Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 16:
Fibular Free Flaps
  A 30-year-old man suffered a shotgun blast to the left arm, destroying a large segment of the humerus and the radial nerve.

FIG. 16-01. Bone defect is prepared.

FIG. 16-02. X ray shows bony defect in humerus.

FIG. 16-03. A curvilinear incision is used to isolate the fibula and harvest nerve grafts. This Henry exposure has now been replaced by a direct approach over the fibula shaft.

FIG. 16-04. A 15 cm segment of fibula was harvested on the peroneal artery. Bone segment isolated in situ.

FIG. 16-05. Bone ready for removal.

FIG. 16-06. After transection of the vascular pedicle, the fibula was taken to a side table, where 10 cm saphenous vein grafts were anastomosed to lengthen the pedicle.

FIG. 16-07. The donor wound was closed primarily over drains.

FIG. 16-08. The fibula has been slotted into the debrided ends of the humerus and impacted with compression of the external fixator. Anastomosis of the vein-grafted fibular pedicle was performed end-to-end to the venae comitantes of the brachial artery and end-to-side to the brachial artery itself. Nerve grafts to the radial nerve were performed.


FIG. 16-09. Postoperative x ray shows anatomic reduction.

FIG. 16-10. Six-month follow-up. The bulky Wagner external fixator has been replaced with a lighter frame. The humerus has solid union without pain. The radial nerve lesion has little improvement at this early stage.

FIG. 16-11. Late x ray shows bony union.

FIG. 16-12. Full range of motion of the left shoulder. Radial nerve function was augmented with tendon transfers.


A shotgun injury to the forearm of a 9-year-old boy was treated with an abdominal flap for soft-tissue coverage.

FIG. 16-13. Sites of injury and of abdominal flap.

FIG. 16-14. The defect in the radius is shown on x ray. Because of the young age of the patient, an attempt to restore pronation and supination was made.

FIG. 16-15. Appearance of the donor leg with the fibula, muscle cuff, and peroneal vessels evident.

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