A critical assessment of the fibula flap donor site

Free vascularized fibula leads to hallux toe flexion deformity due to ischemic muscle contracture of flexor hallucis longus

BACKGROUND

This study aimed to investigate the incidence of toe flexion deformity after fibular free flap transplantation and to analyze the etiology of the deformity.

METHODS

Fifty patients underwent vascularized fibular free flap transplantation were retrospectively included. Statistical analysis examined correlations between deformity occurrence and resected fibula length and residual distal fibula length using the χ2 test. Doppler ultrasound and anatomical evaluations were conducted.

RESULTS

Flexion deformity of the first toe was observed in all patients (100%), exacerbated by ankle dorsiflexion. χ2 test revealed no significant correlation between fibula length, distal residual fibula length, and flexion deformity. Doppler ultrasound revealed elevated echoes and blurred textures in the flexor hallucis longus post-fibular transplantation, while anatomical evaluation confirmed the peroneal artery as its primary nutrient supplier.

CONCLUSION

This study reports a 100% incidence of toe flexion deformity post-transplantation. The deformity correlated strongly with ischemic contracture of the flexor hallucis longus.

Planning of physiotherapeutic procedure in patients after mandible reconstruction taking into account donor site: a literature review

BACKGROUND

Mandible tumors are very rare. One of the main methods of the treatments is resection of the tumor and then reconstruction of the mandible. The donor site is often distant tissue-fibula or ilium. Following this, it is necessary to improve the patient in two ways, on one hand restoring the function of the mandible, and on the other hand, improving the donor site area. For that reason, physiotherapy after tumor resection and reconstruction of the mandible is very complicated. The aim of this bibliographic review was to find the methods of the reconstruction of the mandible in the context of patients' functional assessment after surgeries to create effective physiotherapeutic procedures in the feature.

METHODS

PEDro, Medline (PubMed), Cochrane Clinical Trials were searched.

RESULTS

767 articles were found. 40 articles were included to this literature review.

CONCLUSIONS

Authors showed different kinds of surgeries strategy for patients with tumors of the mandible. They also showed manners of patients' functional assessment in the localization of transplantation and donor site. It could be useful for physiotherapists during planning of comprehensive physiotherapy.

An objective analysis of composite free flap donor site morbidity in head and neck surgery: Prospective series

BACKGROUND

A poor evidence basis exists regarding the objective donor site morbidity associated with osseous free flap harvest. This study prospectively assessed the objective donor site morbidity associated with osseous free flap harvest for the fibula, scapula, and iliac crest (DCIA) donor sites.

METHODS

A single-site, prospective cohort clinical research study was conducted. Sixty-four patients were recruited between 2017 and 2021. Patients were assessed using a donor site specific assessment tool pre-operatively, and again >12 months post-operatively.

RESULTS

There was a significant reduction post-operatively in assessment tool scores compared to the pre-operative period for the fibula, scapula and DCIA. Females were more likely to report a greater reduction in Harris Hip Score post-operatively compared to males.

CONCLUSIONS

The fibula, scapula, and DCIA donor sites are associated with reduced objective function post-operatively compared to patient's pre-operative baseline. The implications are least pronounced for the fibula.

Patient-Reported Outcomes after Fibula Free Flap Harvest: A Pilot Study

SUMMARY

Patient-reported outcomes regarding donor-site morbidity and quality of life for the fibula free flap in head and neck reconstruction patients have not been studied. The authors reviewed and identified patients who had undergone head and neck reconstruction using a fibula free flap (2011 to 2016). Patients were assessed via physical examination and two patient-reported outcomes questionnaires: the Foot and Ankle Outcome Score (score range, 0 to 100) and the Pain Disability Questionnaire (score range, 0 to 100). Quantitative data were analyzed with appropriate statistical tests. Semistructured interviews exploring donor-site challenges were performed and analyzed using thematic analysis. Seventeen patients agreed to participate. Their mean age was 62 years (range, 41 to 81 years). Mean follow-up was 38 months (range, 12 to 65 years). Mean perceived level of function compared to baseline was 67 percent. Mean scores for the Foot and Ankle Outcome Score subscales were 84.6 (pain), 80.5 (symptoms), 86.7 (activities of daily living), 67.7 (sport), and 65.6 (quality of life). The mean Pain Disability Questionnaire score was 26.3 (mild/moderate perceived disability). Higher perceived level of function was associated with higher Foot and Ankle Outcome Score values (pain, symptoms, and activities of daily living, p < 0.05). Donor limbs had decreased range of motion and manual muscle testing scores compared with their contralateral limbs (p < 0.05). Lack of ankle support and balance, resulting in limitations and aversions to daily and sporting activities, were the most common themes regarding donor-site challenges. In conclusion, patients who have undergone fibula free flap harvest struggle with ankle support and balance and face functional difficulties that have an impact on their quality of life. Multidisciplinary approaches for targeted rehabilitation after fibula free flap harvest should be explored to determine the impact on patients' quality of life.

