Distal tibial fractures are a poorly recognised complication with fibula free flaps

Abstract

The fibula free flap is ideal for complex jaw reconstructions, with low reported donor and flap morbidity. We discuss a distal tibial stress fracture two months following a vascularised fibula free flap procedure. Despite being an unrecognised complication, a literature review produced 13 previous cases; only two were reported in the reconstructive surgery literature, with the most recent claiming to be the first. The majority of these studies treated this fracture non-operatively; none reported their patient follow-up. Each case presented with ipsilateral leg pain, which has been cited as an early donor site morbidity in as many as 40% of fibula free flap cases. It is known that the fibula absorbs at least 15% of leg load on weight bearing. Studies have shown severe valgus deformities in up to 25% of patients with fibulectomies. We treated our patient operatively, first correcting his worsening valgus deformity with an external fixator, then reinforcing his healed fracture with a long distal tibial plate. We believe that this complication is underreported, unexpected and not mentioned during the consenting process. By highlighting the management of our case and the literature, we aim to increase awareness (and thus further reporting and appropriate management) of this debilitating complication.

Donor-Site Morbidity after Fibula Transplantation in Head and Neck Tumor Patients: A Split-Leg Retrospective Study with Focus on Leg Stability and Quality of Life

“…Various studies in literature report on the use of fibula grafts for orofacial reconstruction in general and the associated donor-site morbidity in particular. Although these studies describe the limitations that are associated with fibula removal as minor [ 23 , 24 , 25 ], complications can still occur with severe consequences for patients [ 26 , 27 , 28 ]. The methods often differ greatly between individual studies.…”

Three-dimensional virtual planning in precise chimeric fibula free flap for metacarpal defects

“…[ 18 ] However, complications related to osteotomy of the fibula are of concern recently. [ 7 , 19 ] In 6-month follow-up, there were no complications related to osteotomy of the fibula in the 3 cases. This method may improve to maintain the ankle stability to reduce complications.…”

Regeneration of the Fibula with Unidirectional Porous Hydroxyapatite

“…Reconstruction of the fibula defect after harvesting might not be necessary, because the fibula and interosseous membrane carry only 6% to 16% of the load applied to the lower extremity [10, 11] and spontaneous regeneration of the fibula has been reported previously, especially in children [12]. However, incomplete regeneration or nonunion following fibula harvesting has also been described [1, 13], and the loss of the fibula after its removal sometimes results in significant donor site morbidity, such as surgical scar pain, weaknesses of plantar flexion of the ankle [14], valgus deformity of the ankle [1], ankle instability [15], and tibial fracture [2]. Our case demonstrated slight proximal migration of the remaining distal fibula without ankle valgus deformity, which could be avoided by using temporary syndesmotic screw fixation.…”

“…A fibula graft is a standard technique used to reconstruct bone defects in reconstructive orthopedic surgery. Although it remains uncertain whether a segmental fibular defect should be restored, some complications related to persistent defects of the fibula have been reported previously [1, 2]. We believe that regeneration of the fibula may be critical for postoperative function and prevention of complications, especially for juvenile and adolescent patients.…”