Distal Tibial Fractures: A Poorly Recognized Complication With the Fibula Free Flap

The osteocutaneous fibula free fibula has been used in mandibular reconstruction since described by Hidalgo in 1989. The flap properties are ideal for complex jaw reconstructions as a one stage procedure, with low reported donor and flap morbidity.

Here, we discuss a case of ipsilateral distal tibial stress fracture two months following vascularised fibula free flap for mandibular reconstruction. This was a previously unrecognised complication to our surgical teams. 

An extensive literature review was performed using the PUBMED database to ascertain whether this complication had been previously reported, and in what manner it had been treated. 

Despite being an unrecognised complication to our different surgical teams, a review of the literature has produced 13 previous documented cases; only two were reported in plastic/reconstructive literature, with the most recent of these reports claiming to be the first.

All but one of these studies decided to treat this fracture non-operatively, with a minimal number reporting their patient follow up.  In the two cases that had supporting radiographs, severe valgus deformities were present.

Each case presented with ipsilateral leg pain. Leg pain has been cited as an early donor site morbidity in as many as 30% of fibula free flaps. It is known that the fibula absorbs at least 15% of the leg load on weight bearing. Studies have shown severe valgus deformities in up to 25% of patients with fibulectomies.

We treated our patient operatively, first correcting his worsening valgus deformity with an external fixator.  By one month post-operatively his fracture had healed in good position, and decision was made to reinforce his healed fracture with a long distal tibial plate.  At eight month follow-up he remained asymptomatic, fully weight bearing, with clinical and radiographic evidence of a healed tibial diaphyseal fracture. 

We believe that this complication is highly under-reported, not expected and not mentioned in the consenting process for surgery. We believe that highlighting the literature, this case and our management will increase awareness of this complication, as well as what we believe is the appropriate technique for treatment of the iatrogenic fracture.  We hope this increases reporting and proper management of this debilitating complication.

Ling XF, Peng X.  What is the price to pay for a free fibula flap? A systematic review of donor-site morbidity following free fibula flap surgery.  Plast Reconstr Surg. 2012 ;129 :657-74

Lee EH, Goh JC, Helm R, Pho RW. Donor site morbidity following resection of the fibula. J Bone Joint Surg Br. 1990 ;72 :129-31.