Versatility

The combination of these morphologic and biologic properties renders the FVFG a truly versatile flap that can be tailored to suit the need of the individual case. Both the configuration and the composition of the graft may be modified.

The FVFG can not only be used in its naturally straight configuration, but due to its dual vascularity it can undergo a variety of osteotomies. Specifically, it can be transversely osteotomized in the middle of the diaphysis in order to produce 2 cortical struts on a single pedicle (double barrel) to reconstruct the femur or tibia. It can be transversely osteotomized in multiple sites to resemble the shape of the mandible and, moreover, it can be longitudinally osteotomized to create an open-book configuration with increased surface of vascularized bone as an adjuvant to the healing process. Simultaneous transfer of 2 FVFG, although technically demanding and time consuming, can reconstruct femoral defects up to 30 cm of length, without the extended time necessary for hypertrophy of a single FVFG.

The composition of the graft can vary according to the defect requirements. Defects may be classified as osseous, when there is only bone loss, or composite, when an additional soft tissue defect is present. Transfer of skin, fascia, muscle, or combinations of these can accompany the FVFG, as well as transfer of the growth plate of the proximal fibular epiphysis.

A skin paddle of dimensions up to 20 x 10 cm can be simultaneously transferred, based on perforating fascio-cutaneous branches at the middle and distal third of the pedicle, to facilitate coverage and, more importantly, to monitor patency of the pedicle anastomoses. Part of the soleus muscle or the flexor hallucis longus can be included in the flap to reconstruct soft tissue defects and cover otherwise exposed bone. The artery of the soleus branches immediately distally to the origin of the peroneal artery and can be included in the pedicle. Moreover, transfer of the proximal epiphysis permits reconstruction of defects involving the physis and allows for longitudinal growth of the graft in children.

Therefore, the FVFG can be transferred not only as an osseous flap but is very versatile and may serve as a composite as well, to simultaneously reconstruct a skeletal, soft tissue and growth plate defect (Figs. 10A.1 and 10A.2).

Fig. 10A.1, right. The osseous flap is versatile and according to the needs of the defect at the recipient site could be given different configuration, i.e., take the shape of a mandible with multiple osteotomies, split longitudinally, cut in half and folded as a double barrel graft, plain or composite with skin and muscle for simultaneous coverage of soft tissue defects.

Fig. 10A.2. An open tibia type Illb fracture with compound loss of tissues, after debridement, external fixation and reconstruction with a folded free vascularized composite osseous flap with skin and muscle. The 9 cm defect is bridged both for length and width at the same stage. X-ray appearance after 18 months.

Fig. 10A.2. An open tibia type Illb fracture with compound loss of tissues, after debridement, external fixation and reconstruction with a folded free vascularized composite osseous flap with skin and muscle. The 9 cm defect is bridged both for length and width at the same stage. X-ray appearance after 18 months.

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