Fibula Grafting for Oromandibular Reconstruction and its Effect on Patient Quality of Life - A Scoping Review

Abstract

Fibula osteoseptocutaneous flap has been widely used for oncologic bony reconstruction of both the mandible and maxilla. Early and late morbidities of the donor side such as leg weakness, ankle instability, limited ankle mobility, tibial stress fractures or incision area pain are well documented; however, there is a lack of information about the effects of fibula grafting on patient quality of life. To address this issue, a scoping literature search in the PubMed electronic database was performed to identify all relevant studies and reviews in the period between 2010 and 2022. The potential discomforts after free fibula grafting and their impact on different domains of everyday living were identified and evaluated. The present literature review indicates that donor site morbidity can negatively impact patients’ quality of life, albeit generally classified as minor. However, the functional and aesthetic benefits of oromandibular reconstruction clearly outweigh the associated sequelae. Nevertheless, the authors of this review highlight the importance of a comprehensive clinical evaluation of the donor site besides the recipient site during follow-up examinations. This would help to subjectively evaluate the functional and esthetical limitations of a patient’s site and promptly detect morbidities that could lead to long-term complications.

Oral cavity carcinomas are the sixth most common cancer worldwide and account for approximately 4% of all cancers. More than 90% of oral cavity cancers are squamous cell carcinomas, followed by adenoid cystic carcinomas (1). Despite the increasing incidence of these malignancies in younger adults (2-4), oral cavity carcinomas usually occur after the 5^th decade of life (5,6). The primary treatment method for oral cavity carcinomas depends on the stage of the disease, which is why physical and imaging examinations play a decisive role in the exact staging. The primary goal of surgical resection is the complete removal of tumor tissue to minimize the risk of local and regional recurrence, but this often results in increased aesthetic and functional impairment (1), especially if a segmental mandibulectomy must be considered to achieve an adequate resection margin (5). The restoration of the mandibular contour, as well as the reconstruction of the occlusion and the correct position of the mandibular condyles in the glenoid fossae, are crucial to provide affected patients with adequate masticatory function and an aesthetically satisfactory result (7). Two main methods are used for this purpose: 1) alloplastic mandibular reconstruction with mandibular reconstruction plates and secondary bony reconstruction of the defect zone after a recurrence-free interval and 2) primary bony mandibular reconstruction after resection in combination with reconstruction plates or miniplates (7). In this case, the bony reconstruction is usually carried out with microvascular free bone flaps, such as the free fibula flap, the iliac crest flap or the scapula flap (8) and also allows the simultaneous reconstruction of soft tissues, through the grafting of a bone segment with muscles and a skin pad (9). The first free fibula flap transfer was performed in 1974 by Ueba et al. but was not reported until 1983, which is why the article by Taylor et al. in 1975 is often cited as the first describer (10,11). After that, in 1989, Hildago performed the free fibula flap transfer for mandibular reconstruction (9). Due to their length, low morbidity and ability to preserve the bone mass over time, fibular grafts are preferred and allow for simultaneous tumor removal during harvesting of the graft by a two-team approach (9,12). A potential disadvantage is the limited bone height of the fibula, compared to the original thickness of the mandible (9). In addition, when the fibula is harvested for mandibular replacement, there is a risk of donor site morbidity, such as leg weakness, ankle instability, limited ankle mobility, tibial stress fractures or pain in the incision (12). It can therefore be seen that when evaluating fibula grafts, in addition to aesthetic and functional aspects of the reconstruction, the complications and limitations associated with the harvesting must also be considered to determine the extent to which mandibular reconstruction using fibula grafts affects patients’ quality of life.

Generally, ablative surgery for the treatment of oral and maxillofacial carcinomas or other bone pathologies, such as antiresorptive-associated osteonecrosis or osteoradionecrosis, requires mandibular resection resulting to essential functional and aesthetic impairment, thereby, with possible negative influence on health-related quality of life.

