Double-Barreled Vascularized Fibula Free Flap in Pediatric Tibial Bone Defect Reconstruction: A 20-Year Monocentric Experience

Introduction

Reconstructing large bone defects for lower limb salvage in the pediatric population remains challenging due to complex oncological or septic issues, limited surgical options, and lengthy procedures prone to complications. The vascularized double-barreled fibula free flap is pivotal for reconstructing large bones. In this article, we report our experience with this technique in the surgical management of pediatric tibial bone defects.

Materials and Methods

We conducted a retrospective analysis of patients under 18 years of age who underwent tibial reconstruction using a double-barreled fibula free flap at our center between 2004 and 2023. Collected data included demographic information, operative details, time to bone consolidation and full weight-bearing, and functional outcomes using the Musculoskeletal Tumor Society (MSTS) score.

Results

Eight patients (5 females, 3 males) with a mean age of 12.5 years (range 5–17) were included. The average tibial defect length was 11.2 cm (range 7–14 cm), affecting the proximal tibia in 4 cases (50%), the middle third in 3 cases (37.5%), and the distal third in 1 case (12.5%). Reconstruction followed oncologic resection in 7 patients (87.5%) and addressed congenital pseudarthrosis in 1 patient (12.5%).

One patient died of sarcoma. Six patients (75%) achieved full weight-bearing within a median of 7 months (range 6–16) and a bone consolidation at 9 months in median (range 6–18). One reconstruction (12.5%) failed due to septic pseudarthrosis leading to a below-knee amputation. The mean MSTS score was 81.65 (range 63.3–100).

Conclusion

This study is the first to focus on pediatric tibial reconstructions using the double-barreled vascularized fibula free flap. It highlights the technique's reliability for reconstructing tibial defects, particularly in intermediate-sized cases (7–14 cm). This single-stage procedure minimizes stress fracture risk, enables earlier weight-bearing, and is an alternative to the Capanna technique without requiring an allograft.