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Ebeling M, Hagmann A, Derka S, Schramm A, Wilde F, Scheurer M, Pietzka S, Sakkas A. Fibula Grafting for Oromandibular Reconstruction and its Effect on Patient Quality of Life - A Scoping Review. In Vivo 2024; 38:1537-1545. [PMID: 38936931 PMCID: PMC11215598 DOI: 10.21873/invivo.13604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 06/29/2024]
Abstract
Fibula osteoseptocutaneous flap has been widely used for oncologic bony reconstruction of both the mandible and maxilla. Early and late morbidities of the donor side such as leg weakness, ankle instability, limited ankle mobility, tibial stress fractures or incision area pain are well documented; however, there is a lack of information about the effects of fibula grafting on patient quality of life. To address this issue, a scoping literature search in the PubMed electronic database was performed to identify all relevant studies and reviews in the period between 2010 and 2022. The potential discomforts after free fibula grafting and their impact on different domains of everyday living were identified and evaluated. The present literature review indicates that donor site morbidity can negatively impact patients' quality of life, albeit generally classified as minor. However, the functional and aesthetic benefits of oromandibular reconstruction clearly outweigh the associated sequelae. Nevertheless, the authors of this review highlight the importance of a comprehensive clinical evaluation of the donor site besides the recipient site during follow-up examinations. This would help to subjectively evaluate the functional and esthetical limitations of a patient's site and promptly detect morbidities that could lead to long-term complications.
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Affiliation(s)
- Marcel Ebeling
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, Ulm, Germany;
- Medical School, University Hospital Ulm, Ulm, Germany
| | - Alexander Hagmann
- Department of Oral and Plastic Maxillofacial Surgery, University of Ulm, Ulm, Germany
| | - Spyridoula Derka
- Department of Oral and Maxillofacial Surgery, Attikon General University Hospital of Athens, Athens, Greece
| | - Alexander Schramm
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, Ulm, Germany
- Medical School, University Hospital Ulm, Ulm, Germany
| | - Frank Wilde
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, Ulm, Germany
- Medical School, University Hospital Ulm, Ulm, Germany
| | - Mario Scheurer
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, Ulm, Germany
| | - Sebastian Pietzka
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, Ulm, Germany
- Medical School, University Hospital Ulm, Ulm, Germany
| | - Andreas Sakkas
- Department of Oral and Plastic Maxillofacial Surgery, Military Hospital Ulm, Academic Hospital of the University of Ulm, Ulm, Germany
- Medical School, University Hospital Ulm, Ulm, Germany
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Zhang N, Chen J, Wang Z, Ni J. Assessment of lower limb proprioception after fibula free flap harvest: A pilot study. J Back Musculoskelet Rehabil 2024:BMR230436. [PMID: 38607749 DOI: 10.3233/bmr-230436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
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.
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Affiliation(s)
- Nannan Zhang
- a.Department of Rehabilitation Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Department of Rehabilitation Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- a.Department of Rehabilitation Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Jianmin Chen
- a.Department of Rehabilitation Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Department of Rehabilitation Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- a.Department of Rehabilitation Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Zhiyong Wang
- a.Department of Rehabilitation Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Department of Rehabilitation Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Jun Ni
- a.Department of Rehabilitation Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
- Department of Rehabilitation Medicine, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, Fujian, China