Free vascularized bone flaps have been demonstrated to be highly successful in reconstructing critical size mandibular bone defects, with the added effect of an additional skin paddle for covering soft tissue defects. Fibula, iliac crest, and scapula free flaps are more widely accepted as a standard of reconstructing mandibular defects, each one with certain advantages and limitations considering the defect size, donor site morbidity, flap survival, quality of life, and long-term aesthetic and functional outcomes. Most previous studies have investigated the flap success, survival rate and long-term functional and aesthetic outcome at the recipient site. Moreover, the later oral rehabilitation with dental implants, speech intelligibility, and mastication recovery have also been extensively reported. Nevertheless, evaluation of short- and long-term outcomes at the donor site, which can significantly affect the patient’s quality of life, has not been sufficiently investigated.

Therefore, the following literature review was conducted to evaluate the effect of fibula grafting for oral reconstruction on different domains of patients’ quality of life and identify potential advantages and disadvantages of surgical intervention.

Materials and Methods

Protocol. This review article was prepared according to the principle of improving transparency in reporting synthesis of qualitative research (ENTREQ) to highlight and discuss the current evidence on the impact of free fibula flap raising in patients with oral carcinoma on everyday living. The search strategy followed the identification and screening guidelines of the preferred Reporting Items for systematic Reviews and Meta-Analyses (PRISMA).

PICO question. The review was designed based on the following PICO criteria (population, intervention, comparison, outcome): (P) patients with a mandibular or maxillary defect following oncologic resection, (I) vascularized free fibula flap, (C) intervention without free fibula flap, (O) assessment of postoperative donor site functional and esthetical outcomes and their impact on patient’s quality life.

Search strategy. To address the study question of the extent to which free fibula flap harvesting affects patients’ quality of life a scoping literature search was performed in the PubMed electronic database to identify all relevant studies and reviews in the period 2010-2022.

The search strategy combined database thesaurus terms (MeSH and EMTREE) and free terms in abstract and title. The following search concepts were converted into Mesh terms and applied in this database to be fully screened: „head and neck cancer“, „quality of life“, „squamous cell carcinoma“, „daily living“, „daily activity“, „everyday life“, “depression“, „social participation“, „fibula flap“, „free flap raising“, „pain“, and „surgery“. These terms were used in various Boolean combinations. We retrieved all eligible studies and evaluated the reference lists of identified studies and reviews.

Data extraction and selection of studies. After filtrating databases, excluding duplicates and non-full text articles, two reviewers examined full-text articles and collected data in duplicate following the inclusion and exclusion criteria (Figure 1). Literature reviews and case reports were also included in this selection and were surveyed as potential sources to find relevant missing articles in the search. Articles were accessed through the University of Ulm library system.

Figure 1. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flowchart of search strategy.

The process of study selection was performed in two phases. First, article titles and abstracts were screened for relevance by two authors (ME and AS). Reading the full text was performed to evaluate compliance with the inclusion criteria. Articles were included if aspects with relevant impact on patient’s quality life regarding donor site morbidity after oncological resection and reconstruction with free fibula flap were considered. Articles were excluded if they were not relevant to patient’s quality of life, did not address oncological resection, or were not published in English. A total of 11 studies were identified as relevant to our research aim (Figure 1).

All articles with questionable relevance were reviewed independently by both authors to reach a consensus. A total of 58 articles were independently reviewed by both authors. At the end of the second phase, the two reviewers provided a final judgment independently (include, exclude, or uncertain). In cases of disagreement, a third author (FW) was involved in a joint meeting for the final decision.

Study characteristics. The following parameters were extracted from each included study: name of the first author, year of publication, study design, number of participants, sex distribution, mean age, and age range, mean clinical follow-up period, questionnaire type, defect area for reconstruction, short- and long-term functional and esthetical donor site morbidity. Additional parameters included deglutition, diet, mastication, speech, aesthetics, post-operative complications, oral rehabilitation, and chemo-radiotherapy. In the case of missing parameters, the corresponding authors of the publication were contacted by email to request raw data.

Results

Literature review (Table I). Sallent et al. first mention known complications of the donor site, which include possible leg weakness, instability of the ankle joint, limited mobility of the ankle joint, tibial stress fractures, as well as pain occurring around the incision site. The male patients presented in the case report, aged 27 and 36, underwent reconstruction of the mandible using a free fibula flap after a previous hemimandibulectomy. The 27-year-old patient reported pain and deformity of the right hallux, which had limited his activities of daily life for seven years and occurred several months after mandibular reconstruction, while the mobility of the foot and ankle joints in the other leg, whose fibula was not used for mandibular reconstruction, was normal. The second patient also reported pain and deformity of the right hallux six months after mandibular reconstruction. Both patients were diagnosed with a Checkrein deformity, which can also be considered a complication of the removal of a free fibula flap (12).

