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. 2025 Aug 18;20(1):37–46. doi: 10.5005/jp-journals-10080-1643

Vascularised Fibula Transfer for Post-traumatic Critical Tibial Bone Defects: A Systematic Review

Sevasti P Glynou 1,✉, Ariadni Georgiannakis 2, Daria Ardolino 3, Simon Craxford 4, Alexandros Vris 5
PMCID: PMC12445139  PMID: 40979929

Abstract

Introduction

Managing post-traumatic critical bone defects in the tibia remains challenging. Vascularised free fibula grafts (VFFG) are an attractive option due to their versatility and ability to integrate with host bone. However, they are challenging, and their role compared to alternative techniques, such as bone transport and Masquelet, remains unclear. This study aims to assess the safety and effectiveness of free fibula flaps in reconstructing critical tibia defects following trauma.

Materials and methods

Five databases were searched for English-language studies from inception until August 2024. Inclusion criteria involved adult patients undergoing VFFG to the tibia for trauma-induced bone defects. Case reports and studies involving non-traumatic and/or critical bone injury and/or those not undergoing fibula transfer were excluded. Bias was assessed using the ROBINS-I tool.

Results

Fifteen studies involving 83 patients with a mean age of 35.07 ± 12.16 (range: 18–65) were included. Ipsilateral fibula transfer was preferred (n = 13, 80%), of and 89.7% fibulas (n = 35) were transferred using a single-barrel approach. The average union rate was 93.08% (95% CI: 86.56, 99.61) across the 74 patients where union outcomes were reported. Flap survival was 100% in seven studies, whilst two studies reported lower survival rates, the lowest being 50%. The overall complication rate was 39.98% (95% CI: 28.25, 51.71), with stress fractures occurring in 35.5% (n = 16) of cases. Revision rates varied from 10 to 40%. The risk of bias was high in 12 studies, and only three studies had a moderate risk. Four studies compared VFFG to alternative management strategies.

Conclusion

Vascularised free fibula grafts are effective for reconstructing large segmental tibia defects post-trauma, achieving high union and flap survival rates. However, complication rates are high, and study heterogeneity limits definitive conclusions on the technique's superiority. Further prospective comparative studies are required to characterise the role of VFFG.

How to cite this article

How to cite this article: Glynou SP, Georgiannakis A, Ardolino D, et al. Vascularised Fibula Transfer for Post-traumatic Critical Tibial Bone Defects: A Systematic Review. Strategies Trauma Limb Reconstr 2025;20(1):37–46.

Keywords: Bone reconstruction, Critical bone defect, Femoral reconstruction, Fibula flap, Free fibula flap, Free fibular graft, Loss of bone substance, Pedicled vascularised fibular graft

Introduction

A critical bone defect following trauma to the lower limb remains a challenging entity in the field of orthopaedic surgery. Whilst the definition of a critical bone defect remains controversial, it is generally agreed that these injuries do not spontaneously heal without further intervention.1,2 Associated treatments are demanding and costly, placing a significant physical and psychological burden on patients, historically leading to amputations.1,3–6 However, modern techniques for fracture stabilisation and soft tissue reconstruction have significantly improved limb preservation during the acute phase of treatment.7

The primary goals of treatment include skeletal stabilisation, length maintenance, bone alignment and functional restoration.1 Current options include bone transport, induced membrane techniques (Masquelet) and vascularised free fibular grafts.

Bone transport, though effective, is lengthy, resource-intensive and is physically demanding for the patient, whilst the Masquelet technique relies heavily on available bone graft and has variable reproducibility.1,8–11 Emerging methods like 3D-printed scaffolds lack sufficient long-term evidence for widespread adoption.12,13

Compared to the other methods, vascularised fibula grafts (VFGs) have the advantage of incorporating viable, vascularised bone directly to the defect, promising improved host integration, faster healing and advanced graft hypertrophy, especially in weight-bearing bones like the tibia.14 The fibula's long and straight anatomy allows for harvesting with its blood supply, skin and sometimes muscle, making it versatile for complex reconstructions. Whilst both composite and vascularised versions of free fibular grafts have been widely described in the literature, they are not routinely used in trauma settings due to concerns about donor site morbidity, graft hypertrophy and late fractures.15,16 Despite their potential advantages, VFG outcomes are underreported in the literature. This systematic review (SR) evaluates post-operative outcomes of VFGs for critical tibia bone defects.

