Free Vascularised Fibula Transfer

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A non-vascularised cortical graft is dead scaffold: it incorporates by creeping substitution, transiently weakens at 6 to 18 months, and fails unpredictably in defects greater than 6 cm, infected beds and irradiated tissue. The vascularised fibula is living bone.

• Union biology — heals to host bone like a two-level fracture; osteocytes survive, no creeping substitution phase of weakness.
• Hostile beds — carries its own blood supply into irradiated, scarred or previously infected fields; delivers antibiotics and immune cells.
• Adaptation — hypertrophies under cyclical load over 1 to 2 years, eventually approaching host-bone diameter in the tibia and forearm.
• Growth — proximal fibular epiphyseal transfer (on the anterior tibial artery) can reconstruct a growing physis (e.g. proximal humerus in children).
• Geometry — straight tubular cortical bone up to about 26 cm; ideal cross-section for radius, ulna, humerus; double-barrelled for tibia/femur.

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• History and examination — donor leg trauma/surgery, claudication, smoking; palpate dorsalis pedis and posterior tibial pulses; handheld Doppler all three vessels.
• Imaging the donor leg — selective CTA/MRA as above; mandatory in congenital limb anomalies and abnormal pulses.
• Imaging the recipient site — full-length radiographs, CT for defect geometry, MRI for tumour margins; measure defect and add 2 to 3 cm for intramedullary docking or step-cuts.
• Recipient vessels — plan artery (end-to-side to a major axial vessel or end-to-end to a branch) and two venous options; in irradiated necks/limbs consider preoperative angiography of the recipient bed.
• Team and logistics — two-team approach (resection/recipient preparation simultaneous with harvest) shortens ischaemia time; microscope, microinstruments, couplers, implantable Doppler available.
• Consent — flap failure (roughly 5 percent in experienced hands), re-exploration, stress fracture, donor morbidity (great-toe clawing, ankle discomfort, weakness, sensory change), prolonged protected weight-bearing.

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Stress fracture management — most unite with immobilisation/protected loading because the bone is vascularised; persistent instability warrants supplementary fixation and bone graft. Prevention: double-barrel or Capanna constructs for large-diameter bones, spanning fixation retained until hypertrophy, graduated loading.

Related pages. The alternatives this operation is chosen against: Bone Transport Techniques and Masquelet Induced Membrane Technique both avoid a microvascular anastomosis, and Allograft-Prosthetic Composite Reconstruction is the alternative when the defect involves a joint. Nonunion Management frames the whole decision.

• Global epidemiology of use — FVFG is practised worldwide wherever microsurgical expertise exists; the dominant indications differ by region: oncologic intercalary reconstruction and congenital pseudarthrosis in high-income centres; post-traumatic and post-infective defects dominate in many lower-resource settings, where bone transport is often preferred because it needs no microsurgical infrastructure.
• Society guidance — no society issues an FVFG-specific guideline. Relevant framework documents: BOA/BAPRAS BOAST on open fractures (early combined orthoplastic decision-making for segmental bone loss, reconstruction within a definitive soft-tissue plan); AO principles for segmental defect management (defect classification, staged strategies including Masquelet, transport and vascularised graft); musculoskeletal tumour society consensus favours biological reconstruction (allograft, FVFG, Capanna) for intercalary defects in the young where expertise allows.
• Registries — no implant-style registry captures FVFG; evidence rests on institutional series and systematic reviews, which consistently report union above 80 to 90 percent after all secondary procedures, with reoperation common (junctional grafting, stress-fracture management).
• Resource-setting variation — where microsurgery is unavailable: bone transport, Masquelet, ipsilateral pedicled fibula transfer for tibial defects (Huntington procedure — no microsurgery needed), or non-vascularised fibula strut for smaller defects. Selective rather than routine angiography is now the majority international practice for donor-limb assessment.

• Routine versus selective donor angiography — routine imaging detects rare variants but adds cost and (for catheter studies) risk; most units now image selectively on clinical/Doppler criteria, with a lower threshold in congenital deformity.
• FVFG for femoral head osteonecrosis — Urbaniak's results are difficult to reproduce; the operation is long, donor morbidity real, and modern arthroplasty in the young performs well. Many centres have abandoned it; others reserve it for pre-collapse disease in patients under 40.
• FVFG versus Ilizarov transport for tibial defects — comparable union in experienced hands; transport avoids microsurgery and donor morbidity but demands months in frame; choice is driven by defect length, soft tissues, patient tolerance and local expertise.
• Capanna versus fibula alone versus allograft alone — the hybrid adds operative complexity; whether it is required for defects under about 10 cm in the upper limb (where fibula alone performs well) is debated.
• Osteocutaneous paddle versus buried flap with implantable Doppler — paddle gives the most reliable monitoring but adds donor scarring and occasionally skin-graft morbidity.