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Purpose: The fibula flap has been established for orofacial reconstruction following ablative surgery. Donor-site morbidity of the lower leg may be explained by the harvest technique and particularly by detachment of the M. extensor halluces longus (EHL) and M. extensor digitorum longus (EDL)., Material and Methods: On cadaveric lower leg specimens, the tendons of the EHL and EDL were dissected at the proximal phalanges and loaded with corresponding weights. The average displacement of the muscle was evaluated during the harvesting procedure., Results: Cumulative detachment of the interosseous membrane caused considerable displacement of the EHL but less impairment of the EDL. Segmental and cumulative osteotomy of the fibula implicated significant displacement of both EHL and EDL., Conclusion: A recommendation can be given for cautious selection of osteotomy site of the fibula and for limited sacrifice of the fibula and adjacent attachments of the extensors to keep local-site morbidity at a minimum., (Copyright © 2018. Published by Elsevier Ltd.)

Objectives: Bony reconstruction of jaw defects using the free fibular flap and dental rehabilitation mostly requires insertion of dental implants within the transferred fibula bone. The aim of this paper was to discuss results of the implant stability with data on the possible benefit for the patient's quality of life after such treatment., Material and Methods: For clinical outcome of implants, we evaluated 26 patients with a total number of 94 dental implants after a follow-up period of 12 to 132 months. A group of 38 patients who underwent mandibular reconstruction with free fibular flap could be included in the life-quality study. Evaluation included 23 patients with and 15 patients without implant-borne restoration. The quality of life was assessed using the standard QLQ C-30 questionnaire and the H&N35 module of the European Organisation for Research and Treatment of Cancer (EORTC)., Results: Of implants, 94.7 % were stable at the time of investigation and could be used for prosthesis. Patients with dental implants reported improvement of life quality along with better scores in most function and symptom scales; however, only values for global health status (QL2), absence of dyspnea (DY) and absence of feeding tube (HNFE) were significantly better than in the control group., Conclusion: Dental implant insertion in fibula grafts along with implant-borne restoration is a proven concept and might lead to improved quality of life following ablative surgery of the jaw. The effect on the quality of life is not as predictable as on the implant stability., Clinical Relevance: Patients with bony defects of the jaw require bony reconstruction. This allows further masticatory rehabilitation using dental implants and might lead to improved quality of life.

The use of the vascularized fibula graft has already been established for reconstruction of the mandible following ablative surgery. In order to reconstruct the vertical height of the alveolar process and improve implant position as well as angulation, some therapeutic options are available, including primary use of the fibula as a double-barrel graft and vertical distraction as well as later augmentation with avascular bone grafts. We analyzed the anatomic and morphologic features in 40 fibula bones of 20 cadavers and provided the mean cortical thickness of different transplant sites. Furthermore, we investigated the primary implant stability of dental implants inserted monocortically in harvested fibula segments using established biomechanical methods as well as Periotest(®). The minimal bone height of the clinically relevant segments of the fibula transplant measured 9.06 ± 0.45 mm, which was assessed in the most distal part. In contrast, a maximal total bone height of 15.46 ± 0.78 was observed in the middle segment of the fibula bone. We assessed sufficient primary stability in all inserted implants as well as a reliable relative micro-movement of the implants in the fibula bone. Fibula graft as a single-barrel graft alone may provide through monocortical implant insertion a further refinement of the method to fit complex requirements and shorten prolonged therapeutic procedures. Monocortical implant insertion in the fibula graft would simplify oral rehabilitation after ablative surgery of the jaw and reduce costs as well as therapy period.

Our aim was to evaluate the long-term morbidity at the donor site after harvest of free fibular flaps. From a total of 165 patients, we were able to examine (not randomly) 62 donor regions in 57 patients (33 men and 24 women) 2-167 months (mean 45 months) after fibular transfer. Patients' individual risk factors and any disturbances of healing, and dysfunction of the toes, were recorded. The Kitaoka ankle-hindfoot score was used for evaluation of functional impairment. Thirteen donor regions displayed prolonged wound healing, eight of which needed revision of the wounds. Eight (14%) had abnormalities of gait. The median Kitaoka ankle-hindfoot score was 93 (range: 14-100). In 17 patients (27%) after a follow-up period of 4 months, hammer and claw toes and deficits in dorsal extension of the hallux were assessed. Thirty patients (48%) had sensory deficits of the calf and toes. Neither the risk factors recorded nor the factors that indicated disturbance of wound healing or deformities of the toe were significantly associated with the development of functional impairment. In more than three-quarters of the cases healing was uneventful, but in a small number the morbidity at the donor site was severe, forcing the patient to use walking aids. We were not able to identify any risk factors for the development of long-term malfunction., (Copyright 2009. Published by Elsevier Ltd.)

Objectives: Conventional prosthesis is generally inapplicable following reconstruction with free fibula flaps (FFF) due to impaired bone and soft tissue conditions, and rehabilitation via enossal implants in FFF is relatively novel. This retrospective study aimed to document the surgical aspects of this option and to describe related supplementary procedures that can help optimise the definitive outcome. Material and methods: One hundred nineteen implants were inserted within FFFs in 37 patients (mean age 51.8 ± 10.6 years), who underwent ablative surgery of the maxilla (3) and mandible (34). In a cross-sectional study design with a follow-up period of 3-172 months, we analysed types and configurations of graft design, patterns of implant insertion and methods for prosthetic rehabilitation as well as primary stability and survival rate. Results: Most patients underwent jaw reconstruction using a mono-barrel FFF (14 osseous and 18 osteocutaneous/osteomyocutaneous); three patients received double-barrel reconstruction of the mandible. Three patients with maxillary defects were reconstructed using mono-barrel grafts (one osteocutaneous and two prefabricated grafts). Pre-prosthetic procedures were required in 23 patients to optimise conditions in the peri-implant soft tissue. Iliac bone onlay graft was used in six patients to achieve appropriate vertical height in mono-barrel grafts. A total of 10 implants in eight patients (five irradiated) could not be loaded. All other implants showed stable osseous integration and satisfactory peri-implant soft tissue conditions. Conclusion: Masticatory rehabilitation can be achieved using enossal implants inserted in FFF. Special requirements can be met through selection of an appropriate graft configuration and optimal implant positioning. Supplementary pre-prosthetic procedures are usually required as they improve long-term survival. Clinical relevance: This overview provides a reliable and comprehensive algorithm for standard implant-borne rehabilitation of patients with fibula grafts. [ABSTRACT FROM AUTHOR]