Vascularized Fibula Flap Onlay for Salvage of Pathologic Fracture of the Long Bones

Author(s): JB Friedrich, SL Moran, AT Bishop, CM Wood, AY Shin

Source: Plast. Reconstr. Surg. 121: 2001-09, 2008.


Long bone pathologic fractures represent a significant and difficult entity to manage. The ultimate goal of treatment is limb salvage that is often a daunting challenge.  The authors report the results of onlay vascularized fibular grafts to reconstruct pathologic long bone fractures.  A retrospective review of 25 patients was performed with 21 patients demonstrating bony fracture union at an average of 11 months after fibular flap onlay grafting. Twenty-two of the 25 patients had received radiation to the affected bone.  Four patients suffered fibular flap failure; however, later obtained limb salvage after further procedures. Thirteen of 25 patients achieved a good or excellent functional outcome as judged by a common oncologic reconstruction functional outcome scale. Postsurgical complications were common in this patient group, with a total of 22 distinct complications (88 percent incidence).  The authors conclude that despite a high complication rates, onlay fibula flaps achieve relatively good clinical and functional outcomes for the salvage of long bone pathologic fractures.

Pathologic fractures are daunting challenges because the fracture and the antecedent process that incited the fracture must be addressed. This is particularly problematic in the case of radiation induced pathologic fractures where the radiation changes of bone are dramatic and thought to be irreversible.  Despite the high complication rate, the authors have demonstrated that good success rates can be achieved with vascularized onlay fibular grafts.  An interesting study will be the comparison of the onlay technique to the “Cappana” technique where the fibular flap is inserted in the medullary canal of the native bone ends as an intercalated vascularized bone graft.  In this study, the surgeons did not include a skin paddle with the fibular flap.  However, when feasible, incorporation of a skin paddle with the fibular flap is recommended to allow for flap vascular monitoring and the potential to replace the scarred/ irradiated tissues with healthy vascularized tissues.