral thigh musculocutaneous perforator free flaps for customized reconstruction of complex skin and soft tissue defects in the extremities.
        Microsurgery. 2020;
        • Bibbo C.
        • Bauder A.R.
        • Nelson J.
        • Ahn J.
        • Levin L.S.
        • Mehra S.
        • et al.
        Reconstruction of traumatic defects of the tibia with free fibula flap and external fixation.
        Ann Plast Surg. 2020; 85: 516-521
        • Lin C.H.
        • Wei F.C.
        • Chen H.C.
        • Chuang D.C.
        Outcome comparison in traumatic lower-extremity reconstruction by using various composite vascularized bone transplantation.
        Plast Reconstr Surg. 1999; 104: 984-992
        • Ozkan O.
        • Ozgentas H.E.
        • Dikici M.B.
        Simultaneous reconstruction of large maxillary and mandibular defects with a fibular osteocutaneous flap combined with an anterolateral thigh flap.
        J Reconstr Microsurg. 2004; 20: 451-455
        • Qing L.
        • Wu P.
        • Yu F.
        • Zhou Z.
        • Tang J.
        Sequential chimeric deep circumflex iliac artery perforator flap and flow-through anterolateral thigh perforator flap for one-stage reconstruction of complex tissue defects.
        JPRAS. 2019; 72: 1091-1099
        • Adani R.
        • Delcroix L.
        • Innocenti M.
        • Marcoccio I.
        • Tarallo L.
        • Celli A.
        • et al.
        Reconstruction of large posttraumatic skeletal defects of the forearm by vascularized free fibular graft.
        Microsurgery. 2004; 24: 423-429
        • Taylor G.I.
        • Corlett R.J.
        • Ashton M.W.
        The evolution of free vascularized bone transfer: a 40-year experience.
        Plast Reconstr Surg. 2016; 137: 1292-1305
        • Sparks D.S.
        • Wagels M.
        • Taylor G.I.
        Bone reconstruction: a history of vascularized bone transfer.
        Microsurgery. 2018; 38: 7-13
        • Nakatsuka T.
        • Harii K.
        • Yamada A.
        • Ueda K.
        • Ebihara S.
        Dual free flap transfer using forearm flap for mandibular reconstruction.
        Head Neck. 1992; 14: 452-458
        • Makiguchi T.
        • Yokoo S.
        • Takayama Y.
        • Miyazaki H.
        • Terashi H.
        Double free flap transfer using a vascularized free fibular flap and a rectus abdominalis musculocutaneous flap for an extensive oromandibular defect: prevention of sinking or drooping of the flap with an anterior rectus sheath.
        J Craniofac Surg. 2015; 26: e622-e624
        • Tukiainen E.
        • Askoseljavaara S.
        Use of the ilizarov technique after a free microvascular muscle flap transplantation in massive trauma of the lower leg.
        Clin Orthop Relat Res. 1993; : 129-134
        • Moucharafieh R.S.
        • Saghieh S.S.
        • Nassar H.
        • Hamdan A.M.
        • Hashim H.A.
        Atiyeh BS. Microvascular soft-tissue coverage and distraction osteosynthesis for lower-extremity salvage.
        Microsurgery. 1996; 17: 666-673
        • Zhong W.
        • Lu S.
        • Chai Y.
        • Wen G.
        • Wang C.
        • Han P
        One-stage reconstruction of complex lower extremity deformity combining Ilizarov external fixation and sural neurocutaneous flap.
        Ann Plast Surg. 2015; 74: 479-483
        • Xu J.
        • Zhong W.R.
        • Cheng L.
        • Wang C.Y.
        • Wen G.
        • Han P.
        • et al.
        The combined use of a neurocutaneous flap and the ilizarov technique for reconstruction of large soft tissue defects and bone loss in the tibia.
        Ann Plast Surg. 2017; 78: 543-548
        • Li Z.
        • Yu A.
        • Qi B.
        • Pan Z.
        • Ding J.
        Flow-through free fibula osteocutaneous flap in reconstruction of tibial bone, soft tissue, and main artery segmental defects.
        Ann Plast Surg. 2017; 79: 174-179
        • Wei F.C.
        • Seah C.S.
        • Tsai Y.C.
        • Liu S.J.
        • Tsai M.S.
        Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects.
        Plast Reconstr Surg. 1994; 93 (discussion 5-6): 294-304
        • Korompilias A.V.
        • Paschos N.K.
        • Lykissas M.G.
        • Kostas-Agnantis I.
        • Vekris M.D.
        • Beris A.E
        Recent updates of surgical techniques and applications of free vascularized fibular graft in extremity and trunk reconstruction.
        Microsurgery. 2011; 31: 171-175
        • Bi Z.G.
        • Han X.G.
        • Fu C.J.
        • Cao Y.
        • Yang C.L.
        Reconstruction of large limb bone defects with a double-barrel free vascularized fibular graft.
        Chin Med J. 2008; 121: 2424-2428
        • Yajima H.
        • Tamai S.
        Twin-barrelled vascularized fibular grafting to the pelvis and lower extremity.
        Clin Orthop Relat Res. 1994; : 178-184
        • Giannoudis P.V.
        • Harwood P.J.
        • Tosounidis T.
        • Kanakaris N.K.
        Restoration of long bone defects treated with the induced membrane technique: protocol and outcomes.
        Injury. 2016; 47 (Suppl): S53-S61
        • Hollenbeck S.T.
        • Woo S.
        • Ong S.
        • Fitch R.D.
        • Erdmann D.
        • Levin L.S.
        The combined use of the Ilizarov method and microsurgical techniques for limb salvage.
        Ann Plast Surg. 2009; 62: 486-491
        • Wen G.
        • Zhou R.
        • Wang Y.
        • Lu S.
        • Chai Y.
        • Yang H.
        Management of post-traumatic long bone defects: a comparative study based on long-term results.
        Injury. 2019; 50: 2070-2074