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

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.

Early ambulation after fibular free flap surgery is associated with reduced length of stay, increased mobility independence, and discharge to home

BACKGROUND

Fibula free flaps (FFF) are one of the most common bony flaps utilized. This paper describes a quality improvement project aimed at increasing early ambulation.

METHODS

A review of FFF patients at an academic hospital was completed (2014-2023). In 2018, an institutional change to encourage early ambulation without placement of a boot was made. Changes in hospital disposition and physical therapy outcomes were evaluated.

RESULTS

A total of 168 patients underwent FFF reconstruction. There was a statistically significant lower length of stay in Group 2 (early ambulation, no boot) (8.1 vs. 9.4; p = 0.04). A higher rate of discharge to a skilled nursing facility was noted in Group 1 (delayed ambulation with boot) (21.3% vs. 11.9%; p = 0.009). A higher proportion of patients in Group 2 demonstrated independence during bed mobility, transfers, and gait (p < 0.05).

CONCLUSIONS

Early ambulation without boot placement after FFF is associated with decreased length of hospital stay, improved disposition to home and physical therapy outcomes.

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.

Patient-Reported Lower Extremity Outcomes Following Fibula or Medial Femoral Condyle Free Flaps for Upper Extremity Defects

BACKGROUND

Free fibula flap (FFF) and medial femoral condyle (MFC) flap are commonly used for upper extremity osseous reconstruction, yet donor-site morbidity has never been systematically compared.

METHODS

Patients who underwent an FFF or MFC for upper extremity extra-carpal osseous reconstruction at 3 academic hand centers were retrospectively identified. Only patients who underwent reconstruction for a defect in which either flap type is routinely used or has been described in the literature were deemed eligible. Patients who agreed to participate were asked to complete the Lower Extremity Functional Scale (LEFS) and Lower Limb Core Scale (LLCS). The reported population norm median score of LEFS is 77 points. The LLCS population norm mean score is 90.52 points.

RESULTS

Twenty-one patients (10 MFC, 11 FFF) were enrolled. The median LEFS score for patients after MFC was 76 (interquartile range [IQR], 49-80) points and 75 (IQR, 56-79) points after FFF. The median LLCS score for patients after MFC was 96.4 (IQR, 87.9-100) points and 100 (IQR, 91-100) points after FFF. Median LEFS scores were slightly below the population norm, whereas median LLCS scores were above the norm for both FFF and MFC. All patients stated they would have the surgery again and that any dysfunction or pain in the leg was justified by the benefit in the arm.

CONCLUSIONS

When considering whether to use an MFC or FFF for upper extremity reconstruction, both flap types appear to result in modest and comparable donor-site morbidity.

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.

Advantages of the scapular system in mandibular reconstruction

BACKGROUND

Fibula free flaps (FFF) are often considered the first choice for mandibular reconstruction, but scapular system free flaps (SFF) have increased in popularity due to versatility, donor site advantages, and patient factors.

METHODS

Retrospective chart review of patients undergoing mandibulectomy with FFF or SFF reconstruction from 2016 to 2021.

RESULTS

Hundred and seventy-six patients (FFF n = 145, SFF n = 31) underwent the aforementioned procedures. Mean FFF operative time was 9.47 h versus 9.88 for SFF (p = 0.40). Two-flap reconstructions required 12.65 h versus 10.09 for SFF with soft tissue (p = 0.002). Donor site complications were identified in 65.6% of FFF with skin grafting.

CONCLUSIONS

These findings suggest that SFF requires similar operative time and results in reduced donor site morbidity as compared to FFF. Supine, concurrent harvesting of SFF allows for single-flap harvest with significantly shorter operative time. SFF could be considered a primary option for mandible reconstruction for complex defects and in select patients.

