Overview of Fibula Free Flaps

When someone experiences bone loss due to an accident, tumor, infection, or if they were born with a defect, it could greatly affect their quality of life. In extreme situations, it might even lead to a need for amputation. Although there are newer ways to treat these issues, such as endoprostheses (a type of implant) and distraction osteogenesis (a procedure to lengthen the bone), nonvascularized bone grafts remain a popular choice. Bone grafting has been used for over a hundred years in reconstructive surgery to heal nonunions (fractures that fail to heal) and small bone defects.

In 1975, Taylor and his team introduced a new technique of transferring a segment of the fibula (the smaller, outer bone of the leg), using a posterior (towards the back) approach. This method was further refined by Gilbert who proposed using a lateral (from the side) approach. Today, the fibula is being widely used in head and neck reconstruction surgeries, thanks to Hidalgo who, in 1994, introduced techniques for shaping the fibula to resemble the contour of a human jawbone.

There are several ways to use the fibula for reconstruction. These include methods like autografts (using one’s one bone) and allografts (using a bone from a donor), endoprosthetic replacement (using prosthesis), and vascularized bone grafts (transferring bone with its blood supply). Of these, free vascularized fibular grafting is likely the most beneficial as it provides immediate support and has the potential to grow based on the patient’s growth and activity levels. However, it’s important to note that this method might not be suitable for all patients requiring bone reconstruction. It’s often used for large defects (more than 6 cm), where a nonvascularized bone graft has failed, infected nonunion with a bone defect, or after a tumor has been removed, especially when radiation therapy is expected after the surgery.

Anatomy and Physiology of Fibula Free Flaps

The fibula is a long, straight bone in your leg that is about the thickness of a finger. It’s a little longer in men than in women. Its shape is determined by the muscles that attach to it, helping it do its job in the lower leg.

The fibula is connected to the larger bone in the leg, the tibia, at two points. One point is near the knee, where the fibula stems from the tibia and is held in place by a capsule and ligaments. The second connection, closer to the ankle, consists of a network of ligaments that hold the fibula and tibia together. The integrity of the area near the ankle is critical as any damage to these connections can lead to instability in the ankle.

The fibula is nourished by a network of blood vessels. Several small blood vessels throughout different sections of the fibula contribute to the bone’s health. Understanding how these blood vessels supply the bone is very important, especially when parts of the fibula need to be used for grafting purposes in surgery.

Muscles in the leg play a crucial role in the anatomy of the fibula. The muscles mentioned are located around the fibula and play a key role in its function. Two particularly important muscles, the tibialis posterior and the flexor hallucis longus, help stabilize the bone.

Understanding the fibula’s structure is crucial for doctors. This knowledge helps them make the right decisions during surgeries, especially those involving bone grafts. With finer details about how this bone is structured, doctors can limit risks during procedures and promote better post-surgical outcomes for patients.

Why do People Need Fibula Free Flaps

Vascularized free fibula flaps are a type of surgery where a part of the fibula bone (the smaller bone in the lower leg) is moved to another part of the body. This procedure includes the blood vessels, so the moved bone continues to have a good blood supply. This operation can be used in certain situations:

1) When a bone is injured and there is a gap greater than 6cm – the fibula flap can help fill that gap.

2) After a bone tumor has been removed, resulting in a gap where the tumor used to be.

3) In case of resistant pseudarthrosis, a condition where a fracture doesn’t heal properly despite treatment.

4) If there is a noticeable difference in the length of your limbs, the fibula flap can be used to help even them out.

5) Chronic osteomyelitis is a persistent infection in the bone leading to bone loss. The fibula flap can be used to replace the lost bone.

6) In the reconstruction of the lower jawbone or mandible – the fibula is a good match due to its similar shape and size.

7) For children who have had a tumor removed, the fibula flap provides a good option to replace the growth area of the bone.

8) If there is death of bone tissue in the upper arm (humerus), thigh (femur) or jawbone (mandible) due a lack of blood supply – a condition commonly referred to as ‘osteonecrosis’.

When a Person Should Avoid Fibula Free Flaps

There are certain situations where using free fibular flaps, a kind of reconstructive surgery using bone, can’t be done. These include:

If an individual has peripheral vascular disease that affects the lower limbs. This is a condition where blood vessels in the legs are narrowed or blocked, reducing the blood flow.

If the person has a hypoplastic anterior tibial artery, which means the main artery in their lower leg isn’t fully developed.

In cases where only a small portion of skin can be used for creating these flaps.

If someone has venous insufficiency, a condition where the veins in the legs are unable to efficiently send blood back to the heart

If someone is suffering from deep vein thrombosis, a blood clot in the deep veins of the body, often in the lower extremities.