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Hsiao WL, Wu YC, Tai HC. Reduced length of intensive care unit stay and early mechanical ventilator weaning with enhanced recovery after surgery (ERAS) in free fibula flap surgery. Sci Rep 2024; 14:302. [PMID: 38167861 PMCID: PMC10762210 DOI: 10.1038/s41598-023-50881-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 12/27/2023] [Indexed: 01/05/2024] Open
Abstract
This study aimed to evaluate the effects of the enhanced recovery after surgery (ERAS) program on postoperative recovery of patients who underwent free fibula flap surgery for mandibular reconstruction. This retrospective study included 188 patients who underwent free fibula flap surgery for complex mandibular and soft tissue defects between January 2011 and December 2022. We divided them into two groups: the ERAS group, consisting of 36 patients who were treated according to the ERAS program introduced from 2021 to 2022. Propensity score matching was used for the non-ERAS group, which comprised 36 cases selected from 152 patients between 2011 and 2020, based on age, sex, and smoking history. After propensity score matching, the ERAS and non-ERAS groups included 36 patients each. The primary outcome was the length of intensive care unit (ICU) stay; the secondary outcomes were flap complications, unplanned reoperation, 30-day readmission, postoperative ventilator use length, surgical site infections, incidence of delirium within ICU, lower-limb comorbidities, and morbidity parameters. There were no significant differences in the demographic characteristics of the patients. However, the ERAS group showed the lower length of intensive care unit stay (ERAS vs non-ERAS: 8.66 ± 3.90 days vs. 11.64 ± 5.42 days, P = 0.003) and post-operative ventilator use days (ERAS vs non-ERAS: 1.08 ± 0.28 days vs. 2.03 ± 1.05 days, P < 0.001). Other secondary outcomes were not significantly different between the two groups. Additionally, patients in the ERAS group had lower postoperative morbidity parameters, such as postoperative nausea, vomiting, urinary tract infections, and pulmonary complications (P = 0.042). The ERAS program could be beneficial and safe for patients undergoing free fibula flap surgery for mandibular reconstruction, thereby improving their recovery and not increasing flap complications and 30-day readmission.
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Affiliation(s)
- Wei-Ling Hsiao
- School of Nursing, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Yao-Cheng Wu
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Zhong-Shan South Road, Taipei, 10002, Taiwan
| | - Hao-Chih Tai
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, 7 Zhong-Shan South Road, Taipei, 10002, Taiwan.
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Gao N, Fu K, Cai J, He W. A retrospective study on application of fibula/iliac flap surgical techniques to mandibular defects. Sci Rep 2023; 13:16505. [PMID: 37783776 PMCID: PMC10545820 DOI: 10.1038/s41598-023-43643-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 09/26/2023] [Indexed: 10/04/2023] Open
Abstract
This study group consists of a total of 61 patients who underwent fibula flap and iliac flap surgeries to repair mandibular defects. Patients' Quality Of life (QOL) at 6 and 24 months after surgery is investigated and compared by the EORTC-QLQ-H&N and OHIP-14. The base data of the two groups of patients are collected and analysed by the SPSS 20.0 statistical software. Independent sample t test was conducted for EORTC-QLQ-H&N and OHIP-14 scores at two time points in each group. The 61 cases of free flap all survived and the difference in the location of the primary tumor between the two groups is statistically significant. The EORTC-QLQ-H&N showed that the score of speech, diet, social contact, and teeth all went up at 6 months after surgery, but went down dramatically at 24 months after surgery. The OHIP-14 showed that there was significant reduction in functional limitation at 24 months after surgery, with statistical significance (p < 0.05) between the groups of iliac flap (19.16 ± 5.33) and fibula flap (33.77 ± 7.71). Therefore, it is suggested that patients suffering from mandibular defects receive surgery utilizing the iliac flap, while those with a larger range of defects or lesions involving the condyle and chin should receive corrective surgery utilizing the fibular flap.