Table I. Overview of included studies and case reports.

In a case-control study, Hadouiri et al. compared the gait of eleven patients after removal of a vascularized free fibula flap with eleven healthy subjects who were matched to the patient group in age, body weight, height, body mass index, and sex, in order to examine whether the removal of a free fibula flap influences prolonged walking. For this purpose, he performed a six-minute walking test with subjects from both groups, which showed that the distance achieved in six minutes was significantly lower (p<0.001) in the group with graft removal than in the control group. Accordingly, the walking speed in patients with graft removal was 45% slower than that in the healthy control group. In addition, it was evident that the deviation of the midline of the foot compared to the progression line (walking direction) was significantly greater on the operated side in the operated group than in the control group (p-value range=0.01-0.004). However, Hadouiri et al. point out that the patient collective studied had a small number of subjects and that there were also limitations in the comparison with healthy subjects who were cancer-free, did not smoke, nor abused alcohol. Nevertheless, Hadouiri et al. concluded that patients showed an altered ability to walk for longer periods of time after graft removal, which could be partly related to the removal (13).

Bartaire et al. examined the satisfaction of 23 patients who underwent mandibular resection and reconstruction using free microanastomosed fibula flaps due to T3 or T4 oral cavity carcinoma. They assessed satisfaction regarding the morphology at both the donor and recipient sites, as well as functional impairment at the donor site. In addition to the patient survey, two otolaryngologists (cohort experts) also assessed the patients. The patients’ assessment of the morphological evaluation of the recipient site resulted in a satisfaction rate of 74%, whereas the experts’ rate was lower at 47%. The morphological assessment of the donor site had a satisfaction rate of 70% for the patients and 57% for the experts. Regarding functional impairment at the donor site, five patients (22.5%) reported pain requiring analgesics. Walking was impaired in six patients (26%) and running was impaired in eight patients (35%), although only moderately in daily life. Extensor strength in the operated limbs was reduced in six of 22 cases. Range of motion in the ankle of the operated limb differed from that of the non-operated limb in 10 of 22 patients. Remarkably, two-point discrimination, tactile sensitivity and pain sensitivity were well preserved in the operated limb, which could explain why the patients were less disturbed by walking difficulties than initially expected. The results of this study showed that the effects of graft removal morphologically, biomechanically, and functionally could be considered minor (14).

The literature review by Mehra et al. suggests that the short- to medium-term success of dental implants placed in fibula grafts ranges from 96% to 100% and survival rates range from 92 to93%. The author team also points to the exceptional primary stability of implants in free fibula flaps, which may even allow immediate loading of the implant (9), attributed to the quality of the bone with a thick cortex and the average volume of the fibula (15).

Wolff et al. analyzed 24 patient cases after mandibular resection and reconstruction using osseocutaneous fibula grafting and confirmed that a total of 32 endosseous dental implants could be placed secondarily without complications. Wolff et al. also described consistently good primary stability due to the high cortical bone content of fibula grafts. Implant losses were not observed. In the follow-up examinations of four patients whose surgery was at least eleven months ago, a remarkable return of sensitivity of the skin flaps could also be observed, despite the absence of neurocutaneous anastomosis. At the donor sites, 16 of the split skin transplants healed completely without complications, while six patients suffered mild partial necrosis. In two patients, the split skin grafting failed completely, so that a new grafting had to be performed. Eight patients had sensory disturbances in the lateral malleolus. Muscle strength showed restrictions in plantar flexion in the ankle or big toe in 15 patients three to four weeks after surgery. A further eight patients showed limitations in dorsiflexion, although none of the patients were limited in their ability to walk at discharge. Even climbing stairs was not affected. At three to four months after surgery, none of the patients complained of subjective impairment of motor function, thus donor site morbidity was generally considered to be low (16).

