Feasibility of Flexor Hallucis Muscle-Based Fibula Bone Segment for Ramus Reconstruction in Head and Neck Cancers

In mandibular reconstruction with a free fibula flap, ramus reconstruction is very important to match the ramus height, which eventually helps in good mouth opening and mastication. The fibula bone segment attached to the pedicle is used for ramus reconstruction. But when the bone requirement is large and the pedicle is short, we propose an alternate method in which the bone segment is separated from the pedicle but is attached to the flexor hallucis longus (FHL) muscle from which it receives its vascularity indirectly. Through this article, we aim to examine the non-inferiority of the FHL-based ramus in such cases.

This is a retrospective observational report carried out in a tertiary care cancer institute and includes the segmental mandibular defects reconstructed with free fibula flaps (FHL-based vs. vascularized ramus) between January 2019 and December 2021, with a follow-up of a minimum of 1 year. The primary objective is to assess the complication rates for FHL-based ramus for osteoradionecrosis (ORN), hardware exposure, bone union rates, chronic sinus/discharge, and the need for secondary procedures in cases of free fibula flaps.

In 100 patients included in this report, the plate/hardware exposure rate (14% vs. 12%) (p = 1), nonunion rate (5.3% vs. 4%) (p = 1), sinus rate (4% vs. 0%) (p = 0.57), ORN (5.3% vs. 4%) (p = 1), and secondary procedures (16% vs. 16%) (p = 1) in FHL-based ramus versus vascularized ramus fibula flaps. p value is one suggesting the proportion of complications is the same in both groups.

An FHL-based ramus provides an additional tool in the armamentarium when the bone requirement is huge and is not inferior to a vascularized ramus in terms of complication rate related to hardware exposure and bone necrosis.