Long-term results of 149 free fibula flap reconstructions in extensive limb defects: Experiences from nine European hospitals

Background The free vascularised fibula flap (FFF) is the preferred method for managing segmental long bone defects after oncological resection or trauma. This study is one of the most extensive retrospective multicenter analysis of FFF for extremity reconstruction in Europe, aiming to inform surgical practices and update current indications for this procedure. Methods Data from nine European hospitals were analysed retrospectively. Patients who received FFF for traumatic injury (acute or late) or oncological resection were included. Exclusions were intra-articular, trunk, and mandibular reconstructions. Surgical data and clinical outcomes, including bone union time and complication rates, were collected. Results The study included 149 patients. The oncological group (O-F) had fewer surgical interventions prior to the FFF (1.03, 95% CI 0.59–1.47, η2=0.611) compared to the A-F (3.53, 95% CI 2.42–4.64, **p) and L-F groups (5.15, 95% CI 3.93–6.37, ****p). Bone-healing time was similar across groups, averaging 8.3 months. Skin paddle complications were strongly associated with subsequent bone-healing complications (p < 0.001, Chi-square test; OR 5.79, 95% CI 5.79–14.9). Two FFF losses (1.34%) were reported. After revision, 91% of patients achieved radiological union. Conclusions Free fibula flap reconstruction is a definitive solution for long bone defects that come with a relatively high complication rate, especially in patients who have undergone multiple surgical procedures before undergoing an FFF after a traumatic injury.