Maben et al. prospectively studied 20 patients whose mandibular defect was reconstructed with a free fibula flap to document donor site morbidity at 15 days, one month, three months, and six months postoperatively. Outcome variables were determined using a scoring system for pain, walking ability, activities of daily living, gait change and cosmetic appearance using a validated 10-point self-assessment scale. All patients underwent postoperative physiotherapy aimed at restoring full limb mobility and gentle strengthening exercises. A total of 45% of patients reported being free of pain at six months postoperatively. In addition, 50% of patients had no limitations in walking six months postoperatively, while only 55% of participants reported mild limitations in performing daily activities six months postoperatively. Two patients experienced dehiscence at the donor site and two patients had skin graft failure. Eighteen patients were satisfied with the appearance of the scar. Most patients were able to perform their daily routine, e.g., walking 1,000 m, climbing stairs up to three floors and standing for hours, i.e., approximately 2 hours. One patient complained of occasional numbness. Another patient complained of mild pain and weakness after walking more than a mile. Comparison of all donor site variables at specific intervals indicated little donor site morbidity, which was highly statistically significant. Only five percent of patients had moderate limitations and were unable to participate in recreational activities (17).

Di Giuli et al. evaluated clinical morbidity at the donor site and changes in kinematic gait parameters after harvesting a vascularized free fibula flap for reconstruction. Each of the 14 patients underwent a preoperative and 6-month postoperative assessment. Subjective assessment of the donor site was performed by a non-structured clinical interview on pain, paranesthesia, walking ability and activity limitations. A clinical assessment at the donor site assessed muscular deficits, sensory disturbances, and wound healing. Temporal and spatial kinematic parameters were measured by gait analysis while walking at a comfortable speed. The non-structured clinical questions revealed that ten patients (71%) reported no permanent changes in the operated leg. The clinical examination revealed muscular impairment in three patients (21%). Quantitative analysis between the pre- and post-surgery surveys revealed few changes in temporal and spatial parameters, indicating a slightly impaired gait pattern. However, subjective perception of leg impairment was generally low. Ten patients (71%) reported no residual changes in the donor leg six months after surgery. Three patients reported significant discomfort, which was confirmed in one patient in the clinical examinations. In particular, the patient showed a 4-5% decrease in stance duration and a 7.7% increase in double support phase. Three patients (21%) reported pain mainly described as discomfort during activities, while only one patient reported pain at rest. In addition, a claw toe deformity occurred in one patient. During the clinical examination, it was found that patients were usually unaware of the slight change in gait and that they were generally satisfied with their condition. Therefore, Di Giuli et al. concludes that the vascularized free fibula flap is a safe, effective surgical procedure that results in little and unnoticed disruption at the donor site (11).

Rendenbach et al. conducted a prospective clinical cohort study with 27 patients who were examined preoperatively and on average eight months postoperatively, after resection of the mandible and reconstruction using free fibula flaps, regarding balance ability, range of motion, sensory limitations, and maximum peak power per body mass. A significant loss of maximum peak power per body mass was found between pre- and postoperative examination (p<0.001). Maximum peak power is the crucial parameter for performing everyday activities, such as standing up from a seated position or climbing stairs. The more detailed examination of the jump mechanography revealed a significant reduction in jump height, speed, and the Esslinger Fitness Index (EFI). In summary, the postoperative examination did not reveal any ankle instability of the donor leg, but the subjectively perceived gait and stance insecurity could be objectified with the help of balance tests, which is why it can be assumed that the stance and gait insecurities can be misinterpreted as ankle instability. Nevertheless, a high rate of functional impairment was found, so that Rendenbach et al. stated that the removal of a free fibula flap is associated with an impairment of balance ability and strength performance (18).