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Affiliation(s)
- Ning Gao
- Department of Oral and Maxillofacial Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Kun Fu
- Department of Oral and Maxillofacial Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Jinghua Cai
- Department of Oral and Maxillofacial Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Wei He
- Department of Oral and Maxillofacial Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
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Kumar V, Gupta PK, Bindu A, Mantri M, Mathews S, Jaiswal D, Kant Shankhdhar V. Safety of free fibula flap harvest in IIIA and IIIB tibio-peroneal trunk variations. J Plast Reconstr Aesthet Surg 2023; 85:326-333. [PMID: 37541049 DOI: 10.1016/j.bjps.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 08/06/2023]
Abstract
INTRODUCTION In head and neck cancer malignancies, free fibula flap is the gold standard for reconstruction of segmental bone defects owing to its predictable anatomy, long bone length, and feasibility for multiple osteotomies. However, sometimes because of variations in anatomy of tibio-peroneal trunk, it is a dilemma for the surgeons to use free fibula flap for reconstruction. This case series aimed to evaluate the safety of harvest of fibula in such cases in terms of acute and chronic donor-site complications. MATERIAL AND METHODS A retrospective study was conducted from January 2018 to May 2021. All the patients with tibio-peroneal trunk anomaly, diagnosed during surgery, who underwent successful harvest of the free fibula were included in the study and analyzed for the early major and minor donor wound complications, long-term donor complications, and late functional deficit using the Foot and Ankle Disability Index (FADI). RESULTS Out of 714 free fibulae operated, 26 patients (3.6%) had such tibio-peroneal trunk variations: 22 (2.9%) cases of type III A and B anomalies and 4 (0.56%) cases of type III C anomalies. The average FADI score was 95.3%. No one had any difficulty in personal care and activity of daily living. CONCLUSIONS The free fibula flap can be safely harvested in patients with type III A and B anomalies if vascularity of foot after clamping of peroneal vessels is good and anterior tibial vessels are normal.
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Affiliation(s)
- Vineet Kumar
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
| | - Prince Kumar Gupta
- Department of Plastic and Reconstructive Surgery, HBCH and MPMMCC, Tata Memorial Centre, Varanasi and Homi Bhabha National Institute, Mumbai, India.
| | - Ameya Bindu
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
| | - Mayur Mantri
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
| | - Saumya Mathews
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
| | - Dushyant Jaiswal
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
| | - Vinay Kant Shankhdhar
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
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Lu Y, Chen X, Lu X, Sun C, Li M, Chen G, Long Z, Gao Y, Zhang H, Huang M, Ji C, Fan H, Liu D, Hao Y, Wang H, Zhang L, Zhang H, Lu J, Wang Z, Li J. Reconstructing avascular necrotic femoral head through a bioactive β-TCP system: From design to application. Bioact Mater 2023; 28:495-510. [PMID: 37408798 PMCID: PMC10318430 DOI: 10.1016/j.bioactmat.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/09/2023] [Accepted: 06/11/2023] [Indexed: 07/07/2023] Open
Abstract
A variety of techniques have been used for treating avascular necrosis of the femoral head (ANFH), but have frequently failed. In this study, we proposed a β-TCP system for the treatment of ANFH by boosting revascularization and bone regeneration. The angio-conductive properties and concurrent osteogenesis of the highly interconnected porous β-TCP scaffold were revealed and quantified through an in vivo model that simulated the ischemic environment of ANFH. Mechanical test and finite element analysis showed that the mechanical loss caused by tissue necrosis and surgery was immediately partially compensated after implantation, and the strength of the operated femoral head was adaptively increased and eventually returned to normal bone, along with continuous material degradation and bone regeneration. For translational application, we further conducted a multi-center open-label clinical trial to assess the efficacy of the β-TCP system in treating ANFH. Two hundred fourteen patients with 246 hips were enrolled for evaluation, and 82.1% of the operated hips survived at a 42.79-month median follow-up. The imaging results, hip function, and pain scores were dramatically improved compared to preoperative levels. ARCO stage Ⅱ disease outperformed stage Ⅲ in terms of clinical effectiveness. Thus, bio-adaptive reconstruction using the β-TCP system is a promising hip-preserving strategy for the treatment of ANFH.