Donor- and recipient-site morbidity of vascularized fibular and iliac flaps for mandibular reconstruction: A systematic review and meta-analysis

The aim of this article is to evaluate the early and late morbidities of the donor- and recipient-site in patients undergoing mandibular reconstruction using either vascularized fibular flap (VFF) or vascularized iliac flap (VIF). Electronic databases, including PubMed, Web of Science, Cochrane Central and Embase, were explored for literature published until October 2020. A total of twenty-four articles reporting complications following mandibular reconstruction surgery with follow-up periods ranging from six to 63 months were selected based on the exclusion criteria. For each research, the JBI Critical Assessment Tool and the ROBINS-I Tool were used to analyze the methodological quality and the risk of bias. A single-arm meta-analysis was performed to have a synthesized analysis of the donor- and recipient-site early and late morbidities. Results showed that the early morbidities in VFF group ranged from 3% to 12%, and the late morbidities in VFF group ranged from 5% to 67%. In VIF group, the early morbidities ranged from 3% to 16%, and the donor-site late morbidities ranged from 6% to 43%. Complications with the top three morbidities in the VFF group were: chronic sensory disturbances at the donor-site (67%), malocclusion (22%) and chronic lower limb weakness (20%); and in the VIF group were: chronic sensory disturbances at the donor-site (43%), chronic pain at the donor-site (26%), chronic gait disturbance (20%). Further controlled clinical trials are needed to assess the long-term outcome of VFF or VIF grafting.

Donor site morbidity of composite free flaps in head and neck surgery: a systematic review of the prospective literature

Composite free flaps represent the cornerstone for the repair of osseous defects in the head and neck. For many patients, there are often multiple defect-suitable donor sites that may be utilised as part of the reconstructive process. Therefore, to optimise patient outcomes, an evidence-based approach to donor site selection is required to maximise quality of life and long-term functionality. A systematic review of the literature was conducted in accordance with PRISMA guidelines to evaluate the evidence for donor site selection based on minimising the associated donor site morbidity and optimising patient functionality postoperative. The fibula is associated with the greatest potential risk for wound healing complications. Fibula and scapula harvest has the potential to have a significant impact on physical performance. The iliac crest is most favourable in terms of aesthetic scar healing outcomes. Overall, however, the quality and quantity of evidence for all donor sites is limited. Each site is associated with specific complications and morbidity, of which the surgeon and patient must both be aware. Whilst a cross-sectional informed opinion of the likely advantages/disadvantages of one donor site over another can thus be made, there are few head-to-head studies available that directly compare donor sites.

Assessment of fibula flap with flexor hallucis longus's effect on head & neck tumor patients' quality of life and function of donor site

OBJECTIVE

Free fibular flaps (FFFs) have been widely used in mandibular reconstruction. It is still unclear whether retaining flexor hallucis longus (FHL) is needed for flaps. This study introduces a comparison in quality of life and donor-site function between those who have and haven't harvested FHL with FFF.

METHODS

Patients with FFFs were single-blind-randomly assigned into the FHL group or nFHL group. Patients were followed up preoperatively and 1, 3 and 6 months postoperatively via subjective evaluations (SF-36/AOFAS) and objective evaluation s(muscle strength and range of motion). Patients' hospitalization and intraoperative information, donor site morbidity were recorded.

RESULTS

Each group had 15 patients. The flap harvesting time in FHL group was shorter significantly than nFHL group (125.9 ± 24.8 min vs 146.7 ± 29.9 min, P = 0.048). There were no significant differences in hospitalization information such as operation time, hospitalization days and cost. Donor site morbidities at 1, 3 and 6 months postoperatively showed no significant differences except for the presence of claw toes (nFHL group > FHL group, 40% vs 0, P = 0.017; 53.3% vs 6.7%, P = 0.014; 60.0% vs 13.3%, P = 0.021). There were no significant differences in SF-36 and AOFAS scores. There were no significant differences in muscle strength and range of motion.

CONCLUSION

Excision of the FHL lowered the flap harvesting time. It did not increase donor site morbidity. The impacts on patients' quality of life and foot function were the same. The surgeons can use the FHL without considering the influence on patients if not retaining the FHL.

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.

