Delayed pathologic tibial fracture with chronic osteomyelitis after fibula free flap

The reported donor site morbidity of the fibula free flap (FFF) is low; however, several uncommon complications have been reported with tibia fracture rarely being reported. We present a case of a pathological tibial fracture in the setting of chronic osteomyelitis after FFF. A 54-year-old female presented with a benign fibro-osseous lesion of the right mandible and was treated with mandibulectomy and reconstructed with a left FFF. Approximately 1 year following surgery, the patient presented to the emergency department. Imaging showed a pathological fracture of the distal third of the tibial shaft with persistent erythema and cellulitis of the lateral prior graft harvest site without signs of systemic infection. She was taken to the operating room for irrigation and debridement with culture and biopsy as well as external fixation of the tibial fracture. Intraoperative biopsy and culture demonstrated fracture site change with callus formation and negative culture. The patient was discharged on 6 weeks of IV vancomycin and ceftriaxone. In conclusion, tibial fracture following FFF is an uncommon complication, yet it can be exacerbated by chronic osteomyelitis. This report highlights the importance of close observation and comprehensive wound care of donor sites after free flap harvest for head and neck reconstruction.