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Affiliation(s)
- Yajie Lu
- Department of Orthopedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
- Department of Clinical Oncology, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
- The State Key Laboratory of Cancer Biology Biotechnology Center, School of Pharmacy, Air Force Medical University, Xi'an, 710032, China
| | - Xiantao Chen
- Department of Osteonecrosis of the Femoral Head, Luoyang Orthopedic-Traumatological Hospital of Henan Province, Luoyang, 471002, China
| | - Xiao Lu
- Shanghai Bio-lu Biomaterials Co., Ltd, Shanghai, 201100, China
- Shanghai Technology Innovation Center of Orthopedic Biomaterials, Shanghai, 201100, China
| | - Changning Sun
- State Key Laboratory for Manufacturing System Engineering, Xi'an Jiaotong University, Xi'an, 710054, China
- National Medical Products Administration (NMPA) Key Laboratory for Research and Evaluation of Additive Manufacturing Medical Devices, School of Mechanical Engineering, Xi'an Jiaotong University, Xi'an, 710054, China
| | - Minghui Li
- Department of Orthopedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Guojing Chen
- Department of Orthopedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Zuoyao Long
- Department of Orthopedics, General Hospital of Northern Theater Command, Shenyang, 110000, China
| | - Yuan Gao
- The State Key Laboratory of Cancer Biology Biotechnology Center, School of Pharmacy, Air Force Medical University, Xi'an, 710032, China
| | - Haoqiang Zhang
- Department of Orthopedics, The 940th Hospital of Joint Logistics Support Force of People's Liberation Army, Lanzhou, 730000, China
| | - Mengquan Huang
- Department of Orthopedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Chuanlei Ji
- Department of Orthopedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Hongbin Fan
- Department of Orthopedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Dong Liu
- Department of Orthopedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Yuewen Hao
- Department of Medical Imaging, Xi'an Children's Hospital, Xi'an, 710000, China
| | - Hong Wang
- Department of Medical Imaging, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Leilei Zhang
- Department of Osteonecrosis of the Femoral Head, Luoyang Orthopedic-Traumatological Hospital of Henan Province, Luoyang, 471002, China
| | - Hongmei Zhang
- Department of Clinical Oncology, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Jianxi Lu
- Shanghai Bio-lu Biomaterials Co., Ltd, Shanghai, 201100, China
- Shanghai Technology Innovation Center of Orthopedic Biomaterials, Shanghai, 201100, China
| | - Zhen Wang
- Department of Orthopedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Jing Li
- Department of Orthopedics, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
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Rosslenbroich SB, Oh CW, Kern T, Mukhopadhaya J, Raschke MJ, Kneser U, Krettek C. Current Management of Diaphyseal Long Bone Defects-A Multidisciplinary and International Perspective. J Clin Med 2023; 12:6283. [PMID: 37834927 PMCID: PMC10573364 DOI: 10.3390/jcm12196283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/14/2023] [Accepted: 09/11/2023] [Indexed: 10/15/2023] Open
Abstract
The treatment of defects of the long bones remains one of the biggest challenges in trauma and orthopedic surgery. The treatment path is usually very wearing for the patient, the patient's environment and the treating physician. The clinical or regional circumstances, the defect etiology and the patient´s condition and mental status define the treatment path chosen by the treating surgeon. Depending on the patient´s demands, the bony reconstruction has to be taken into consideration at a defect size of 2-3 cm, especially in the lower limbs. Below this defect size, acute shortening or bone grafting is usually preferred. A thorough assessment of the patient´s condition including comorbidities in a multidisciplinary manner and her or his personal demands must be taken into consideration. Several techniques are available to restore continuity of the long bone. In general, these techniques can be divided into repair techniques and reconstructive techniques. The aim of the repair techniques is anatomical restoration of the bone with differentiation of the cortex and marrow. Currently, classic, hybrid or all-internal distraction devices are technical options. However, they are all based on distraction osteogenesis. Reconstructive techniques restore long-bone continuity by replacing the defect zone with autologous bone, e.g., with a vascularized bone graft or with the technique described by Masquelet. Allografts for defect reconstruction in long bones might also be described as possible options. Due to limited access to allografts in many countries and the authors' opinion that allografts result in poorer outcomes, this review focuses on autologous techniques and gives an internationally aligned overview of the current concepts in repair or reconstruction techniques of segmental long-bone defects.
