Utilization of the Pedicled and Free Fibula Flap for Ankle Arthrodesis : Plastic and Reconstructive Surgery – Global Open

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Reconstructive: Original Article

Utilization of the Pedicled and Free Fibula Flap for Ankle Arthrodesis

Gupta, Rohun BA*; Pfennig, Mitchell BS*; Gannon, James BS*; Young, Devin BA*; Gupta, Monik BA; Chaiyasate, Sean; Stieg, Gretchen MD§; Kissel, Brian G. DPM, MBA, FACFAS*,¶; Kissel, Erik C. DPM, FACFAS*,¶; Fortin, Paul MD*,∥; Chaiyasate, Kongkrit MD*,**

Author Information
Plastic and Reconstructive Surgery - Global Open: November 2022 - Volume 10 - Issue 11 - p e4670
doi: 10.1097/GOX.0000000000004670
  • Open
  • Associated Video
  • UNITED STATES

Abstract

Takeaways

Question: Should surgeons look to utilize the pedicled or free fibula flap for ankle arthrodesis?

Findings: Both pedicled and free fibula flaps lead to successful operative outcomes after a detailed preoperative analysis is conducted.

Meaning: In patients where limited reconstructive techniques are possible, physicians should look to utilize the pedicled or free fibula flap for ankle arthrodesis.

INTRODUCTION

Ankle arthrodesis is a surgical procedure consisting of fusion of two or more bones to the ankle.1 Ankle arthrodesis was first described by Albert2 in 1879 as a surgical technique pertaining to pediatric knee and ankle fusion. Although the surgical principles guiding arthrodesis have remained the same, there have been drastic advances in fixation modalities, including the utilization of screw fixation, external fixation, and minimally invasive approaches.3 Ankle arthrodesis has become a critical procedure in patients with end-stage ankle arthritis, chronic infection, and bony misalignment.4,5 Other conditions include rheumatoid arthritis, osteonecrosis, gout, and idiopathic arthritis.6,7

Studies have found that type of fracture, open injuries, medical comorbidities, and avascular necrosis are commonly associated with ankle nonunion after arthrodesis.8 Some sources have found that nonunion postankle arthrodesis has ranged from 0% to 40%.9 Patients with persistent nonunion may require multiple attempts at arthrodesis, which can lead to substantial decreases in bone volume.10 Furthermore, it has been determined that age, technique, and history of multiple arthrodesis operations were not associated with increased rate of nonunion.8 In addition, due to limited collateral blood supply in the ankle, studies have determined that fractures of the talar neck may lead to avascular necrosis.9

There are several surgical techniques that have been utilized for arthrodesis. Ankle arthrodesis is broken down into two general categories: arthrodesis in situ and realignment.11 For cases with ankle arthrodesis in situ, the procedure can be performed adequately with arthroscopy or screw fixation with arthrotomy.12,13 Although minimally invasive, arthroscopy requires increased provider experience and special equipment and has been reported to be more demanding than other arthrodesis techniques.14 Also, Morash et al15 have found that total ankle arthroplasties tend to have higher reoperation rates when compared with that of ankle arthrodesis. On the other hand, several approaches have been utilized for open arthrodesis, including an anterior, posterior, medial, lateral, and a combined medial and lateral approach.

Autologous bone grafting is a procedure that utilizes the patient’s own bony tissue in order to restore native structure and function to a recipient site.16 Two main categories of grafting include vascularized and nonvascularized bone grafts. Although more technically challenging, the vascularized flap demonstrates superior healing compared with the nonvascularized flap, likely due to preserving osteocyte life and function in the donor tissue.17 A study comparing bone grafts used for mandibular reconstruction in cancer patients found higher rates of osseointegration and lower rates of reoperation for patients receiving vascularized grafts.18 These techniques have also proven successful in lower extremity reconstruction. A review by Beris et al19 outlined the use of the fibula bone as a vascularized graft and its usage for reconstruction of the lower limb in cases of malignancy, infection, and trauma. The authors emphasized the superiority of the vascularized graft over the nonvascularized graft in reconstructing large defects (>6 cm).19 Despite being a long-trusted technique, prior surgery, infections, or other insults can create bone defects, which worsen patient outcomes.20 Several types of vascularized flaps have proven successful, including the free fibula,21 the pedicled fibula,22 the medial femoral condyle,23 and the free iliac crest.24 Although some authors have shown their preference to certain grafts, to our knowledge no studies have directly compared these flaps in ankle arthrodesis salvage procedures.25

Our institution utilizes both the pedicled and free fibula flaps for surgical management pertaining to ankle arthrodesis. Our study looks to evaluate the work of an experienced plastic surgeon regarding patient outcomes undergoing reconstruction of the ankle.

