Table 1.

Summary of VFET Technique Considerations to Guide Surgical Planning

	Summary of Technique Considerations
Harvest
Vascular pedicle
ATA	Reports of limb growth with average range of 0.44–1.72 cm/y Risk of postoperative peroneal palsy due to close proximity of deep peroneal nerve during dissection
Peroneal artery	Reports of average limb growth of 0.5 cm/y Associated with premature growth plate closure
ILGA	Limited used reported in distal radius/ulna reconstruction No reports of peroneal palsy
Dual pedicle	Potential benefit of maintaining adequate perfusion to both fibular head and diaphysis Increased complexity due to multiple anastomoses and increased donor site morbidity due to one-vessel runoff
Periosteum	May promote bony union at recipient site
Recipient site inset
Fixation method
Plates + screws	Most common fixation method Offers more stability, and may be less prone to postoperative fracture
Screws	Less stability, prone to postoperative fracture
External fixation	Most commonly used for hip reconstruction
Utilization of biceps femoris tendon	Used for ligamentous reconstruction at the recipient site
Management of donor site
Knee stability	Suture remaining slip of biceps femoris tendon and lateral collateral ligament to lateral tibia
Ankle stability	Leave at least 6 cm fibula distally Consider tibiofibular syndesmotic screw
Peroneal nerve	Neurorrhaphy if divided during dissection
Modifications
Combined used with allograft	Offers additional structural support while allowing for epiphyseal growth Offers more space for screw purchase and reattachment of surrounding structures
Pedicled flap without microsurgery	Ipsilateral pedicled flap based on retrograde anterior tibial artery for reconstruction of lateral malleolus or calcaneus Avoids complexity of microvascular anastomosis
Double barrel with vascularized fibula flap	Peroneal-based VFET connected in series with peroneal-based diaphyseal free fibula flap for proximal femur reconstruction