In the event that the patient has previously had an amputation on the opposite lower limb.

If a person has heart or lung conditions that mean they are unable to tolerate long periods under general anaesthesia.

Interestingly, just being older does not necessarily prevent a person from having this type of surgery.

Equipment used for Fibula Free Flaps

The needed equipment for the surgery includes a variety of tools:

A scalpel is a small, sharp knife that’s used in surgeries to make cuts. Here, we’re using a #15 blade scalpel.

Monopolar and bipolar electrocautery are devices that use electricity to heat tissues to stop bleeding or to cut through tissue.

A soft tissue set with Langenbeck retractors, forceps, hemostats, clamps, needle drivers, and Metzenbaum scissors helps the surgeon handle and move tissues during the surgery. Forceps are like tweezers, used to handle or move tissues. A retractor helps keep the wound or incision open during the procedure, clamps and hemostats can control bleeding, and needle drivers hold suturing needles while closing an incision. Metzenbaum scissors are a type of surgical scissors used for cutting delicate tissues.

A Gigli saw or a reciprocating saw can be used to cut through bone.

Plates, screws, and other fixation hardware might be utilized if necessary to fixate fragments of bone. A screwdriver and a drill are used to install these pieces.

An operating microscope is used for highly precise procedures.

Microvascular instruments are used for handling small blood vessels.

Hemoclips are tiny clips used to stop bleeding from small blood vessels, while a Doppler probe helps assess blood flow in the vessels.

A dermatome is used for harvesting a skin graft, which is a piece of skin taken from one area of the body to cover another area, if necessary.

We will use various types of sutures to close incisions on both the leg and the recipient site upon completion of the procedure.

Suction drains are inserted into the wound area to remove any fluids that accumulate post-surgery.

Depending on the location of the surgery, a tracheostomy set and tube might be needed. This is where a hole is made in your neck to help you breathe. Similarly, a feeding tube might also be used, which is a tube inserted through your abdomen into your stomach or small intestine to provide nutrition.

Finally, we’ll use dressing supplies to cover and protect the surgical site after the procedure is finished.

Who is needed to perform Fibula Free Flaps?

Your surgery team will be made up of several different healthcare professionals, each with a unique role in making sure your operation goes smoothly.

The anesthesiology team, which includes doctors and nurses who specialize in anesthesiology, will make sure you are comfortable and pain-free during surgery. They may use medication to keep you asleep or just numb a certain area.

The primary surgeon, might be a plastic surgeon (fixes or improves the body’s appearance), orthopedic surgeon (specializes in problems of the musculoskeletal system), head and neck surgeon (specializes in diseases and disorders that affect the head and neck), or an oral surgeon (Specializes in conditions of the mouth, teeth, and facial regions).

The surgical assistants will be there to assist the primary surgeon during the operation by helping to ensure the procedure goes smoothly and safely.

A radiographic technician also known as a radiology tech, will be present to take images such as X-rays if needed during the surgery to guide the surgeon.

The circulating nurse is a specialized nurse who manages the overall nursing care in the operating room and helps to maintain a safe, comfortable environment.

The surgical technician, who has been trained to set up the room and helps the surgeon during the procedure by handing them instruments, making sure everything is sterile and the surgery goes as planned.

Preparing for Fibula Free Flaps

Before a surgical procedure, doctors need to evaluate the area where the operation will take place. This evaluation includes identifying blood vessels that can supply blood to the new tissue graft, deciding the best patient position during the procedure, and determining the best method of fixing the bone. Doctors should have various tools available for this, like plates, screws, K-wires, external fixators, and intramedullary nails.

Similarly, the doctor will also evaluate the donor site- this refers to the part of the body where the tissue graft is taken from. Important details such as skin condition, muscle size, and the state of blood vessels are taken note of. They also need to check the patient’s neurological condition as surgery can sometimes lead to temporary nerve weakness or damage. To ensure safe surgery, doctors must make sure that the foot (where the graft is typically taken from) has good blood flow from certain arteries. If there’s any uncertainty, they may use additional tests like Doppler ultrasonography, CT scans or MRI to check the status of blood vessels.

If the peroneal artery – a significant blood vessel in the leg – is responsible for most of the blood supply to the foot, it might not be safe to take a graft from that area. On the flip side, if the peroneal artery does not have good blood flow, doctors will also not take a graft from that area. Certain risk factors such as a history of smoking and alcohol consumption may impact your blood vessels’ health and affect the decision to take a graft from the leg in patients with oral cavity cancer.

For a safe graft transfer, it’s not necessary that every blood vessel in your foot is working perfectly. But it is very important that there’s sufficient blood flow to the foot from other arteries if the peroneal artery is not functional. If the peroneal artery is the sole supplier of blood to the foot, this might not be a safe option.