METHODS

A retrospective analysis of all patients who underwent surgery between 2014 and 2022 for salvage ankle arthrodesis with vascularized bone grafting by the senior surgeon was conducted. Demographic data, operative details, complications, medical comorbidities, and patient outcomes were retrospectively gathered and analyzed. Six patients who met the inclusion criteria were identified. Each patient underwent computed tomography angiography (CTA) of bilateral lower extremities as part of preoperative workup. Surgical risks were discussed at length, and informed written consent was obtained before all surgical procedures. All procedures were performed under general anesthesia unless otherwise stated in the patient descriptions. Ipsilateral fibula flaps were preferred regardless of preoperative plan for the use of a pedicled or free flap. If the ipsilateral fibula was not available due to history of surgery or injury, the contralateral fibula was utilized.

Free fibula flaps were harvested in the standard surgical fashion. Osteocutaneous rather than pure osseous flaps were routinely used with extra skin to prevent compression of the vascular pedicle. Choice of end-to-end or end-to-side anastomosis was left to the surgeon’s discretion at the time of operation. For pedicled fibula flaps, the initial flap dissection was performed in a similar surgical fashion. The peroneal artery was dissected to its take-off from the tibioperoneal trunk to maximize pedicle length. To maximize bony length of the flap, rather than performing a distal osteotomy, the lateral malleolus was separated from tibia and talus completely, and the synovial joint tissues were completely excised. Of note, no skin paddle was harvested with pedicled flaps as there was no anastomosis to protect. Once the fibula bone flap was completely mobilized, the pedicle flap could be mobilized distally to the level of the midcalcaneus. (See Video [online], which demonstrates the rotational arc of the harvested pedicle fibula flap from two of our patients.) For both free and pedicled fibula flaps, the fibula was shaped and rigidly fixated to the surrounding bone by orthopedic or podiatric surgeons.

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RESULTS

Free Fibula Approach

Case 1

This is a 20-year-old White woman with a medical history of hypothyroidism, current tobacco use, and spinal fusion complicated by Charcot neuroarthropathy of the right ankle, nontraumatic talus fracture, and avascular necrosis of the talus (Table 1). The patient had undergone prior reconstructive ankle surgery in 2015 followed by ankle arthrodesis with nonvascularized fibula bone graft from the left leg in 2019 (Fig. 1). She presented to our clinic with chronic right ankle pain and persistent nonunion of the subtler joint. Despite the lateral nature of her bony defect, due to her previous ankle fusions, a pedicled fibula flap was not possible, and she was recommended a free fibula flap reconstruction. After obtaining informed consent, the patient underwent revision of the right ankle arthrodesis with hardware removal, external fixator placement, and ipsilateral osteocutaneous free fibula flap (Figs. 2, 3). There were no postoperative complications, and the patient was discharged on postoperative day 8. At 2-month follow-up, the flap was found to be healing well.

Table 1. - Overview of Cases
Case Age/Gender Indication Procedure
Case 1 20 F Failed right ankle arthrodesis + fibular osteotomy for charcot neuropathy and nonunion of subtalar joint Free fibula flap for lateral defect
Case 2 39 F Right talus and right medial malleolus fracture nonunion s/p ORIF Free fibula flap for medial defect
Case 3 40 M Right limb salvage s/p chronic refractory osteomyelitis of right distal tibia Free fibula flap for medial defect
Case 4 52 F Nonunion following multiple failed left ankle procedures for osteoarthritis Pedicle fibula flap for lateral defect
Case 5 51 F Avascular necrosis of left distal tibia and posterior calcaneus Pedicle fibula flap for lateral defect
Case 6 40 M Distal tibia osteonecrosis s/p ankle fracture ORIF complicated by septic arthritis Pedicle fibula flap lateral defect

F1
Fig. 1.:
Case 1. Preoperative image of a patient with prior right ankle reconstruction presenting with chronic right lower extremity pain due to avascular necrosis of the talus.
F2
Fig. 2.:
Case 1. Intraoperative image demonstrates right osteocutaneous free flap utilized for ankle arthrodesis.
F3
Fig. 3.:
Case 1. Intraoperative image of right ankle revision and tarsal arthrodesis with right fibula osteocutaneous free flap and hardware removal before external fixator placement.

