The Fibula Free Flap for Salvage of Complications After Orthopedic Extremity Bony Fixation in Oncologic Patients

Advances in orthopedic oncology have significantly improved outcomes following extremity tumor resections; however, complications like nonunion, hardware failure, and radiation-induced fractures can occur after orthopedic fixation. While the vascularized fibula-free flap (FFF) is well-established in primary reconstructions, its effectiveness as a salvage option is not well described. We report our 25-year experience with the use of FFF in salvage extremity reconstruction.

This retrospective case series included patients undergoing extremity salvage with FFF after failure of primary oncologic reconstructions from 1995 to 2021. Demographics, surgical indications, reconstructive details, functional outcomes, complications, and Musculoskeletal Tumor Society (MSTS) scores were analyzed.

Fifteen patients (ages 6-71 years) met inclusion criteria, which included nine humeral and six femoral reconstructions, with an average follow-up of 6.7 years. Indications for salvage were radiation-induced fracture (n = 6), nonunion (n = 3), allograft fracture (n = 3), and hardware failure (n = 3). The median interval between the initial surgery for tumor resection and FFF for limb salvage was 4 years 3 months (mean: 9 years, range: 10 months to 29.3 years). All lower-extremity reconstructions achieved full weight-bearing without pain. Upper-extremity reconstructions resulted in full functional restoration in six patients and minor functional deficits in three. Bony union of fibula flap was achieved in 78.5% patients. Reoperation were performed in 4 patients for wound issues (n = 2) and hardware removal (n = 2).

FFF is a reliable and effective option for management of oncologic-related complications of the extremities. It can avoid amputations and improve limb function.