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Affiliation(s)
- Steffen Bernd Rosslenbroich
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, 48149 Münster, Germany;
| | - Chang-Wug Oh
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Jung-gu, Daegu 41944, Republic of Korea;
| | - Thomas Kern
- Department of Trauma Surgery/Murnau, BG Unfallklinik Murnau, 82418 Murnau am Staffelsee, Germany;
| | - John Mukhopadhaya
- Orthopedic and Trauma Department, Paras HMRI Hospital, Patna 800014, Bihar, India;
| | - Michael Johannes Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, 48149 Münster, Germany;
| | - Ulrich Kneser
- BG Trauma Center Ludwigshafen, Department of Plastic Surgery, University of Heidelberg/Ludwigshafen, 67059 Heidelberg, Germany;
| | - Christian Krettek
- Trauma Department/Hannover, Hannover Medical School, 30625 Hannover, Germany;
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Ettinger KS, Arce K, Bunnell AM, Nedrud SM. Mandibular Reconstruction: When to Graft, When to Flap, and When to Say No. Atlas Oral Maxillofac Surg Clin North Am 2023; 31:91-104. [PMID: 37500204 DOI: 10.1016/j.cxom.2023.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Affiliation(s)
- Kyle S Ettinger
- Section of Head & Neck Oncologic and Reconstructive Surgery, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine and Science, Rochester, MN, USA.
| | - Kevin Arce
- Section of Head & Neck Oncologic and Reconstructive Surgery, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic and Mayo College of Medicine and Science, Rochester, MN, USA
| | - Anthony M Bunnell
- Department of Oral & Maxillofacial Surgery, Division of Head and Neck Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
| | - Stacey M Nedrud
- Department of Oral & Maxillofacial Surgery, Division of Head and Neck Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, FL, USA
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Lipari ML, Laxson SE. Donor-Site Complication of Severe Valgus Ankle Deformity in an Adult With Ehlers-Danlos Syndrome Following Free Vascularized Fibular Grafting. Cureus 2023; 15:e42397. [PMID: 37621815 PMCID: PMC10446786 DOI: 10.7759/cureus.42397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 08/26/2023] Open
Abstract
Valgus deformity of the ankle joint is a well-known and relatively common donor-site complication of free vascularized fibular graft harvest in children. Due to children having naturally greater ligamentous laxity than adults, the tibiofibular syndesmosis can be compromised with the loss of the fibular shaft, leading to valgus ankle deformity (VAD). Syndesmotic stabilization with screws is commonly recommended in subsets of pediatric patients at the greatest risk of this complication. In adults, the occurrence of VAD is seldom reported in the literature following fibular graft harvest. As such, no recommendation for syndesmotic stabilization exists in the adult population. We present a case of end-stage VAD in an adult patient with Ehlers-Danlos syndrome (EDS) following free vascularized fibular graft harvest. We hypothesize that other patients with generalized joint hypermobility may face the same complication and, thus, recommend the consideration of syndesmotic stabilization or primary syndesmotic fusion at the time of graft harvest in this patient population.
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Donor-Site Morbidity after Osteocutaneous Free Fibula Transfer: Longitudinal Analysis of Stair Climbing Asymmetry and Functional Outcome. Symmetry (Basel) 2022. [DOI: 10.3390/sym14091888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The autologous vascularised free fibula flap is currently considered the best option for facial reconstruction after oncological surgery, but its donor-site morbidity has not been fully examined. The purpose was to evaluate donor-site changes in temporal and spatial kinematic gait parameters during stair climbing, as well as the gait symmetry. Fourteen patients (48 ± 16 years) were evaluated before and six months after harvest of a vascularised free fibula flap. Temporal gait variables for both the ascent and descent phases did not change after surgery (2-way ANOVA, p > 0.05). During stair ascent, ankle flexion (healthy side, increased; donor side, reduced; low effect size) had a significant time × side interaction. During stair descent, hip flexion was significantly larger on the donor side (medium effect size). Significant time × side interactions were observed for ankle inversion (healthy side, reduced; donor side, increased; and low effect size) and knee flexion (healthy side, increased; donor side, unchanged; and low effect size). Medium effect sizes were found for hip flexion side differences (significant). No relevant spatio-temporal nor kinematic asymmetry emerged apart from ankle joint kinematics. Overall, only the side effect of hip flexion during descent was both statistically significant and practically meaningful. Considering the slight modifications of the gait variables, no major functional limitations were found following vascularised free fibula flap reconstruction during stair climbing and descent.