Case 2

This is a 39-year-old White woman with a medical history of systemic lupus erythematosus, Raynaud’s phenomenon, diabetes mellitus, hypothyroidism, and anemia, who presented with nonunion of the right talus and medial malleolus (Table 1). She had previously undergone open reduction internal fixation (ORIF) of a talus fracture including medial malleolar osteotomy, and subsequently developed medial malleolar nonunion that persisted after nonvascularized bone grafting (Fig. 4). The patient was recommended vascularized free fibula flap due to the medial nature of the defect. Once the risks and benefits were discussed, the patient agreed to proceed with surgical intervention. The patient underwent hardware removal from the right tibia and right talus, excision of medial malleolar fracture fragment, fusion of distal tibiofibular joint, ankle fusion, and application of external multiplane fixation to the ankle (Fig. 5). In addition, the patient had subsequent reconstruction with a fibula osteocutaneous flap and Z-plasty of the right leg. She developed venous congestion on postoperative day 1 and required take-back to the operating room and revision of the venous anastomosis due to a kink. The patient was discharged after 6 days and presented for follow-up appointment 2 weeks later, where the flap was found to be healing well. The patient followed up at 1 year and was able to bear weight on the ankle (Fig. 6).

F4
Fig. 4.:
Case 2. Preoperative image of a patient with prior right ankle fracture status after ORIF with subsequent development of medial malleolar nonunion.
F5
Fig. 5.:
Case 2. Intraoperative image demonstrates preparation of the recipient site by creation of a bone slot for free fibula flap to be placed.
F6
Fig. 6.:
Case 2. One-year follow-up demonstrates that the flap has healed without complications and that the patient is able to successfully bear weight on her right lower extremity.

Case 3

This is a 40-year-old African American man with a history of smoking and a right ankle pilon fracture 4 years prior that was initially managed with ORIF and ankle fusion (Table 1). The patient then developed osteomyelitis, which required washout, removal of four inches of infected tibia, placement of antibiotic spacer, and soft tissue coverage with anterolateral thigh flap that later dehisced due to recurrent infection (Fig. 7). The patient presented at our clinic to discuss possible bone grafting options for limb salvage. He was counseled on options including risks and benefits of each and decided to proceed with vascularized bone grafting. The patient underwent removal of prior implants, debridement of tibia to healthy bone, and placement of external fixator with orthopedic surgery. Two days later, reconstruction of the right distal tibia with free fibula osteocutaneous flap from the contralateral leg was performed (Fig. 8). He tolerated the procedure well with no immediate postoperative complications. Six months later, the patient was found to have nonunion at the distal fibula and talus junction. He later underwent multiple debridements and eventually a salvage operation with a chimeric medial femoral condyle free flap using an interpositional vein graft (Figs. 9, 10). The patient tolerated the procedure well, and there were no intraoperative or postoperative complications. The patient followed up 2 weeks later, and he reported that he was doing well with a clinically viable flap on examination.

F7
Fig. 7.:
Case 3. Preoperative image of a patient who presents with initial right open pilon fracture before surgical intervention with ORIF. He subsequently developed infected hardware and osteomyelitis, which led to hardware removal, bone debridement, and placement of antibiotic spacer.
F8
Fig. 8.:
Case 3. Intraoperative image demonstrates removal of the antibiotic bone spacer and preparation of the recipient site for free fibula flap.
F9
Fig. 9.:
Case 3. Intraoperative image of the chimeric medial femoral condyle free flap.
F10
Fig. 10.:
Case 3. Intraoperative image demonstrates creation of an arteriovenous loop.