A Novel Design Method of Gradient Porous Structure for Stabilized and Lightweight Mandibular Prosthesis

Compared to conventional prostheses with homogenous structures, a stress-optimized functionally gradient prosthesis will better adapt to the host bone due to its mechanical and biological advantages. Therefore, this study aimed to investigate the damage resistance of four regular lattice scaffolds and proposed a new gradient algorithm for stabilized and lightweight mandibular prostheses. Scaffolds with four configurations (regular hexahedron, regular octahedron, rhombic dodecahedron, and body-centered cubic) having different porosities underwent finite element analysis to select an optimal unit cell. Meanwhile, a homogenization algorithm was used to control the maximum stress and increase the porosity of the scaffold by adjusting the strut diameters, thereby avoiding fatigue failure and material wastage. Additionally, the effectiveness of the algorithm was verified by compression tests. The results showed that the load transmission capacity of the scaffold was strongly correlated with both configuration and porosity. Scaffolds with regular hexahedron unit cells can withstand stronger loads at the same porosity. The optimized gradient scaffold showed higher porosity and lower maximum stress than the target stress value, and the compression tests also confirmed the simulation results. A mandibular prosthesis was established using a regular hexahedron unit cell, and the strut diameters were gradually changed according to the proposed algorithm and the simulation results. Compared with the initial homogeneous prosthesis, the optimized gradient prosthesis reduced the maximum stress by 24.48% and increased the porosity by 6.82%, providing a better solution for mandibular reconstruction.

Novel Design and Optimization of Porous Titanium Structure for Mandibular Reconstruction

A porous material is considered to be a potential material that can be used to repair bone defects. However, the methods of designing of a highly porous structure within the allowable stress range remain to be researched. Therefore, this study was aimed at presenting a method for generating a three-dimensional tetrahedral porous structure characterized by low peak stress and high porosity for the reconstruction of mandibular defects. Firstly, the initial tetrahedral porous structure was fabricated with the strut diameters set to 0.4 mm and a mean cell size of 2.4 mm in the design model space. Following this, the simulation analysis was carried out. Further, a homogenization algorithm was used for homogenizing the stress distribution, increasing porosity, and controlling peak stress of the porous structure by adjusting the strut diameters. The results showed that compared with the initial porous structure, the position of the large stress regions remained unchanged, and the peak stress fluctuated slightly in the mandible and fixation system with the optimized porous structure under two occlusions. The optimized porous structure had a higher porosity and more uniform stress distribution, and the maximum stress was lower than the target stress value. The design and optimization technique of the porous structure presented in this paper can be used to control peak stress, improve porosity, and fabricate a lightweight scaffold, which provides a potential solution for mandibular reconstruction.

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 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.

Comparison of the Translational Potential of Human Mesenchymal Progenitor Cells from Different Bone Entities for Autologous 3D Bioprinted Bone Grafts

Reconstruction of segmental bone defects by autologous bone grafting is still the standard of care but presents challenges including anatomical availability and potential donor site morbidity. The process of 3D bioprinting, the application of 3D printing for direct fabrication of living tissue, opens new possibilities for highly personalized tissue implants, making it an appealing alternative to autologous bone grafts. One of the most crucial hurdles for the clinical application of 3D bioprinting is the choice of a suitable cell source, which should be minimally invasive, with high osteogenic potential, with fast, easy expansion. In this study, mesenchymal progenitor cells were isolated from clinically relevant human bone biopsy sites (explant cultures from alveolar bone, iliac crest and fibula; bone marrow aspirates; and periosteal bone shaving from the mastoid) and 3D bioprinted using projection-based stereolithography. Printed constructs were cultivated for 28 days and analyzed regarding their osteogenic potential by assessing viability, mineralization, and gene expression. While viability levels of all cell sources were comparable over the course of the cultivation, cells obtained by periosteal bone shaving showed higher mineralization of the print matrix, with gene expression data suggesting advanced osteogenic differentiation. These results indicate that periosteum-derived cells represent a highly promising cell source for translational bioprinting of bone tissue given their superior osteogenic potential as well as their minimally invasive obtainability.

