Tibial Stress Fracture After Fibular Graft Harvesting: An Unusual Complication

Delayed pathologic tibial fracture with chronic osteomyelitis after fibula free flap

The reported donor site morbidity of the fibula free flap (FFF) is low; however, several uncommon complications have been reported with tibia fracture rarely being reported. We present a case of a pathological tibial fracture in the setting of chronic osteomyelitis after FFF. A 54-year-old female presented with a benign fibro-osseous lesion of the right mandible and was treated with mandibulectomy and reconstructed with a left FFF. Approximately 1 year following surgery, the patient presented to the emergency department. Imaging showed a pathological fracture of the distal third of the tibial shaft with persistent erythema and cellulitis of the lateral prior graft harvest site without signs of systemic infection. She was taken to the operating room for irrigation and debridement with culture and biopsy as well as external fixation of the tibial fracture. Intraoperative biopsy and culture demonstrated fracture site change with callus formation and negative culture. The patient was discharged on 6 weeks of IV vancomycin and ceftriaxone. In conclusion, tibial fracture following FFF is an uncommon complication, yet it can be exacerbated by chronic osteomyelitis. This report highlights the importance of close observation and comprehensive wound care of donor sites after free flap harvest for head and neck reconstruction.

[Specific intraoperative and secondary complications of biological reconstructions following extralesional tumour resections of malignant bone tumours]

BACKGROUND

The treatment of primary malignant bone tumours is interdisciplinary and individually adapted to the patient. Nowadays, limb salvage surgery is usually possible, and the subsequent reconstruction is carried out either by implantation of modular tumour megaprostheses or by biological reconstruction procedures. Special surgical and secondary complications have to be considered.

OBJECTIVES

Indication and explanation of various biological reconstruction procedures and presentation of specific peri- and postoperative complications.

MATERIALS AND METHODS

An adapted literature review and the contribution of our own therapy experiences and case studies for the presentation of biological reconstructions and their complication management was performed.

RESULTS

In biological reconstructions, autografts, allografts or a combination of autografts and allografts are used. Stabilization is achieved with screw and plate osteosyntheses. The most common secondary complications are pseudarthrosis, interponate fracture, graft necrosis and secondary malpositions.

CONCLUSION

In selected cases, particularly at the upper extremities and in dia- or metaphyseal tumour sites, biological reconstruction after extralesional tumor resection is the surgical therapy of choice. The rate of long-term revision interventions is significantly lower compared to modular tumour megaprostheses. Biological reconstructions and the treatment of specific complications have to be performed in specialized centres for musculoskeletal surgical oncology/tumor orthopedics.

Accuracy of Computer-Aided Design/Computer-Aided Manufacturing-Assisted Mandibular Reconstruction With a Fibula Free Flap

BACKGROUND

The recent increase in computer-aided design and computer-aided manufacturing (CAD/CAM)-assisted surgery has warranted a thorough evaluation of the accuracy of virtual plan execution. Mandibular reconstructions with a fibula free flap were evaluated by comparing the fibular segments postoperatively with the virtual surgical plans.

METHODS

This study included computed tomography data for 20 patients (11 males; mean age 61.3 years, range 47-74) that received a mandibular reconstruction with a fibula free flap. Linear distances (superior and inferior borders) of 41 fibula segments and intercoronoid distances were measured.

RESULTS

The mean difference was 3.11 ± 2.80 mm for superior borders (range 0.02-12.20 mm), and 2.75 ± 2.61 mm for inferior borders (range 0.22-13.58 mm). The mean intercoronoid difference was 3.57 ± 1.80 mm (range 0.91-6.11 mm).

CONCLUSION

This study confirmed the presumed accuracy regarding the use of fibular and mandibular cutting guides. CAD/CAM is an attractive technique which enhances efficiency and assurance during surgery and preoperative planning.

Distal tibial fractures are a poorly recognised complication with fibula free flaps

The fibula free flap is ideal for complex jaw reconstructions, with low reported donor and flap morbidity. We discuss a distal tibial stress fracture two months following a vascularised fibula free flap procedure. Despite being an unrecognised complication, a literature review produced 13 previous cases; only two were reported in the reconstructive surgery literature, with the most recent claiming to be the first. The majority of these studies treated this fracture non-operatively; none reported their patient follow-up. Each case presented with ipsilateral leg pain, which has been cited as an early donor site morbidity in as many as 40% of fibula free flap cases. It is known that the fibula absorbs at least 15% of leg load on weight bearing. Studies have shown severe valgus deformities in up to 25% of patients with fibulectomies. We treated our patient operatively, first correcting his worsening valgus deformity with an external fixator, then reinforcing his healed fracture with a long distal tibial plate. We believe that this complication is underreported, unexpected and not mentioned during the consenting process. By highlighting the management of our case and the literature, we aim to increase awareness (and thus further reporting and appropriate management) of this debilitating complication.