Paediatric distal fibula reconstruction using a pedicled composite second metatarsal flap: a technical note

The case of a 4-year-old boy in whom a pedicled second metatarsal flap was used for lateral malleolar reconstruction after lawnmower injury is presented. Leg initial assessment demonstrated a 5cm bone loss at the distal fibula combined with severe soft tissue damage. Immediate healing was achieved with split-thickness skin graft but secondary reconstruction was necessary to obtain bone replacement with soft tissue coverage to allow bone growth and shoe donning. To avoid microsurgical fibular epiphyseal transplant morbidity and complications, we used a pedicled second metatarsal flap based on the dorsalis pedis vessels including the second metatarsal bone, the skin of the second toe and the brevis pedis muscle. Repair of the donor side was performed with direct suture and no post-operative course complication was noted. At seven-year follow-up, transferred bone had excellent growth and the patient had adequate ankle function and stable ride. The case provides technique descriptions, considerations in the paediatric population, an overview of other techniques and a seven-year follow-up. It suggests that vascularized chimeric second metatarsal flap may be a useful option in paediatric distal fibula reconstruction.