Pedicled Fibula Approach

Case 4

This is a 52-year-old Hispanic woman with a medical history of left ankle osteoarthritis for the past 10 years (Table 1). To correct her ankle and foot pain, the patient reported that she had previously undergone seven procedures, including hardware implantation, bone grafting, and neurectomy. She developed ankle nonunion after her prior procedures and had ongoing pain requiring daily narcotic use. After discussing treatment options, including risks and benefits, the patient wished to proceed with pedicled left fibula vascularized bone flap and left ankle arthrodesis in conjunction with podiatry (Fig. 11). (See Video [online], which demonstrates the rotational arc of the harvested pedicle fibula flap from two of our patients.) The fibula was burred and shaped to create tibiotalar fusion. The patient was discharged 13 days after the procedure with no complications. At her 2-week follow-up visit, the patient demonstrated appropriate wound healing, pain control, and neurologic function (Fig. 12).

F11
Fig. 11.:
Case 4. Intraoperative image of the harvested left fibula rotational bone flap that would be utilized for ankle arthrodesis.
F12
Fig. 12.:
Case 4. Postoperative three-dimensional CT scan demonstrates placement of the fibula flap in the bone slot for ankylosis.

Case 5

This is a 51-year-old White woman with a medical history of myelodysplastic syndrome and stem cell transplant requiring extended dexamethasone course who presented to our office with a 9-month history of left ankle swelling and pain (Table 1). CT and CTA of the left ankle revealed evidence of avascular necrosis in the distal tibial and posterior calcaneus. Various treatment options were discussed, and the patient elected to undergo operative repair involving left tibiotalar arthrodesis using pedicled vascularized fibula bone graft, application of an external fixator, and left-leg tissue rearrangement with the assistance of podiatry (Fig. 13). (See Video [online], which demonstrates the rotational arc of the harvested pedicle fibula flap from two of our patients.) There were no intraoperative complications, and her hospital course was uneventful. She was discharged 4 days postoperatively and followed up after 1 month. At her follow-up appointment, the patient had minimal pain and swelling, and a physical examination demonstrated a clinically viable flap (Fig. 14).

F13
Fig. 13.:
Case 5. Intraoperative image of the harvested left fibula rotational bone flap that would be utilized for ankle arthrodesis.
F14
Fig. 14.:
Case 5. Postoperative three-dimensional CT scan demonstrates placement of the fibula flap in the bone slot for ankylosis.

Case 6

This is a 40-year-old White man with a medical history of an open right ankle fracture treated with ORIF. One year following surgery, the patient had complications of septic arthritis and subsequently underwent hardware removal and washout. The patient continued to have pain postoperatively. A follow-up CT 1 year later demonstrated osteonecrosis of the right distal tibial and incongruency of the right ankle mortise. CT angiogram of the right lower extremity demonstrated widely patent two-vessel runoff, distal posterior tibial artery occlusion, and a plantar arch reconstituted by the distal peroneal artery. Given the imaging and clinical findings, treatment options were discussed with the patient who agreed to proceed with staged right ankle arthrodesis with a combined right fibula pedicled flap. To ensure there was no remaining infectious process, the patient was first taken to the operating room with podiatry for debridement of necrotic portions of tibia and talus and implantation of an antibiotic spacer. Two weeks later, the patient underwent removal of the antibiotic spacer, right ankle reconstruction utilizing right pedicled fibula flap, and placement of a multiplane external fixator (Fig. 15). The patient tolerated the procedure well and was admitted to the surgical ICU postoperatively for flap maintenance. The rest of the hospital course was uneventful with no complications, and the patient was discharged on postoperative day 4.

F15
Fig. 15.:
Case 6. Intraoperative image of the harvested left fibula rotational bone flap that would be utilized for ankle arthrodesis.

DISCUSSION

The limited collateral blood supply of distal lower extremity has led to a high incidence of complication after conventional ankle arthrodesis, including nonunion requiring revision, hardware failure requiring removal, and below-the-knee amputation.26 These incidences are more frequent in high-risk cases of ankle arthrodesis such as trauma, osteomyelitis, and tumor due to the additional presence of poor soft tissue quality and bone loss. In these situations, vascular bone grafts have been advocated for as a means of reconstruction or salvage. In comparison to nonvascular autografts, vascular bone grafts provide immediate vascularity for osteocyte preservation and accelerated healing rates.27

