Comparison between primary closure and skin grafts of the free fibula osteocutaneous flap donor site

Morbidity of the Free Fibular Flap in Reconstructive Surgery

BACKGROUND

Our study evaluated long-term morbidities in patients and compared subjective morbidities to those measurable objectively.

METHODS

Patients completed a questionnaire regarding long-term morbidity, filled out the Pain Sensitivity Questionnaire by Ruscheweyh et al. and were examined physically.

RESULTS

Eighty-two patients were included in the study, 31 patients returned to the clinic for further evaluation and testing. The most common morbidities were weakened dorsiflexion of the great toe (34 patients), reduced ambulatory status (33), and muscle weakness (31). A significant correlation (p < 0.01) was found between higher pain intensity and high pain sensitivity scores. However, donor-site morbidities were not significantly associated with pre-existing comorbidities like smoking, diabetes, or age over 70. Subjective morbidities were reported 2.3 times more frequently than objectively measured ones.

CONCLUSIONS

Our findings suggest a notable discrepancy between subjective and objective morbidities, highlighting the importance of considering patients' subjective experiences when assessing postoperative outcomes and rehabilitation progress.

Factors Associated With Claw Toe Deformity Following Vascularized Fibula Flap Harvesting: A Retrospective Analysis of Potential Risk Factors and Preventive Strategies

BACKGROUND

Claw toe deformity at the donor site is a complication following vascularized fibula flap surgery. Despite its potential to necessitate further surgery, the factors contributing to this complication are not well understood. Therefore, this study aimed to identify factors associated with this complication and propose potential preventive strategies.

PATIENTS AND METHODS

This retrospective study analyzed 40 cases of vascularized fibula flap harvesting conducted between 2010 and 2022. The presence of claw toe deformity was evaluated, and various patient and surgical factors were analyzed. Postoperative magnetic resonance imaging (MRI) and intraoperative indocyanine green angiography images were also assessed.

RESULTS

Claw toe deformity was observed in 25% of patients, with a significantly higher incidence among those undergoing primary wound closure (p = 0.018). Age (p = 0.595), body mass index (p = 0.482), smoking status (p = 0.157), diabetes (p = 0.556), peripheral arterial disease (p > 0.999), preoperative chemotherapy (p = 0.715), operative time (p = 0.080), harvested fibula length (p = 0.981), skin paddle size (p = 0.695), and horizontal width of skin flap (p = 0.906) were not significantly associated with claw toe deformity. The cutoff values for primary wound closure were identified as a skin flap horizontal width of 3.5 cm and a horizontal width-to-circumference ratio of 10.4%. MRI revealed signal changes in the flexor hallucis longus on T2-weighted images in all six cases with claw toe deformity and in 6 of the 12 cases without deformity. Indocyanine green angiography revealed ischemia in the flexor hallucis longus in all six examined cases; however, four of these cases did not develop claw toe deformity.

CONCLUSION

This study emphasizes the importance of the wound closure method and skin flap size in primary closure for preventing claw toe deformity after vascularized fibula flap procedures. These findings may contribute to improved postoperative outcomes.

Long-Term Postoperative Donor Site Musculoskeletal Morbidity after Osseous Free Flap Harvest

Objective

Complex ablative maxillary and mandibular defects often require osseous free flap reconstruction. Workhorse options include the fibula, scapula, and osteocutaneous radial forearm flap (OCRFF). The choice of donor site for harvest should be driven not only by reconstructive goals but also by donor site morbidity. The goal of this study is to evaluate the long-term postoperative musculoskeletal morbidity at the donor site after osseous free flap harvest.

Study Design

Cohort study and cross-sectional analysis.

Methods

A retrospective review of patients who underwent free flap harvest at 1 of the 3 donor sites from 2015 through 2021 was performed. An additional cross-sectional analysis at ≥1 year postoperatively was performed from 2021 to 2022 using validated patient-reported orthopedic surveys: Disabilities of the Arm, Shoulder, and Hand for scapula or OCRFF harvest, and Foot and Ankle Ability Measure for fibula harvest.