If any issues with the blood vessels make it unsafe to transfer tissue from the leg, doctors can consider other areas like the bones in the hip region, shoulder blade, or forearm. Dental implants can also be placed into these grafts, but they are generally the second choice due to the thinness of the available bone.

For reconstructing parts of the leg, doctors prefer to use a graft from the other leg. When reconstructing parts of the upper limb, either leg can be considered. However, for head and neck reconstruction, which graft is used depends on various factors such as the blood vessels in the neck, the specific area being reconstructed and whether the skin graft replaces oral mucous membranes or facial skin. Careful planning important to success of the procedure.

Virtual planning is utilized in these cases to aid in the decisions concerning the graft, such as where to connect the blood vessels, how to shape the graft to match the shape of the patient’s mandible (low jaw bone), and where to place dental implants. The surgeon can use 3D renderings of the patient’s face and leg CT scan images to simulate the surgery, allowing them to plan precisely. Patient-specific guides can also be 3D printed so that the graft matches perfectly during the surgery.

How is Fibula Free Flaps performed

To start with, the patient’s understanding and agreement for the procedure are secured, then antibiotics which prevent infection are given. Preparations for the procedure involve putting the patient to sleep with general anesthesia and positioning the patient’s knee in a way that provides easy access to the lower leg. The fibula, another name for the calf bone, is then mapped out and marked on the skin. Doppler ultrasound, a device that uses sound waves to produce images, identifies blood vessels in the area. An Esmarch bandage, a special type of bandage used to control bleeding, is used to drain the blood away from the leg. A blood pressure cuff-like device, called a tourniquet, is then applied and inflated for a maximum of 2 hours. Extra padding is added to points of pressure on the patient’s body, considering that the procedure takes a while. Other necessary devices might also be added for monitoring the patient. It’s key that the patient is positioned in a way that allows two medical teams to work simultaneously – one at the recipient site and the other, the donor site.

The procedure at the recipient site, the area that will receive the transplanted bone, varies based on the particular medical problem at hand. For instance, conditions like pseudarthrosis may require portions of the bone to be removed, while chronic osteomyelitis might require a clean-up (debridement) of the affected area. Reconstruction can be carried out in a single or split into two procedures as is done in cases of bone infection or cancer. Selecting suitable blood vessels for the transfer of blood vessels is crucial to the procedure. The size of the bone defect imperatively determines how large the graft from the fibula will be.

On the other hand, the procedure at the donor site, where the fibula is being taken from, usually involves a lengthy incision along the calf bone. Only a portion of the fibula is typically removed, while the ends, about 5 cm at the top and bottom, are left untouched to avoid impacting the nerve function and ankle joint stability. Particular attention is given to preserving the peroneal artery and the blood vessels that accompany it, as these are critical for a successful transplant.

The surgical procedure starts with a cut on the anterior, or front, part of the skin paddle, involving precise dissection through the subcutaneous fat and fascia layers leading to the fibula. After the fibula is fully exposed, the interosseous membrane is carefully split to avoid harming the anterior tibial artery, veins, and deep peroneal nerve. The fibula is then cut off, after which the fibular harvest and the closing osteotomy are performed. Osteotomy is the removal of a piece of bone, in this case, the fibula. Following this, the removal site is properly stitched up, sometimes requiring a skin graft where a piece of the skin is transplanted.

The next step is graft fixation, where the harvested bone is attached to the recipient site. Several methods of fixation exist, like using intramedullary nails or compression plates. Utmost care is taken during this step as improper fixation can interfere with the blood supply to the graft. More so, an appropriately sized graft is sutured into the defect before routing the blood vessels. It helps to ensure the right orientation of the blood vessels avoiding any disruption in the blood flow. The harvested fibula is then molded to fit the shape of the mandible, for instance.

These steps provide a functional understanding of the process involved in fibular harvesting for reconstructive surgeries. There might be deviations, however, as your doctor will determine what techniques are best suited to your specific medical conditions.

Possible Complications of Fibula Free Flaps

Fibula free flap – a kind of surgery that involves using bone, muscle, and skin from the lower leg (fibula) to repair other parts of the body- can have several complications. These can occur at different stages of the process: during anesthesia, during the operation, or after the operation.

During anesthesia, issues can include feelings of sickness and throwing up, damage to the teeth while the breathing tube is being inserted, a sore throat, severe allergic reactions to anesthesia, heart attack, difficulty breathing, lung infection from inhaling food or drink, and unusually low body temperature.

Complications during the operation can involve bleeding, the graft (the piece of fibula being moved) might be the wrong size, accidental damage to the graft, issues with securing the graft in place, and damage to the bundle of nerves and blood vessels nearby.