In another prospective biomechanical analysis, 19 patients were examined 13-51 months after surgery to perform a long-term analysis. This study also revealed a significant decrease in peak maximum power; however, this effect disappears when considering the “Esslinger Fitness Index”, which normalizes peak maximum power for age and sex, accounting for the fact that patients aged two and a half years between examinations. Additionally, there is insufficient evidence to attribute the observed decrease, which persists beyond the mid-20s even without fibula removal, solely to fibula removal alone. Accordingly, as Rendenbach et al. postulated, the short-term effect of removal on peak maximum power and EFI seems to be compensated over time. This is further enhanced by a symmetrical decrease in maximal peak power on both the donor and contralateral leg. A similar effect was found for balance ability. Even after a mean follow-up of more than two and a half years, there was still a significant lack of sagittal motion with reduced dorsiflexion and plantar flexion in the ankle joint and several patients complained of load-dependent pain and subjectively perceived limitations in daily activities. In summary, one year after harvesting, functional morbidity at the donor site was low, maximal peak power and balance ability were unaffected; however, there may be persistent ankle motion deficits and chronic pain (19).

Attia et al. focused mainly on the stability and balance of the affected leg. For this purpose, tests to determine ankle stability and balance were performed in 68 patients, on average 1428 days after fibula graft removal. In addition, the Foot, and Ankle Disability Index (FADI) questionnaire was selected to additionally investigate the influence of ankle function on quality of life. There was a long-term complication rate of 16%, which was mainly paranesthesia (7.3%). The most common temporary complications were wound healing problems (38%) and oedema (3%), with twelve of the subjects (18%) requiring surgical revision due to persistent wound infection. A total of 4.4% of subjects reported persistent pain; however, the mean score for postoperative pain intensity, on a numerical scale of 0 to 10, was only 3.2. An 88% of subjects in this study reported pain duration of up to three months at the donor site. The significant decrease in stability and ankle function due to surgery noted in the clinical examinations can be classified as chronic ankle instability (CAI). However, limitations in quality of life and daily activities were minimal in most subjects, so donor site morbidity after fibula grafting was found to be relatively low. Most patients are satisfied with both the functional and aesthetic outcome (20).

Xu et al. conducted a prospective study involving 30 subjects to comprehensively evaluate the functional outcomes of the donor site following fibula graft harvesting for mandibular reconstruction. The results of objective assessments, such as isokinetic testing of the ankle joint, electromyographic testing of the peroneal superficial nerve, and preoperative and postoperative foot scans were specifically performed before surgery and at three months, six months, and 12 months after surgery, and showed that although the majority of patients had no long-term mobility limitations and daily living disorders, the functional parameters of the donor site actually worsened in the functional assessments. Thus, there was a discrepancy between the patients’ perceptions and the actual limitations. On the donor site, peak torque/weight and total work of plantar flexion and dorsiflexion of the ankle decreased significantly 1 year postoperatively (p<0.05). However, peak torque/weight of the contralateral side was also slightly decreased (p>0.05). The subjective evaluation of donor site aesthetics, except for one patient who suffered from scarring, showed satisfactory results, which were confirmed by outside observers. The incidence of discomfort in the donor lower limb within six months postoperatively can be summarized as follows: Numbness in the lateral calf was reported in 73.33% of cases, weakness of the lower extremity in 16.67% of cases, chronic pain in 6.67% of cases, cold intolerance in 6.67% of cases and a swollen ankle after prolonged walking or standing in 56.67% of cases. In addition, three patients developed a claw toe (10).

Discussion

This literature review shows that various studies have already dealt with morbidities of the donor side after fibula graft harvesting. However, the included studies have a very heterogeneous study design, which makes a comparative analysis of the results unfeasible. Although mandibular reconstructions by means of free fibula flaps can certainly be associated with essential donor site morbidity, the postoperative impact on patients’ quality of life is weighted and evaluated differently.

Three of the considered studies report the occurrence of toe deformities (10-12), such as claw toes, and the associated pain, which, as Sallent et al. described, can significantly restrict patients’ daily routines (12). The clinical examinations aimed at assessing walking ability, balance, and range of motion of the ankle joint, showed significant deviations compared to control groups or the contralateral leg in some cases (13,14,17,19). However, Rendenbach et al. in particular, showed that the initially observed functional impairments in balance ability and strength performance seem to be compensated for over longer examination periods, concluding that the functional morbidity at the donor site can be classified as low (11,14,16-20). What is striking here is the frequent deviation between the subjective feelings of the patients and the objective examination results. While objective assessments often identified limitations, these were not always consciously perceived by the patients themselves. Reduced extensor strength of the donor leg (14), lower walking speeds (13), muscular impairments (11), gait and stance insecurities (18), paranesthesia’s (20) and chronic pain (10) were described, although not universally, and can certainly lead to restrictions in the everyday life of individual patients. Consequently, despite the overall minimal morbidity described, we highlight the importance of comprehensive clinical evaluation and questioning of patients regarding functional and esthetical restrictions during follow-up examinations. This approach is crucial for effectively treating or at least alleviating these issues. This was possible in the patients presented in the case report of Sallent et al. by means of a relatively simple operation, which may have had a positive effect on the patients’ quality of life (12).

