We read with great interest the article by Piccolo et al. entitled “Ankle Arthrodesis with Free Vascularized Fibula Autograft Using Saphenous Vein Grafts: A Case Series.”1 We want to thank the authors for their contribution because few reports based on short case series can be found dealing with this issue,2,3 mainly because ankle arthrodesis with vascularized bone is not a frequent procedure. The authors also depict a technical modification to prevent bone harvest from the contralateral unaffected leg, allowing early weight-bearing, and anastomose the flap to proximal healthy recipient vessels. It should be analyzed whether this benefit outweighs the increased risk of flap failure because of using interposition vein grafts,4 the sacrifice of a very long segment of the saphenous vein, which can be needed in flap reexploration or revascularization procedures, and the prolonged operative time (using the ipsilateral fibula prevents the two-team approach, which is possible when the contralateral fibula is harvested).
Between 2015 and 2017, we performed five ankle arthrodeses with a vascularized contralateral free fibula flap in five patients as a treatment for nonunion following fracture of the distal tibia (one case), open fracture with extensive combined bone and soft-tissue loss (two cases), tumor resection (one case), and osteomyelitis (one case). The tibiotalar joint was fused in three cases, and two patients had tibiocalcaneal arthrodesis. [See Figure, Supplemental Digital Content 1, which shows a distal tibia defect after open fracture (above) and tibiocalcaneal arthrodesis with free vascularized fibula graft (below), http://links.lww.com/PRS/D456.] The graft was placed in inlay fashion in all of the patients. Internal fixation with Kirschner wires and screws and an external fixator were used in four patients. In the oncologic patient, a double-strut fibula flap was fixed with a plate. All of the flaps survived. One patient required reexploration for venous congestion. Another patient presented minor wound necrosis that healed with local wound care. Primary bony union was achieved in all of the cases, with an average time to full weight-bearing of 8 months (range, 5 to 12 months). Although it includes only five patients, the results of our series are in accordance with the study by Piccolo et al., which supports the role of vascularized fibula in selected complex ankle arthrodesis.
The authors have no financial interest to declare in relation to the content of this communication.
Alberto Pérez-García, M.D.
Alberto Ruiz-Cases, M.D.
Department of Plastic Surgery and Burns
José Baeza, M.D.
Department of Orthopedic Surgery
Enrique Salmerón-González, M.D.
Eduardo Simón-Sanz, M.D.
Department of Plastic Surgery and Burns
Hospital Universitario y Politécnico La Fe
1. Piccolo PP, Ben-Amotz O, Ashley B, Wapner KL, Levin LS. Ankle arthrodesis with free vascularized fibula autograft using saphenous vein grafts: A case series. Plast Reconstr Surg. 2018;142:806–809.
2. Bishop AT, Wood MB, Sheetz KK. Arthrodesis of the ankle with a free vascularized autogenous bone graft: Reconstruction of segmental loss of bone secondary to osteomyelitis, tumor, or trauma. J Bone Joint Surg Am. 1995;77:1867–1875.
3. Yajima H, Kobata Y, Tomita Y, Kawate K, Sugimoto K, Takakura Y. Ankle and pantalar arthrodeses using vascularized fibular grafts. Foot Ankle Int. 2004;25:3–7.
4. Inbal A, Silva AK, Humphries LS, Teven CM, Gottlieb LJ. Bridging the gap: A 20-year experience with vein grafts for free flap reconstruction: The odds for success. Plast Reconstr Surg. 2018;142:786–794.
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