Setting

Single, high-volume tertiary care institution.

Results

Among 731 eligible patients, 162 (22.1%) answered the telephone surveys and were included. Functional differences between operated and nonoperated sides were 18.5% (scapula, n = 33), 13.5% (OCRFF, n = 29), and 10% (fibula, n = 98). Postoperative physical therapy (for all donor sites), ipsilateral neck dissection (for scapula and OCRFF), and extent of bony resection (for OCRFF) were not factors associated with long-term morbidity. Acute donor site complications were most common in fibula patients and were associated with worse long-term functional outcomes (7.5% difference; 95% confidence interval, -14.0 to -1; P = .03).

Conclusion

There is acceptable long-term musculoskeletal morbidity at the donor site after osseous free flap harvest, and patients should be counseled appropriately.

Assessment of lower limb proprioception after fibula free flap harvest: A pilot study

BACKGROUND

After undergoing fibula-free flap harvest, patients may experience complications such as ankle instability. It remains unclear whether these patients have deficits of proprioception, and the recovery process is also uncertain.

OBJECTIVE

This study aimed to objectively evaluate proprioception on the donor and normal side of surgical patients during long-term follow-up using the Pro-kin system.

METHODS

This study enrolled 36 patients who underwent reconstruction of the head and neck using osseous free flaps harvested from the fibula. Each patient underwent pre-operative evaluations and was subsequently evaluated at postoperative months 1, 3, 6, and 12. The study assessed the proprioceptive evaluation of the lower limbs, muscle function, range of motion of the ankle, and donor side complications.

RESULTS

On the donor side, the average trace error (ATE) at postoperative month 1 was significantly higher than pre-operation, postoperative months 6 and 12 (P< 0.05). The test execution time (TTE) at postoperative month 1 was significantly increased by 9.875s compared to the pre-operative levels (P= 0.012, 95% confidence interval [CI] 4: 1.877-17.873) and by 11.583s compared to postoperative month 12 (P= 0.007, 95% CI: 2.858-20.309). The reduction in range of motion of ankle dorsiflexion was most pronounced at postoperative month 1, exhibiting an 11.25∘ decrease compared to pre-operative levels (P< 0.001, 95% CI: 6.304-16.16). Although the range of motion of ankle dorsiflexion gradually improved over time at postoperative months 3, 6, and 12, it remained lower than pre-operative levels (P< 0.05).

CONCLUSION

The study revealed that the patients exhibited proprioceptive disturbances in both lower limbs at postoperative month 1. The proprioceptive function gradually improved over time, with a gradual decrease in donor site complications.

Comparison of propeller flaps versus skin grafts for coverage of osteocutaneous fibula free flap donor site defects

BACKGROUND

Authors compare use of propeller flaps versus skin grafts in defect coverage after fibula flap harvest.

MATERIALS AND METHODS

Retrospective review of patients who received either PFPF or STSG. Primary predictor variable was technique, and secondary predictor variables were comorbidities. Primary outcome variable was flap/graft healing, and secondary outcome variables were cosmesis, adverse events, effect on activities of daily living (ADLs), pain, additional procedures, and cost. Statistical analysis performed via independent sample t tests, ANOVA, and χ² tests. Logistic regression analysis was performed.

RESULTS

Study sample was 50 patients. PFPFs showed higher rates of success, while STSG showed increased complications and adverse events. Pain and ADLs significantly affected in STSG group. Cosmesis was better in the PFPF group, and overall cost was significantly higher in STSG group.

CONCLUSION

PFPFs show greater success rates, fewer complications, improved cosmesis, less pain, reduced cost compared to STSG for wound coverage after fibula flap harvest.