Through precise virtual planning using computer-aided-design (CAD)/computer-aided-manufacturing (CAM) techniques, measures that reduce the morbidity of the donor site can also be considered and planned preoperatively. For example, preserving 5-7 cm of distal fibula at the ankle and 4-6 cm at the knee can reduce donor site morbidity (17). At the same time, as shown by Kuo et al., regular home training can improve the strength of dorsiflexion of the ankle and eversion of the foot of the donor leg and allow more symmetrical motor function of the ankle between the donor and healthy leg (21). The short-term complications that have occurred at the donor site in the literature reviewed, such as wound dehiscence, partial necrosis, and wound healing problems (16,17,20), may affect the immediate postoperative quality of life and lead to a prolonged inpatient stay, as well as necessitate repeat split-thickness skin grafting (16). One method to minimize wound healing complications in cases where a skin puddle can be omitted is the transplantation of a pure fat fascia. In this case, the skin is not removed with the flap so that the leg can be closed directly without the need for skin grafts (22). Given the widespread use of free fibula flap reconstruction in head and neck surgery, this technique offers an alternative promising solution to avoid donor site complications and delayed healing but is a rarely used technique to date (22). However, it must be noted that the patient population consisted of only five patients, so further studies with larger patient populations and longer follow-up periods would be needed to assess this. The restoration of adequate masticatory and swallowing function also plays an important role in the assessment of postoperative quality of life, according to this team. Ohkoshi et al. first demonstrated the positive effects of CAD/CAM mandibular reconstruction on masticatory and swallowing function after surgery for locally advanced oral cavity carcinoma (23), so given the increasing use of these CAD/CAM techniques, we can expect better clinical outcomes in the recipient region to justify the use of fibula grafts. The gain in quality of life at the recipient site will increase with increasing digitization and thus relativize the morbidities at the donor site, which are already described as low.

The main strength of this study was the long-term evaluation of the donor site functional parameters following reconstruction with vascularized fibula or iliac bone grafts, which has received little attention in the previous literature. In the same instance, our scoping review was accompanied by certain limitations. First, the variation in the follow-up period and utilization of different questionnaires resulted in heterogeneity and skewness of the reported data. Second, inadequate sample size and loss of patients at follow-up in a few studies could have led to a lack of adequate significance. Third, only studies evaluating the donor site morbidity after oncological resection were included. The absence of studies regarding mandibular reconstruction by antiresorptive-associated osteonecrosis of the jaw or osteoradionecrosis can influence the impact of our study since a significant number of fibula free flap cases cannot be evaluated. Further studies with a prospective protocol should be performed utilizing standardized and validated questionnaires to optimize patient-related and surgery-related factors which might influence the donor site morbidity.

Conclusion

This literature review demonstrated that donor site morbidity after fibula free flap harvesting may have a negative impact on the postoperative patients’ daily life, however, can generally be classified as minor, so that the benefit of reconstruction with fibula grafts is clearly greater than the associated sequelae. Nevertheless, the authors of this review highlight the importance of a comprehensive clinical evaluation of the donor site besides the recipient site during follow-up examinations. This would help to evaluate the functional and esthetical limitations of a patient’s site subjectively and early detect morbidities that could lead to long-term additional complications.

Conflicts of Interest

The Authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The Authors have no relevant financial or non-financial interests to disclose.

Authors’ Contributions

All Authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Marcel Ebeling and Andreas Sakkas. The first draft of the manuscript was written by Marcel Ebeling and all authors commented on previous versions of the manuscript. All Authors read and approved the final manuscript. The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.