Our six cases featured large bone defects, multiple prior attempts at fixation, and previous failed nonvascularized bone grafts that indicated use of a vascular bone graft. Several techniques for vascular bone grafting have been used for ankle arthrodesis such as the free medial femoral condyle flap, free iliac crest flap, pedicled fibula flap, and free fibula flap. Bishop et al28 compared free fibula and iliac crest flaps, finding the blood supply to the skin paddle for iliac crest flaps to be unreliable. Yajima et al22 utilized a free fibula flap in seven cases, finding it superior to other grafts such as the iliac crest given the ease of harvesting the peroneal vessels along the fibula and the nature of the skin being more similar to the recipient site along the ankle. Most recently, Piccolo et al21 demonstrated 0% nonunion and 0% amputation rates in a cohort of 12 patients undergoing free vascularized fibula grafts for salvage ankle arthrodesis. In our patient population, there were no incidences of nonunion or amputation through the utilization of a pedicle or free fibula flap.

At our facility, we prefer the fibula flap based on its structural characteristics, including its long, thin shape, mechanical strength, consistent blood supply with long pedicle, and ease of harvest, making it suitable for reconstructing ankle bone defects.29 Iliac crest flaps and medial femoral condyle flaps have shorter pedicles, more difficult dissection, and significantly less bony volume that can be harvested making them less ideal options. When harvesting fibula flaps, the procedure remains the same for both free and pedicled flaps except that microvascular anastomosis is required for the free flap, which can be more technically challenging.30 Additionally, during harvest of the pedicled flap, distal osteotomy of the fibula is not performed in order to preserve bony length for distal advancement.

Deciding between a pedicled flap and a free fibula flap for ankle arthrodesis remains a source of debate. Based on our experience, we have developed indications for the use of pedicled versus free fibula flap for complex ankle arthrodesis (Fig. 16). Pedicled fibula flap is advantageous as it requires shorter operative time and utilizes the ipsilateral fibula, limiting postoperative morbidity to just one lower extremity. However, if the peroneal vessels in the ipsilateral limb have been compromised, the option of pedicled fibula transfer is eliminated. Similarly, contralateral free fibula flap is necessary in cases when there is damage to the ipsilateral peroneal vessels.22 For these reasons, preoperative CTA is obtained to visualize the extent of vascular damage or vascular anomalies, such as a dominant peroneal artery nourishing the foot.31 The next consideration is whether the defect requiring reconstruction is in the medial or lateral ankle. Medial defects require free fibula flaps as a pedicled flap will not reach. If the defect is lateral but the lateral malleolus has been previously taken down or injured, or if you wish to preserve the lateral malleolus for future procedures, then again, a free fibula flap should be used. If the reconstruction requires vascularized bone for tibiocalcaneal fusion, a pedicled flap likely cannot be mobilized that distally and will require free fibula flap. Lateral defects involving distal tibia or tibiotalar fusion are ideal for pedicled fibula flaps. From the six patients in our study, we have demonstrated that stable bony union can be achieved using vascularized bone grafts in patients with difficult ankle reconstructive problems.

F16
Fig. 16.:
Flowchart demonstrating our indications on when a fibula or pedicled fibula flap should be utilized for ankle arthrodesis.

This study has several strengths and limitations. There was no comparison group within our study; however, the intention of our study was primarily to demonstrate our experience and outcomes from six patients who underwent vascularized bone grafts using free fibula and pedicled fibula flaps to achieve ankle arthrodesis. The procedures were performed by a single surgeon within one major health institution in the United States, which helped provide consistency in surgical technique and postoperative follow-up. However, this may reduce generalizability of our results. The average follow-up time was 2 years; however, one patient was lost to long-term follow-up. The small sample size and the relatively short duration of follow-up are other limitations to this study. Additionally, there is always a consideration of a learning curve and surgeon skills that play a role in the overall success of the operation and postoperative course.

CONCLUSIONS

This study reports six successful cases of free fibula and pedicled fibula flaps to achieve ankle arthrodesis that were not amenable to primary surgical interventions or had failed prior interventions. Using the indications we have developed for free versus pedicled fibula flaps can help guide surgeons in determining the best option for these complex problems. With the right expertise and surgical indication, free and pedicled fibula flaps are options that surgeons should consider for salvage in ankle arthrodesis cases.

PATIENT CONSENT

Patients provided written consent for the use of their images and for surgical treatment.

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