Crescent-shaped skin paddle for a fibular flap: Avoiding skin grafting at the donor site

A fibular osteocutaneous flap is the mainstay of oromandibular reconstruction. This report aimed to present a crescent-shaped skin paddle, a novel fibular skin paddle designed to achieve both sufficient intraoral lining and primary closure of the donor site. A 3-5-cm-wide crescent-shaped skin paddle was harvested according to the locations of the distal septocutaneous perforators on preoperative color Doppler sonography. This narrow skin paddle fits well morphologically into the mucosal defect, enabling a reliable intraoral lining. This advantage becomes more evident when the mandibular defect crosses the midline or extends posteriorly to the maxillary tuberosity as the shape of the mucosal defect becomes arcuate. Primary closure of the donor site is easier to achieve because the required width of the crescent-shaped skin paddle is minimized. This method reduces donor-site morbidity associated with skin grafting while ensuring safe intraoral closure with a fibular osteocutaneous flap.

Closure of a free osteofasciocutaneous fibula flap donor site using local skin grafts or flaps: A systematic review and meta-analysis

BACKGROUND

In free osteofasciocutaneous fibula flaps, secondary donor sites are avoided using one of three local closure methods: full-thickness skin grafts (FTSGs), split-thickness skin grafts (STSGs), or flaps. This systemic review aimed to evaluate the differences in outcomes among the three groups of closure methods used for free fibula flap defects.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, we systematically searched the PubMed and Web of Science medical databases from inception to January 2021 for articles focused on closure of the free fibula flap donor site using the lower leg area-local skin graft or flap-that mentioned the free fibula flap defect size, and/or complications of the donor site. Study characteristics, free fibula flap size, and short-term complication rates were extracted for analysis. The pooled complication rates and confidence intervals were calculated based on the random-effects model.

RESULTS

Eleven studies were included in the qualitative synthesis, and ten studies were included in the quantitative synthesis (meta-analysis). The FTSG (n = 79, 52.3%) was the most widely used method, while both STSG (n = 36, 23.8%) and flap (n = 36, 23.8%) were the least commonly used methods. The mean free fibula flap length and width were largest for the flap method (11.5 ± 2.5 cm and 6.0 ± 1.8 cm), and all closure methods were used for free fibula flap widths ≥3 cm. Rates of partial and complete necrosis were highest for the FTSG method (20.3%, p = .95, I²  = 0%) and lowest for the flap method (12.7%, p = .95, I²  = 0%).

CONCLUSION

This systemic review indicated that any closure method could be adapted for a free fibula flap width ranging from 3 to 9 cm, and the flap method was associated with the lowest rate of short-term complications.

The Evolution of the Free Fibula Flap for Head and Neck Reconstruction: 21 Years of Experience with 128 Flaps

BACKGROUND

 The free fibula flap is commonly referred to as a "workhorse" for head and neck reconstruction. During our 21-year experience with this flap, we have performed several changes in preoperative planning, operative technique, and postoperative follow-up.

PATIENTS AND METHODS

 A retrospective cohort study designed to analyze the cohort of patients who underwent free fibula transfer for head and neck reconstruction. Demographics, medical background, operative data, and postoperative outcome were collected. The changes we performed in preoperative planning, operative technique, and postoperative follow-up were assessed and their impact on outcome discussed.

RESULTS

 During 1998 to 2019 a total of 128 free fibula flaps were transferred for head and neck reconstruction. When comparing the patients treated in the early years to those who were treated in recent years we found no statistically significant difference in minor or major nonmicrosurgical complications in the recipient and donor site and in the rate of take backs due to microsurgical reasons. However total flap failure rate improved from 28% in early years to 8% in recent years (p = 0.012).

CONCLUSION

 During this 21-year period, we performed several changes in our practice. This included the use of a three-dimensional (3D) prefabricated model of the mandible, a shift toward side-table osteotomies, increasing the rate of osteofascial flaps in contrast to osteocutaneous flaps and the use of an implantable Doppler. These changes, together with a learning curve of the surgical team, significantly improved our overall success rates.

