Reconstruction of Segmental Defects of the Upper Extremity with Autogenous Vascularized Osteocutaneous Fibula Grafts

This was a retrospective review of 24 patients who underwent osteocutaneous free fibula grafts for upper extremity defects. The average age of the patients was 43 years (range 7–79). The indications were complex segmental defects after malignant tumor resection in 6 patients, acute traumatic segmental defect with soft tissue loss in 7 patients, segmental nonunion in 7 patients and infected nonunion in 2 patients. The patients with nonunion each had failed more than 4 (range 4–5) different operative stabilization procedures, supplemented with autogenous iliac crest bone grafting over an average time period of 20 months (range 16–24). Associated injuries included segmental radial nerve defects in 2 patients. The fibula graft length ranged from 10–16 cm. Two cases involved a double- barrel graft (7.5 and 8 cm) for shoulder arthrodesis. The size of the skin paddle was between 2 × 4 cm and 5 × 8 cm. All donor defects were closed with a split–thickness skin graft. Associated procedures included cable nerve grafting for the radial nerve in one case. Two of the cases required early revision of the anastomosis due to venous thrombosis, noted by decreased perfusion to the skin paddle as measured by laser Doppler. Average follow–up was 28 months (range 4–48). There was no significant donor site morbidity in any patient. Six patients had isolated nonunions of the graft treated effectively with open reduction and internal fixation. Forequarter amputation was performed in one patient for recurrent synovial sarcoma 4 years after the reconstruction. For these complex reconstructions, the use of osteocutaneous free fibula grafts offers an option that allows for both osseous union and soft tissue coverage. The use of a vascularized bone graft proved to be effective in the treatment of recalcitrant nonunions. The cutaneous paddle also served as a monitor of blood flow to the free fibula transplantation and supplemented soft tissue defects.