Replacing one evil with another: Is the fibula really a dispensable spare part available for transfer in patients with medication-related osteonecrosis of the jaws?

Because of the long-term and consecutive use of different causative agents, clinicians are increasingly encountering patients needing restoration of the stomatognathic system after surgical resection of highly advanced necroses of the jaw. For plastic restoration in these cases, microvascular reconstruction seems to represent the most viable option. According to the limited data available, the risks of this operation are considered comparable with those faced by other patient cohorts. We report here the case of a patient who suffered 2 successive pathologic fractures of the tibia after microsurgical reconstruction of the mandible with a free fibula flap. This exemplifies a general problem, especially because the patient also suffered from a treatment-refractory infection of the transplanted bone. Although the present literature indicates otherwise, fibula transplants might not be the gold standard in these cases. Therefore, alternatives to transplants from the weight-bearing parts of the body need to be considered until more data are available.

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.

A unidirectional porous beta-tricalcium phosphate material (Affinos®) for reconstruction of bony defects after excision of fibular bone for spinal surgery graft

The aim of this study was to elucidate the bone regeneration-inducing capability of Affinos®, a newly developed, high-porosity unidirectional porous β-TCP artificial bone. We compared the ability of Affinos® and OSferion®, a commercially available β-TCP product, to induce bone regeneration following implantation into bony defects left after fibula harvesting for spinal fusion surgery. Study subjects underwent surgery to harvest non-vascularized fibula grafts for spinal fusion surgery and were implanted with either Affinos® (19 patients) or OSferion® (15 patients, control group) at the defect site. The minimal and mean follow up periods were 6 and 11 months after surgery, respectively. X-rays of the lower leg taken 1-2 weeks after surgery and at the final follow-up visit were used to evaluate fibular-β-TCP continuity and fibula defect filling ratio. There was no significant difference in radiographic continuity in the fibula between the two groups. The fibula defect filling ratio for the Affinos® group decreased from 0.94 ± 0.17 at 1-2 weeks to 0.77 ± 0.14 at 10 months. For the OSferion® control group, the fibula defect filling ratio decreased from 0.94 ± 0.14 at 1-2 weeks to 0.52 ± 0.27 at final follow-up. The Affinos® group showed a significantly higher fibula defect filling ratio compared to that for the OSferion® group (p = 0.003). These results indicate that Affinos® has slow absorption rates and significant defect filling activity compared with OSferion®. Thus, Affinos® could be a suitable substitute to fill bony defects induced by fibula harvesting for spinal reconstruction surgery.

Design of porous titanium scaffold for complete mandibular reconstruction: The influence of pore architecture parameters

Patients having a medical history of oral cancer, infectious diseases or trauma are often advised surgical intervention with customized complete mandibular constructs (CMC) made of Titanium (Ti) scaffolds. A numerical framework based on a homogenization technique was developed to investigate the influence of pore architecture parameters on homogenized orthotropic material properties of the scaffolds. A comparative 3D Finite Element (FE) analysis of six CMC models, having homogenized orthotropic material properties, under a mastication cycle, was undertaken to pre-clinically determine the optimal CMC for a patient. Orthotropic material properties of Ti-scaffolds decreased with an increase in the inter-strut distance. Stress and strain distributions of CMC models during right molar bite were investigated. Despite small differences in stress distributions in the 'body' region of CMC models, the overall stress distribution (tensile and compressive) of CMC models (30-32 MPa) were well comparable to that of an intact mandible (34.54 MPa). Higher magnitudes of tensile strains were observed for models with 0.2 mm (9884μɛ) and 0.4 mm strut diameter (SD), both having 0.5 mm inter-strut distance (ID), at articular condyle area, body and symphysis equivalent part of the constructs. The maximum principal tensile strains were higher in the CMC models with 0.5 mm ID as compared to those having 0.3 mm ID. Comparatively, the scaffolds with lesser ID (0.3 mm) resulted in higher stiffness, thereby evoking less principal strains in the CMC models. Moreover, considering the weight of the scaffolds, the CMC models having 0.3 mm ID with 0.2 mm SD and 0.5 mm ID with 0.6 mm SD seemed most appropriate for a patient.