After the operation, complications that might occur include the graft breaking (which is the most common issue), infection at the site of the surgery (the second most common problem), a longer stay in the hospital than expected, the big toe bending too much (which can often be corrected by lengthening a specific muscle), damage to a specific nerve in the leg, issues or failures with the surgical equipment used, pain that leads to walking difficulties (normally less than that caused by breaking the fibula), poorly healed or wrongly healed grafts, unusual growth due to damage to the growth plates in children, the surgical wound reopening, amputation, discrepancies in leg length, and the leg that the graft was taken from being bent outwards.

Other issues can involve uncontrolled ankle movement, nerve damage leading to loss of feeling or movement, constant ankle pain, an increasing pool of blood, blockages to the reconnected (anastomosed) blood vessels that can lead to failure of the moved flap.

What Else Should I Know About Fibula Free Flaps?

Autogenous vascularized fibular grafting is a medical procedure that uses your own fibula (the smaller bone in your lower leg) to repair significant damages in long bones, infections that won’t heal, and defects caused by cancer in both adults and children. This type of graft not only strengthens the bone but also promotes growth. A major benefit of this graft is its unique ability to adapt and become stronger under pressure, making it a more durable solution as compared to other bone repair methods.

The success of the operation highly depends on the skill and experience of the medical team, carefully choosing the right patients, and setting effective expectations before the surgery.

Frequently asked questions

1) Is a fibula free flap the best option for my specific condition and needs? 2) What are the potential risks and complications associated with a fibula free flap procedure? 3) How long is the recovery process after a fibula free flap surgery? 4) Will I need any additional treatments or therapies after the surgery? 5) Are there any long-term effects or limitations I should be aware of after the procedure?

Fibula Free Flaps are a surgical procedure that involves using parts of the fibula bone for grafting purposes. Understanding the structure of the fibula is important for doctors to make informed decisions during these surgeries and minimize risks. By using the fibula for grafting, doctors can promote better post-surgical outcomes for patients.

You may need Fibula Free Flaps if you have certain conditions or situations that prevent other types of reconstructive surgery using bone. These include peripheral vascular disease, hypoplastic anterior tibial artery, limited available skin, venous insufficiency, deep vein thrombosis, previous amputation on the opposite lower limb, or inability to tolerate long periods under general anesthesia. Age alone does not necessarily prevent you from having this type of surgery.

You should not get Fibula Free Flaps if you have peripheral vascular disease, hypoplastic anterior tibial artery, limited skin availability, venous insufficiency, deep vein thrombosis, previous amputation on the opposite lower limb, or heart/lung conditions that make you unable to tolerate long periods under general anesthesia.

The recovery time for Fibula Free Flaps can vary depending on the specific medical condition and the extent of the surgery. However, it generally involves a period of immobilization and limited weight-bearing on the affected leg for several weeks to allow for proper healing. Physical therapy and rehabilitation may also be necessary to regain strength and mobility in the leg.

To prepare for Fibula Free Flaps, the patient should have a thorough evaluation of the area where the operation will take place, including identifying blood vessels that can supply blood to the new tissue graft and assessing the condition of the donor site. The patient should also undergo tests to check the status of blood vessels, such as Doppler ultrasonography, CT scans, or MRI. Additionally, the patient should understand the procedure, agree to it, and receive antibiotics to prevent infection before the surgery.

The complications of Fibula Free Flaps can occur during anesthesia, during the operation, or after the operation. During anesthesia, complications can include sickness, damage to teeth, sore throat, allergic reactions, heart attack, difficulty breathing, lung infection, and low body temperature. Complications during the operation can involve bleeding, incorrect size of the graft, accidental damage to the graft, issues with securing the graft, and damage to nearby nerves and blood vessels. After the operation, complications can include graft breaking, infection, longer hospital stay, toe bending too much, nerve damage, equipment issues, walking difficulties, poorly healed grafts, growth plate damage in children, surgical wound reopening, amputation, leg length discrepancies, and outward bending of the leg. Other complications can involve uncontrolled ankle movement, nerve damage leading to loss of feeling or movement, ankle pain, blood pooling, and blockages to blood vessels.

Symptoms that require Fibula Free Flaps include bone injuries with a gap greater than 6cm, bone tumors resulting in a gap, resistant pseudarthrosis (fracture that doesn't heal properly), noticeable limb length difference, chronic osteomyelitis (persistent bone infection), reconstruction of the lower jawbone, tumor removal in children, and death of bone tissue due to lack of blood supply (osteonecrosis) in the upper arm, thigh, or jawbone.

There is no specific information provided in the given text about the safety of Fibula Free Flaps in pregnancy. It is recommended to consult with a healthcare professional for a comprehensive evaluation and personalized advice regarding this matter.

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