No adverse affect after harvesting of free fibula osteoseptocutaneous flaps on gait function

Gait asymmetries after fibular free flap harvest: A cross-sectional observational study

BACKGROUND

The ability to walk safely after head and neck reconstruction with fibular free flaps in tumor surgery is a high priority for patients. In addition, surgeons and patients require objective knowledge of the functional donor-site morbidity. However, the effects of fibular free flap surgery on gait asymmetries have only been studied for step length and stance duration. This study analyses whether patients who have undergone fibular free flap reconstruction have enduring gait asymmetries compared to age-matched controls.

METHODS

Patients who underwent head and neck reconstruction with fibular free flaps between 2019 and 2023 were recruited, as well as age-matched controls. Participants walked on an instrumented treadmill at 3 km/h. The primary outcome measures were 22 gait asymmetry metrics. Secondary outcome measures were the associations of gait asymmetry with the length of the harvested fibula, and with the time after surgery.

FINDINGS

Nine out of 13 recruited patients completed the full assessment without holding on to the handrail on the treadmill. In addition, nine age-matched controls were enrolled. Twenty out of the 22 gait asymmetry parameters of patients were similar to healthy controls, while push-off peak force (p = 0.008) and medial impulse differed (p = 0.003). Gait asymmetry did not correlate with the length of the fibula harvested. Seven gait asymmetry parameters had a strong correlation with the time after surgery.

INTERPRETATION

On the long-term, fibular free flap reconstruction has only a limited effect on the asymmetry of force-related and temporal gait parameters while walking on a treadmill.

Strategy for preventing skin paddle necrosis in mandibular reconstruction with free fibula osteocutaneous flap

BACKGROUND

Non-thrombotic skin paddle necrosis occasionally occurs during mandibular reconstructions with free fibula osteocutaneous flaps. The number of perforators, size of the skin paddle, and ischemia time of the flap are considered as causes of skin paddle necrosis. The importance of donor side selection has also been highlighted. This study aimed to investigate the leading cause of skin paddle necrosis and the optimal reconstructive procedure.

METHODS

A total of 66 patients who underwent mandibular reconstruction using a free fibula osteocutaneous flap were retrospectively analyzed. Skin paddle necrosis, number of cutaneous perforators, size of the skin paddle, and ischemia time of the flap were investigated. An incorrect "laterality" was defined as a skin paddle (septum) covering the reconstruction plate. Donor-site morbidity was recorded.

RESULTS

Skin paddle necrosis occurred in 15.2% of patients. An incorrect laterality was associated with a higher incidence of skin paddle necrosis (odds ratio, 22.0; 95% confidence interval, 2.5-195; p = .005). Donor-site morbidity was noted in 18.8% of the patients, without any significant difference in terms of the donor side with and without skin graft (p = .592). The postoperative activities of daily living were not affected.

CONCLUSIONS

To prevent skin paddle necrosis, donor side selection is an important safety strategy during mandibular reconstruction with free fibula osteocutaneous flap. The postoperative activities of daily living were found to be little affected by differences in the donor side.

[Possible applications of free microsurgical fibula transplantation in the reconstruction of complex bone defects in the extremities: review of the literature and case series]

BACKGROUND

 Extensive osseous defects of the extremities following trauma and tumour resection represent a major challenge for plasticreconstructive surgical teams. Defect reconstruction by free microsurgical fibula transplantation has become a standard method but is associated with a considerable rate of complications. The aim of the present work is to provide an up-to-date overview of the various reconstruction methods and to report our personal experiences with free fibula transplantation in a case series.

PATIENTS AND METHODS

 The literature search on the subject was performed on Pubmed and Web of Science, and a retrospective collection of data was conducted based on our own cases, including clinical and radiological data.

RESULTS

 From 2007 to 2018, free fibula transplantation was performed in 11 patients under the guidance of the senior author (MS). The defects were a result of pseudarthrosis in four cases, osteitis in three, and a tumour in two cases. Two patientssustained a primary defect due to a high-energy trauma. In nine cases the upper limb was affected; only two had the defect in the lower limb. No graft failure was observed. In eight cases, an osteoseptocutaneous graft was taken; in two cases there was a post-operative loss of the skin island. Fibula length ranged between 5 and 22 cm. In all cases, bony integration of the graft was complete. The range of motion in the affected limb after physiotherapy was very good to satisfactory.