The application of fibular free flap with flexor hallucis longus in maxilla or mandible extensive defect: a comparison study with conventional flap

Background

The repair and reconstruction of maxillary and mandibular extensive defects have put huge challenges to surgeons. The fibular free flap (FFF) is one of the standard treatment choices for reconstruction. The conventional FFF has deficiencies, such as forming poor oral mucosa, limited flap tissue, and perforator vessel variation. To improve the use of FFF, we add the flexor hallucis longus (FHL) in the flap (FHL-FFF). In this paper, we described the advantage and indication of FHL-FFF and conducted a retrospective study to compare FHL-FFF and FFF without FHL.

Methods

Fifty-four patients who underwent FFF were enrolled and divided into two groups: nFHL group (using FFF without FHL, 38 patients) and FHL group (using FHL-FFF, 16 patients). The perioperative clinical data of patients was collected and analyzed.

Results

The flaps all survived in two groups. We mainly used FHL to fill dead space, and the donor-site morbidity was slight. In FHL group, flap harvesting time was shorter (118.63 ± 11.76 vs 125.74 ± 11.33 min, P = 0.042), the size of flap’s skin paddle was smaller (16.5 (0–96) vs 21.0(10–104) cm², P = 0.027) than nFHL group. There were no significant differences (P > 0.05) in hospital days, hospitalization expense, rate of perioperative complications, etc. between the two groups. Compared with FFF without FHL, FHL-FFF will neither affect the use of flap nor bring more problems.

Conclusion

The FHL-FFF simplifies the flap harvesting operation. The FHL can form good mucosa and make FFF rely less on skin paddle. It can be used for adding flap tissue and dealing with perforator vessel variation in reconstruction of maxillary and mandibular extensive defects.

Evaluation of donor site morbidity after medial triceps brachii free flap for lower limb reconstruction

INTRODUCTION

The medial head of the triceps brachii muscle (MTB)-free flap is an attractive solution to cover small-to-medium defects of the lower limb. This muscular head has no well-identified function, suggesting minimal impact of its removal on elbow mobility. The aim of this study was to evaluate the safety and reliability of the harvest procedure and the functional and cosmetic morbidity of this donor site.

MATERIALS AND METHODS

Twenty-four consecutive MTB-free flaps were performed for reconstructive surgery of the lower limb between 2011 and 2015. Patients and their records were retrospectively examined. Functional results were evaluated by assessing elbow extension strength using a dynamometer and with a QuickDASH questionnaire. Cosmetic results were assessed using the POSAS observer and patient scales.

RESULTS

Twenty-four patients were followed up postoperatively for an average of 33.9 [min 12-max 59] months. No major complication (in particular, no ulnar or radial nerve injury) occurred during harvest. No patient complained of elbow pain or reduction in strength. Elbow extension was complete in all patients and the mean strength was calculated at 89 [61.1-112.5] % of the opposite arm. The POSAS scale scored an average 8.6 [7-21] for the observer and 10 [7-26] for the patient. Cosmetic results using the POSAS scale were satisfactory in all patients.

CONCLUSIONS

Objective evaluation of patients who underwent an MTB-free flap for limb reconstruction shows no impact of the harvesting procedure on elbow extension. Patient satisfaction with the donor site was high. From this retrospective study, it appears that this surgery is safe, aesthetically acceptable, and has minimal impact on donor site elbow function.

Functional donor site morbidity longer than one year after fibula free flap: A prospective biomechanical analysis

OBJECTIVES

The fibula free flap is the workhorse procedure for osseous reconstruction. The objective of this study was to investigate long-term functional outcomes of the harvesting site.

PATIENTS AND METHODS

About 19 patients (10 male, 9 female, mean age 58.1 years) were available for the long-term analysis 13-51 months after surgery. Jumping mechanography and balance testing on a ground force reaction plate (Leonardo Mechanograph GFRP) were performed before and surgery. The Esslinger Fitness Index (EFI, maximum peak power in W/kg normalized for age and gender) was considered as primary endpoint. Secondary outcomes were maximum force, range of motion in the ankle joint, sensory limitations, the American Orthopedic Foot and Ankle Society Score (AOFAS-Score), and subjective perceptions.

RESULTS

We found no significant difference between pre- and postoperative EFI (70.4% versus 66.0%, P = 0.07) and body sway (1.72 cm² versus 2.60 cm² , P = 0.093). The AOFAS-Score was reduced by 8.8 points (99.1 points versus 90.3 points, P < 0.001). Dorsal extenstion (31.6° versus 24.1°, P < 0.001) and flexion (32.3 versus 25.6° flexion, P = 0.011) were significantly reduced and 6 patients had chronic pain.

CONCLUSIONS

Reduced peak power and balance ability seem to be reversible short-term effects after fibula harvesting. We recommend preoperative patient education and standardized protocols for physiotherapy.