Fibula Anterior Ankle Surgery

Fig. 7.3. B) Reconstruction of right breast with a free TRAM flap.

resection. For longer defects, however, free vascularized bone flaps are indicated. These, unlike nonvascularized bone grafts, remain viable; their blood supply is through the nutrient vessels. Bone healing occurs at a rate comparable to that of normal bone, creeping substitution does not occur and the quality of the recipient bed does not influence their survival.

Many vascularized bone grafts have been described as a component of fascial or fasciocutaneous flaps. Free rib flaps have also been described. None of these are good choices for extremity92 or mandibular reconstruction; all are too small to be useful except possibly in the forefoot or the hand. The most frequently used vascularized bone flaps are: the iliac crest flap and the fibula flap.

The iliac crest free flap73'82'83 is based on the deep circumflex branch of the iliac artery. Bone only or bone with overlying skin and subcutaneous tissue may be included, depending on the requirements at the recipient site. Experience, is mandatory for the elevation of this flap, (Fig. 7.4). The vasculature is reliable, but problems, mentioned previously, with flaps whose vessels originate from below the aortic bifurcation in arteriosclerotic patients, may be encountered. The major problem with using this flap is that the bone is inadequate, both in shape and volume, for replacement of defects longer than 10 cm. Longer defects are probably best bridged with vascularized bone flaps of sufficient length and suitable shape, namely the fibula flap2090 based on the peroneal artery. This artery, like the radial artery in the radial forearm flap, is a large vessel in transit to the distal limb. It may be used not only as the circulatory supply for the fibula flap, but also as a "flow through" vessel to replace a damaged segment of artery. The flap, besides the bone, may incorporate muscle up to half of the soleus or a cutaneous component, or both, to provide soft tissue coverage if the defect is of moderate size. Up to 25 cm of fibula may be taken, depending on the patient's body habitus. If the flap is used in the lower extremity, the bone is then telescoped into the medullary cavities of the tibia or femur. This added requirement means that the bone must be at least 5 cm longer than the defect.

There is no significant donor limb morbidity. It is necessary to be cautious in dissecting the upper end, to avoid damage to the common peroneal nerve, and at the lower end to leave enough length of distal fibula to retain ankle stability (8 cms) Exercise of a normal degree of surgical care, including hemostasis and suction drain-

Squamous Cell Carcinoma Ankle

Fig. 7.4. A) Extensive squamous cell carcinoma of the anterior mouth floor with mandibular involvment.

Fig. 7.4. A) Extensive squamous cell carcinoma of the anterior mouth floor with mandibular involvment.

Fig. 7.4. B) Extensive resection of the anterior floor of the mouth and mandible (angle to angle) with bilateral neck dissection.

age, should prevent postoperative problems. Osteotomy of the flap, in order to obtain double barrel configuration for femur replacement or in order to provide the desired shape for mandibular reconstruction, is feasible.

Healing is rapid with the prompt appearance of callus at about 2 months in adults. The bone undergoes compensatory hypertrophy with stress. Unassisted weight bearing is usually possible by 15 months. It is not unusual for stress fractures to appear after initiating weight bearing, but these stabilize and heal quickly with immobilization, usually within 4-6 weeks. Some patients may require additional cancellous bone grafting if delayed union occurs, as it sometimes does at the distant junction of the tibia with the vascularized bone graft (17% in Weiland series).89

In summary, fasciocutaneous, muscle, or perforator flaps have advantages and disadvantages and the reconstructive surgeon should feel comfortable working with all types. The versatility of the vascularized fibula makes it very useful as a living bone flap for segmental bony defects of any significant length. Finally replacement of both soft tissues and bone in one stage, results in the salvage of limbs that would otherwise be lost or would require a protracted reconstructive course and allows the functional reconstruction of the face following severe trauma or tumor extirpation.

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