CONCLUSION

 Extensive bone defect reconstruction using free fibula flaps is undoubtedly the gold standard method, but the high rate of complications described in the literature necessitates a strict indication in due consideration of possible alternatives. Close cooperation between the disciplines of plastic reconstructive surgery and trauma orthopaedics is indispensable.

Complication of osteo reconstruction by utilizing free vascularized fibular bone graft

The success of free vascularized fibular bone graft (FVFBG) has accelerated the osteo reconstruction which results from trauma, resection of a tumor or an infectious bone segment, or correction of congenital deformity. But the complication behind should not be overlooked. The failure could necessitate a second surgery, which prolong the rehabilitation period and produce further health cost. Worst, the patients may suffer a permanent impaired ankle function, or a sustained morpho-functional loss on reconstructive area which are hard to save. To provide an overview of the complication related to reconstruction by FVFBG, a narrative review is conducted to identify the complications including their types and rates, the contributing factors, the approaches to measure and the techniques to avoid. Methodologically, by quick research on Pubmed and abstract reading of reviews, we characterize five reconstructive areas where FVFBG were most frequently applied: extremities, mandible, spine, osteonecrosis of femoral head, and penile. Following, the complications on different reconstructive areas are retrieved, studied and presented in five (or more specifically, six) separate sections. By the way, meaningful difference between FVFBG and other bone flap was presented in a few words if necessary. Donor-site morbidities were studied and summarized as a whole. In these literatures, the evidences documented on limb and mandibular reconstruction have the fullest detail, followed by the spine and lastly the penile. In conclusion, FVFBG, though a mature technique, needs further deep and comprehensive study and maybe device-based assistance to achieve better reconstructive effect and minimize donor-site damage.

Donor-Site Morbidity After Osteocutaneous Free Fibula Transfer: Longitudinal Analysis of Gait Performance

PURPOSE

The purpose was to evaluate donor-site clinical morbidity and changes in kinematic gait parameters after the harvest of a vascularized free fibula flap for facial reconstruction.

MATERIALS AND METHODS

We enrolled 14 patients (aged 50 ± 15 years) in a longitudinal study. Every patient underwent a double evaluation in which a presurgical assessment and 6-month postsurgical assessment were performed. Subjective donor-site evaluation was carried out through unstructured clinical questioning about pain, paresthesia, walking ability, and restrictions in activity. Further subjective evaluations were assessed through the Western Ontario and McMaster Universities Osteoarthritis Index and the Point Evaluation System for Lower Extremity Fibulectomy. A clinical evaluation of the donor site assessed muscular deficits, sensibility disturbance, and wound healing. Temporal and spatial kinematic parameters were measured through gait analysis during overground walking at a comfortable speed.

RESULTS

Postsurgical clinical examinations detected 1 patient affected by a neurologic disorder and 3 patients with donor-site pain, whereas 10 patients (71%) declared no residual alterations in the operated leg. On average, the Western Ontario and McMaster Universities Osteoarthritis Index score was 367 of 2,400, and the Point Evaluation System for Lower Extremity Fibulectomy score was 19 of 24. Presurgical versus postsurgical gait analysis comparison showed no significant differences in gait parameters except for a 6% reduction in the double-support phase. Stance values were higher for the operated limb in both evaluations (+1.3% before surgery, +1.8% after surgery). No alterations were detected in the range of motion of the lower-limb joints.

CONCLUSIONS

Considering the slight modification of the gait pattern, which is not usually perceived by patients, vascularized free fibula flap harvest was generally associated with successful functional and subjective outcomes of the donor site.

Donor site morbidity after vascularized fibula free flap: gait analysis during prolonged walk conditions

The aim of this study was to determine the effect of vascularized fibula free flap (VFFF) harvest on gait variables during the six-minute walk test (6MWT). Eleven patients who had undergone VFFF harvest and 11 healthy peers participated in this case-control study. The main evaluation consisted of the collection of gait variables using the GAITRite system during three periods of the 6MWT: beginning (0-1min), middle (2:30-3:30min), and end (5-6min). The 6MWT was significantly shorter in the VFFF group than in the reference group (-31%, P<0.001). Most gait variables differed significantly between the groups for each period (P-value range 0.04-0.0004), including toe in/out on the operated side (P-value range 0.005-0.01). The increase in toe in/out on the operated side suggests a functional modification caused by an imbalance of the agonist-antagonist muscles. On comparison of the different periods, gait velocity decreased between the beginning and middle periods and increased between the middle and end periods in both groups. However, a significantly lower velocity between the beginning and end periods was found only for the VFFF group (P=0.026), suggesting an alteration in physical management. In conclusion, these results suggest that VFFF harvesting could alter gait and joint integrity.