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Kusumoto J, Hashikawa K, Sakakibara A, Murai N, Akashi M. Strategy for preventing skin paddle necrosis in mandibular reconstruction with free fibula osteocutaneous flap. Microsurgery 2022; 42:451-459. [PMID: 35293039 DOI: 10.1002/micr.30881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 01/06/2022] [Accepted: 03/10/2022] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Junya Kusumoto
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazunobu Hashikawa
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan.,Department of Plastic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akiko Sakakibara
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Nobuyuki Murai
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masaya Akashi
- Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Knitschke M, Baumgart AK, Bäcker C, Adelung C, Roller F, Schmermund D, Böttger S, Streckbein P, Howaldt HP, Attia S. Impact of Periosteal Branches and Septo-Cutaneous Perforators on Free Fibula Flap Outcome: A Retrospective Analysis of Computed Tomography Angiography Scans in Virtual Surgical Planning. Front Oncol 2022; 11:821851. [PMID: 35127535 PMCID: PMC8807634 DOI: 10.3389/fonc.2021.821851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 12/24/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundVirtual surgical planning (VSP) for jaw reconstruction with free fibula flap (FFF) became a routine procedure and requires computed tomography angiography (CTA) for preoperative evaluation of the lower limbs vascular system and the bone. The aim of the study was to assess whether the distribution and density of periosteal branches (PB) and septo-cutaneous perforators (SCP) of the fibular artery have an impact on flap success.MethodThis retrospective clinical study assessed preoperative CTA of the infra-popliteal vasculature and the small vessel system of 72 patients who underwent FFF surgery. Surgical outcome of flap transfer includes wound healing, subtotal, and total flap loss were matched with the segmental vascular supply.ResultA total of 72 patients (28 females, 38.9 %; 44 males, 61.1 %) fulfilled the study inclusion criteria. The mean age was 58.5 (± 15.3 years). Stenoses of the lower limbs’ vessel (n = 14) were mostly detected in the fibular artery (n = 11). Flap success was recorded in n = 59 (82.0%), partial flap failure in n = 4 (5.5%) and total flap loss in n = 9 (12.5%). The study found a mean number (± SD) of 2.53 ± 1.60 PBs and 1.39 ± 1.03 SCPs of the FA at the donor-site. The proximal FFF segment of poly-segmental jaw reconstruction showed a higher rate of PB per flap segment than in the distal segments. Based on the total number of prepared segments (n = 121), 46.7% (n = 7) of mono-, 40.4% (n = 21) of bi-, and 31.5 % (n = 17) of tri-segmental fibula flaps were at least supplied by one PB in the success group. Overall, this corresponds to 37.2% (45 out of 121) of all successful FFF. For total flap loss (n = 14), a relative number of 42.9% (n = 6) of distinct supplied segments was recorded. Wound healing disorder of the donor site was not statistically significant influenced by the detected rate of SCP.ConclusionIn general, a correlation between higher rates of PB and SCP and the flap success could not be statistically proved by the study sample. We conclude, that preoperative PB and SCP mapping based on routine CTA imaging is not suitable for prediction of flap outcome.
