Versatility of Vascularized Fibular Graft in Forearm Bone Loss: From Initial Treatment to Secondary Nonunion Treatment

Purpose: Managing mangled forearms poses a considerable challenge for hand surgeons. The vascularized fibular graft (VFG) is a commonly used technique for addressing this complex issue. This retrospective study aims to assess the outcomes of advanced treatment for complex forearm bone loss necessitating microsurgical treatment with a vascularized fibula flap. Methods: Patients treated with VFG between January 2010 and December 2022 were included in this analysis. Physical and radiographic evaluations were performed for all patients, and they completed patient-reported outcome measures such as the disability of the arm, shoulder, and hand scores, Mayo Wrist scores, and visual analog scale pain (VAS-Pain) scores for both the recipient and donor sites. Patients treated with one-bone forearm (OBF) reconstruction were also assessed using the outcome score of the OBF according to Peterson. Results: A total of 26 cases were treated with VFG for forearm bone defect reconstruction (13 for primary treatment and 13 for secondary treatment of nonunion). Vascularized fibular graft was employed to create a OBF in four cases, a double barrel in three cases, and an osteocutaneous composite flap in nine cases. The average bone defect measured 81 ± 3.4 mm (range: 50–150 mm). Bone healing was achieved at an average of 8.3 ± 5.5 months (range: 4–15 months), with nonunion at one docking point observed in eight cases necessitating revision. At the follow-up end point, patients reported an average disability of the arm, shoulder, and hand score of 13.5%, a Mayo Wrist score of 80%, and a VAS-Pain score of 3/10. The VAS-Pain outcome at the donor site was rated at 4/10. One-bone forearm's mean score was 7/10. Conclusions: Vascularized fibular graft stands as a viable option for mangled forearm reconstruction. Whether through the double barrel technique or as an osteocutaneous composite graft, VFG allows for the simultaneous reconstruction of both forearm bones and associated soft tissue injuries. Type of study/level of evidence: Therapeutic IV.