The relative position of the human fibula to the tibia influences cross-sectional properties of the tibia

OBJECTIVES

The fibula transmits loads within the lower limb of hominids. The few studies of variation in the cross-sectional geometric (CSG) properties of the fibula have established differences in its rigidity among groups engaged in distinct habitual loading activities. This study adds to this research by considering the relationship between CSG properties and the anatomical position of the fibula relative to the tibia among groups with differences in documented activity patterns.

MATERIAL AND METHODS

We used pQCT scans taken at 50% of the length of the lower leg in 83 healthy young adult collegiate-aged individuals divided into five activity groups: runners, swimmers, cricketers, field hockey players, and non-athletes. We compared variation in calculated CSG properties against the distance between fibular and tibial centroids, as well as the angle of that plane relative to the plane of tibial I_max .

RESULTS

Tibial and fibular CSG properties vary with respect to the relative position of the two bones. Tibial CSG properties differ in concert with the relative angle of the fibula to tibial I_max , while fibular CSG properties differ with the distance between the elements. Fibulae are more posterior-medially positioned in groups engaged in terrestrial athletics than among swimmers.

DISCUSSION

The tibia and fibula experience different loads. The relative position of the two bones leads to compensatory differences in their CSG properties, perhaps due to increased resistance to bending in fibulae with greater distances from the tibia. Examinations of tibial CSG properties without considering the fibula limits interpretations about activity.

Long-term donor-site morbidity after vascularized free fibula flap harvesting: Clinical and gait analysis

The aim of this study was to determine the clinical morbidity and changes in gait temporal spatial parameters after harvesting of a vascularized free fibula flap. This study included 11 patients (mean age: 52 ± 17 years) and 11 healthy controls (mean age: 50 ± 14 years). The patients were assessed between 5 and 104 months post surgery. The study consisted of a subjective functional evaluation with two validated clinical scores (Kitaoka Score and Point Evaluation System (PES) score), clinical and neurological examination of the legs, and evaluation of gait temporal spatial parameters while walking at a comfortable speed. The mean functional Kitaoka score was 78/100, and the mean PES score of 12.18 was considered average. At the time of the review, five patients had sensory disorders, two had toe deformities, and eight had pain at the donor site. The gait analysis showed that the patient's comfortable walking speed was significantly lower in comparison to that of the controls, and that stride length and cadence were reduced. In addition, most of the gait-specific parameters were significantly different. The donor leg displayed greater variability during walking. To reduce the risk of falling, this study revealed that the patients' gait pattern had changed as they took a more cautious approach during walking. Early rehabilitation is expected to help improve and/or restore the physical abilities of patients after harvesting of the vascularized free fibula flap.

Subtalar fusion with iliac bone free flap after a recalcitrant nonunion: Report of two cases

Fractures of the calcaneus are associated with secondary osteoarthritis of the subtalar joint. In a persistent nonunion, vascularized bone flaps offer superior biologic and mechanical properties as well as accelerates joint fusion and decreases morbidity. In this report, we present results of the use of vascularized iliac bone free flap for treating subtalar failed fusions in two patients. Two patients sustained calcaneal fractures due to foot trauma, which were initially or subsequently treated with subtalar arthrodesis. Case one developed septic subtalar nonunion during treatment and case two failed three attempts at subtalar arthrodeses. The iliac crest bone flap harvested measured 4 × 4 cm (case one) and 3 × 3 cm (case two). The flap was pedicled by the deep circumflex iliac artery, which was anastomosed to the anterior tibial artery at the recipient site. No flap donor or recipient site complications occurred. Fusion was confirmed on CT scan and weight bearing was initiated at 5-6 months. At latest follow up (1-2 years), no complications occurred. Our results show that subtalar nonunion treatment with a vascularized iliac bone flap may be feasible and such a reconstruction could be clinically successful. © 2015 Wiley Periodicals, Inc. Microsurgery 36:501-506, 2016.