Microsurgical Reconstruction of the Lower Extremity

Reconstruction of bony and soft tissue defects of the lower extremity has been revolutionized by the advent of microsurgical tissue transfer. There are numerous options for reconstruction. Possibilities include transfer of soft tissue, composite (bone and soft tissue) tissue, and functional muscle. Many lower extremity reconstructions require staged procedures. Planning is of paramount importance especially in regard to vascular access when multiple free flaps are required. Soft tissue reconstruction of the lower extremity may be accomplished with muscle flaps such as the rectus femoris and latissimus dorsi covered with a skin graft. Fasciocutaneous flaps such as the anterolateral thigh flap may be more appropriate in a staged reconstruction which requires later elevation of the flap. Loss of a significant portion of bone, such as the tibia, can be difficult to manage. Any gap greater than 6 cm is considered a reasonable indication for vascularized bone transfer. The contralateral free fibula is the donor site of choice. Functional reconstruction of the anterior compartment of the leg may be performed with a gracilis muscle transfer, effectively eliminating foot drop and providing soft tissue coverage. Muscle tensioning is critical for effective excursion and dorsiflexion of the foot. Long-term results of microsurgical reconstruction of the lower extremity show good results and reasonable rates of limb salvage.

Complication rates and clinical outcomes of osseous free flaps: a retrospective comparison of CAD/CAM versus conventional fixation in 128 patients

Studies evaluating plate-related complications in patient-specific versus conventional fixation systems in free flap surgery are lacking. This was a retrospective study of 128 osseous free flaps with a minimum follow-up of 12 months. Wound healing disorders, plate exposure, fixation failure, and subtotal osseous union were recorded and evaluated statistically by univariate and regression analysis. Complication rates were as follows: wound healing disorders 33.6% (computer-aided design and computer-aided manufacturing (CAD/CAM) vs. conventional: 35.1% vs. 33.0%); plate exposure 21.9% (29.7% vs. 18.7%); fixation failure 7.0% (8.1% vs. 6.6%); subtotal osseous union 36.7% (45.9% vs. 33.0%). Radiotherapy (P<0.001) and more than two segments (P=0.026) were independent variables for the overall complication rate and were negatively correlated with the dental implantation rate. The time between diagnosis and ablative surgery was increased by 11.0days in the CAD/CAM group (34.2±16.2days vs. 23.2±12.0 days; P=0.002). Rates of dental rehabilitation were not significantly different (35.1% vs. 44.0%, P=0.358). On average, 3.2±1.7 dental implants were placed into flap segments. Plate-related complications were increased with radiotherapy and multisegment flaps. There was a non-significant trend towards increased complications with patient-specific plates in comparison to conventional reconstruction plates.

Bilateral Harvesting of a Fibula Free Flap: Assessment of Morbidity

PURPOSE

To investigate morbidity related to harversting of bilateral fibula free flap for head and neck reconstruction using subjective and functional tests.

METHODS

Patients were retrospectively evaluated using point evaluation system (PES) and balance evaluation systems test (BESTest) questionnaires to assess morbidity related to surgery.

RESULTS

Five patients were enrolled in the study. Mean PES scores was 22.2 over 24. Mean overall function assessed with BESTest was 77.6%, and the results were poorest for section I. Sections V and VI had scores of 88% and 83%, respectively, indicating that the sensory balance and gait stability of the patients were compromised only minimally.

CONCLUSION

Bilateral harvesting of the fibula free flap is not associated with an increase in long-term morbidity and does not lead to significant functional impairments. Therefore, this procedure should be considered safe, and can be performed without concern regarding morbidity, when bone reconstruction with a fibula free flap is indicated.