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Affiliation(s)
- Michael Knitschke
- Department of Oral and Maxillofacial Surgery, Justus-Liebig-University, Giessen, Germany
- *Correspondence: Michael Knitschke,
| | - Anna Katrin Baumgart
- Department of Oral and Maxillofacial Surgery, Justus-Liebig-University, Giessen, Germany
| | - Christina Bäcker
- Department of Oral and Maxillofacial Surgery, Justus-Liebig-University, Giessen, Germany
| | - Christian Adelung
- Department of Diagnostic and Interventional Radiology and Pediatric Radiology, Justus-Liebig-University, Giessen, Germany
| | - Fritz Roller
- Department of Diagnostic and Interventional Radiology and Pediatric Radiology, Justus-Liebig-University, Giessen, Germany
| | - Daniel Schmermund
- Department of Oral and Maxillofacial Surgery, Justus-Liebig-University, Giessen, Germany
| | - Sebastian Böttger
- Department of Oral and Maxillofacial Surgery, Justus-Liebig-University, Giessen, Germany
| | - Philipp Streckbein
- Department of Oral and Maxillofacial Surgery, Justus-Liebig-University, Giessen, Germany
| | - Hans-Peter Howaldt
- Department of Oral and Maxillofacial Surgery, Justus-Liebig-University, Giessen, Germany
| | - Sameh Attia
- Department of Oral and Maxillofacial Surgery, Justus-Liebig-University, Giessen, Germany
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Rubin SJ, Sayre KS, Kovatch KJ, Ali SA, Hanks JE. Segmental mandibular reconstruction in patients with poor lower extremity perfusion, vessel-depleted necks and/or profound medical frailty. Curr Opin Otolaryngol Head Neck Surg 2021; 29:407-418. [PMID: 34387289 DOI: 10.1097/moo.0000000000000755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Options for segmental mandibular reconstruction in patients poorly suited to undergo fibula free flap (FFF). RECENT FINDINGS Although FFF is the current 'gold standard' for segmental mandibular reconstruction, other reconstructive options must be considered when FFF is contraindicated or disfavoured and/or patient frailty precludes a lengthy anaesthetic. In addition to various nonvascularized and soft tissue only reconstructions, excellent osseous free flap alternatives for functional segmental mandibular reconstruction may be employed. The subscapular system free flaps (SSSFF) may be ideal in frail and/or elderly patients, as SSSFF allows for early mobility and does not alter gait. In extensive and/or symphyseal defects, functional mandibular reconstruction in lieu of a free flap is extremely limited. Pedicled segmental mandibular reconstructions remain reasonable options, but limited contemporary literature highlights unpredictable bone graft perfusion and poor long-term functional outcomes. SUMMARY There are several excellent free flap alternatives to FFF in segmental mandibular reconstruction, assuming adequate cervical recipient vessels are present. On the basis of the current literature, the optimal mandibular reconstruction for the medically frail, elderly and/or patients with extreme vessel-depleted necks is limited and debatable. In qualifying (i.e. limited, lateral) defects, soft tissue only reconstructions should be strongly considered when osseous free flaps are unavailable.
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Affiliation(s)
- Samuel J Rubin
- Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine
| | - Kelly S Sayre
- Department of Oral and Maxillofacial Surgery, Boston University School of Dentistry
| | - Kevin J Kovatch
- Department of Otolaryngology-Head and Neck Surgery, Geisinger Medical Center
| | - S Ahmed Ali
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System
| | - John E Hanks
- Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine
- Department of Otolaryngology-Head and Neck Surgery, VA Boston Medical Center, MA, USA
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Microvascular reconstruction of the mandible with medial femoral condylar flap for treatment of mandibular non-union. Int J Oral Maxillofac Surg 2021; 51:175-181. [PMID: 34059402 DOI: 10.1016/j.ijom.2021.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 03/18/2021] [Accepted: 05/11/2021] [Indexed: 11/24/2022]
Abstract
Mandibular non-union occurs in 2-9% after open reduction and internal fixation of a mandibular fracture (trauma surgery, orthognathic cases, access osteotomy for oncological purposes). The medial femoral condyle (MFC) has emerged more recently as one of the most versatile donor sites in the treatment of challenging bone reconstruction. This is the first description of MFC for treatment of mandibular non-union. A retrospective chart review was conducted for all patients who underwent reconstruction with a microvascular MFC flap for bone defects of the head and neck area between January 2015 and December 2018 at Careggi Hospital of Florence. Inclusion criteria were patients where the FMC was used for mandibular defects arising due to non-union. Seven patients presented mandibular defects reconstructed by MFC flap and were included in this investigation (two cases of segmental mandible defect due to post-traumatic non-union; two patients of pathological mandibular fracture after prolonged bisphosphonate therapy for osteoporosis; three patients with mandibular continuity loss after failed orthognathic surgeries). At one-year follow-up, all patients had satisfactory occlusion. One-year postoperative CTs revealed full osteointegration of the flaps. In conclusion, the MFC free flap is an attractive option for mandibular reconstruction. Small defects (3-5 cm) in poorly vascularized beds are the ideal target.