Donor-Site Morbidity after Fibula Transplantation in Head and Neck Tumor Patients: A Split-Leg Retrospective Study with Focus on Leg Stability and Quality of Life

The free fibula flap has been one of the most important microvascular grafts for orofacial reconstruction for more than 30 years. The complication rates at the donor-site reported in literature are considered to be low, but the published data vary greatly in some cases. In particular, restrictions in the stability and balance of the involved leg and their effects on the quality of life have been described very inconsistently to date. Therefore, this study mainly focuses on the stability and balance of the affected leg in a split-leg design. Between December 2014 and January 2018, out of 119 subjects who underwent mainly jaw ablative tumor surgery and reconstruction using a fibula flap, 68 subjects were examined for donor site morbidity. Besides reporting general types of complications, two specific test procedures were used. The Star Excursion Balance Test (SEBT) as a practical test for ankle function and the Foot and Ankle Disability Index (FADI) as a questionnaire in order to assess quality of life, depending on the lower leg function. SEBT revealed an average of 55.3 cm with the operated leg as the supporting leg, which corresponds to 95.5% of 57.9 cm achieved with the healthy leg as the supporting leg. An average FADI score of 89.4% was recorded. SEBT and FADI seem to be suitable methods of examination for subjects post fibular transplantation and pointed out minimal limitations of the involved legs in comparison to the unaffected legs. These limitations were clinically not relevant and they had minor influence on the subjects' quality of life and their daily activities.

Impact of wound closure on fibular donor-site morbidity: a meta-analysis

Background

Vascularized free fibular flaps have been the “workhorses” for reconstruction of many kinds of bone defects. Nevertheless, there is no consensus regarding the optimal wound closure method for fibular donor sites. This study aimed to compare prognostic outcomes of primarily closures (PC) and skin grafts (SG) for fibular donor sites.

Methods

Studies regarding donor-site outcomes of PC versus SG in patients undergoing free fibular flap procedures were included. Two authors individually searched PubMed, Web of Science, EMBASE, Cochrane Library and clinicaltrials.gov up to February 2019, extracted the data and assessed quality of each selected article. Ultimately, The incidences of donor-site morbidities were evaluated.

Results

Five studies with a total of 119 patients were included in our analysis. No significant differences were found with respect to the rates of donor-site problems between the PC and SG groups.

Conclusions

Fibular flap patients undergoing PC and SG wound closures may have similar donor-site outcomes. Additional large-scale studies are necessary to draw a solid conclusion.

Electronic supplementary material

The online version of this article (10.1186/s12893-019-0545-1) contains supplementary material, which is available to authorized users.

Osteocutaneous flaps for head and neck reconstruction: A focused evaluation of donor site morbidity and patient reported outcome measures in different reconstruction options

With significant improvements in success rates for free flap reconstruction of the head and neck, attention has turned to donor site morbidity associated with osteocutaneous free flaps. In this review, we address the morbidity associated with harvest of the four most commonly used osteocutaneous flaps; the free fibula flap, the scapula flap, the iliac crest flap and the radial forearm flap. A comprehensive literature search was performed to identify articles relevant to donor site morbidity for these flaps. We assessed morbidity in terms of incidence of delayed healing, chronic pain, aesthetic outcomes, site specific complications and patient satisfaction/quality of life. Weighted means were calculated when sufficient studies were available for review. The radial forearm and free fibula flaps are associated with high rates of delayed healing of approximately 20% compared to the scapular (<10%) and iliac flaps (5%). The radial forearm flap has higher rates of chronic pain (16.7%) and dissatisfaction with scar appearance (33%). For the majority of these patients harvest of one of these four osteocutaneous does not limit daily function at long-term follow-up. The scapular osteocutaneous flap is associated with the lowest relative morbidity and should be strongly considered when the recipient defect allows. The radial forearm is associated with higher morbidity in terms of scarring, fractures, chronic pain and wrist function and should not be considered as first choice when other flap options are available.