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Knitschke M, Sonnabend S, Bäcker C, Schmermund D, Böttger S, Howaldt HP, Attia S. Partial and Total Flap Failure after Fibula Free Flap in Head and Neck Reconstructive Surgery: Retrospective Analysis of 180 Flaps over 19 Years. Cancers (Basel) 2021; 13:cancers13040865. [PMID: 33670721 PMCID: PMC7922890 DOI: 10.3390/cancers13040865] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/10/2021] [Accepted: 02/16/2021] [Indexed: 11/16/2022] Open
Abstract
Fibula free flap (FFF) is widely used in head and neck reconstructive surgery and is considered as a standard and therapy of choice after ablative cancer surgery. The aim of this retrospective monocenter study was to determine the success rates of fibula free flaps for jaw reconstruction after ablative tumor surgery. The disease course of patients who underwent jaw reconstructive surgery with FFF from January 2002 to June 2020 was evaluated regarding the flap success rate. Flap failure was analyzed in detail and categorized into two groups: partial flap failure (PFF) and total flap failure (TFF). A total of 180 free fibular flaps were performed over the last 19 years and a total of 36 flap failures were recorded. TFF occurred in n = 20 (56.6%) and PFF in n = 16 cases (44.4%) cases. No statistically significant differences were found concerning patients' age at flap transfer, sex, BMI, ASA-Score, preoperative non-virtual or virtual surgical planning (non-VSP vs. VSP), and time of reconstruction (immediately vs. delayed). Duration of hospitalization shows statistically significant differences between both groups (p = 0.038), but no differences concerning operating time and duration on Intensive Care Unit (ICU). Partial flap failure appears to be underreported in literature. Sub- and complete failure of the skin paddle leads to clinical complaints like uncovered bone segments and plate exposure. Partial or complete FFF failure lead to infections on the recipient site and prolonged wound healing and therefore may cause a delay of the beginning of adjuvant radiation therapy (RT). PFF of hard tissue can be induced by RT.
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Heterotopic Ossification of the Vascular Pedicle after Maxillofacial Reconstructive Surgery Using Fibular Free Flap: Introducing New Classification and Retrospective Analysis. J Clin Med 2020; 10:jcm10010109. [PMID: 33396904 PMCID: PMC7794830 DOI: 10.3390/jcm10010109] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/18/2020] [Accepted: 12/27/2020] [Indexed: 01/08/2023] Open
Abstract
Heterotopic ossification (HO) is one of the described phenomena after maxillofacial reconstructive surgery using fibular free flap (FFF) at the reception-site. The aim of this study was to determine the radiological incidence and form of HO along the fibular vascular pedicle as well as the rate of clinical symptoms if present. CT-scans of 102 patients who underwent jaw reconstructive surgery by using FFF from January 2005 to December 2019 were evaluated concerning the presence of HO. Subsequently, the patient files were evaluated to identify the cases with clinical signs and complications related to the presence of HO. A radiological classification of four different HO types was developed. Out of 102 patients, 29 (28.43%) presented radiological findings of HO. Clinical symptoms were recorded in 10 cases (9.8%) (dysphagia (n = 5), trismus (n = 3), bony masses (n = 2)) and from these only five (4.9%) needed surgical removal of calcified structures. HO occurs significantly in younger patients (mean 52.3 year). In maxillary reconstructions, HO was radiologically visible six months earlier than after mandibular reconstruction. Furthermore, HO is observed after every third maxilla and every fourth mandible reconstruction. This study developed for the first time a classification of four distinct HO patterns. HO types 1 and 2 were mostly observed after mandible reconstruction and type 4 predominantly after maxilla reconstruction.
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