A previous SR of 2,226 cases assessed union, re-intervention rates and functional outcomes of VFGs but did not focus on specific aetio-pathologies or limb location, both of which impact recovery.17 This review focuses on trauma-induced critical tibial defects, aiming to assess the safety and effectiveness of fibula flaps in reconstructing large tibial defects.

Materials and Methods

Study Protocol

The study protocol was registered with PROSPERO (ID: CRD42023446322), and the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed.18

Literature Search

A literature search was conducted on Embase, Ovid, PubMed, Scopus and Web of Science databases and included the terms: “free fibula flap”, “vascularised fibular graft”, “lower limb trauma”, “segmental bone defect”, “critical bone defect”, “effectiveness”, “safety”, “complications”, “flap survival” and “bone union”. The initial search covered studies from inception up to July 2023, with an updated search, using the same search strategy from July 2023 to August 2024.

Table 1 demonstrates the search string using the PICOs framework. The inclusion and exclusion criteria for this literature search are detailed in Table 2.

Table 1.

Detailed population, intervention, comparison and outcomes (PICOs) analysis for this review question

Study PICO
Population(s) Patients of skeletally mature age who have sustained a large bone defect injury following lower limb trauma.
Intervention(s) Free fibula flap reconstruction.
Comparators Any other widely accepted methods for reconstructing large bone defects of the lower extremity.
Outcomes Effectiveness: Frequency of bone union and flap survival at a minimum of six months following the operation.
Safety: Frequency of post-operative complications, both short- and long-term.
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Table 2.

Inclusion and exclusion criteria

Criteria Inclusion Exclusion
Study design Retrospective/prospective studies, case series Editorials, conference proceedings, animal studies
Language Studies written in English Papers not written in English
Population Patients of skeletally mature age (>18 years old) Patients not undergoing tibia reconstruction
Intervention Undergoing a vascularised or non-vascularised single- or double-barrel free fibula graft Non-trauma patients (e.g., those with osteomyelitis, cancer)
Condition Having a segmental or critical bone defect in the tibia Patients with non-segmental/critical defects
Injury type Sustained a primary injury from trauma (including falls, motor vehicle accidents, gunshot injuries) Patients without a segmental bone defect
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Study Selection

Data extraction and screening were independently conducted by two reviewers through COVIDENCE.19 Duplicate entries were removed, followed by a two-tier screening process: Title/abstract screening and full-text screening. Both stages were completed by two independent reviewers, and discrepancies were resolved by a senior author.

Study Quality

Study quality was assessed using the risk of bias in non-randomised studies of interventions (ROBINS-I) tool, following Cochrane recommendations.20,21 Two independent reviewers evaluated bias as “serious”, “moderate” or “low”.

Data Extraction and Analysis

Data was synthesised qualitatively and quantitatively. For studies that reported outcomes from patients not meeting our inclusion criteria, we extracted only the relevant individual patient data. The respective means for the subgroup included in this systematic review were calculated on Microsoft Excel. Additionally, we pooled averages from the included studies to compute weighted means and 95% confidence intervals, to provide a summary of outcomes such as the union rate.

Results

A total of 650 records were identified from five databases. An additional search of ongoing trials on Cochrane Central Register of Controlled Trials (CENTRAL) yielded no additional studies. After screening, 125 records were selected for full-text retrieval, with 15 studies meeting the inclusion criteria for the SR. The article selection process is in Figure 1.

Fig. 1.

Fig. 1

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Preferred reporting items for systematic meta-analyses (PRISMA) flowchart for selection of the included studies. Results are shown using the PRISMA 2020 flow diagram app30

Risk of Bias Results

Risk of bias analysis results are available in Figure 2. Overall, most of the studies were of high risk, and three were of moderate risk.22–24

Fig. 2.

Fig. 2

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Risk of bias in studies assessed using the ROBINS-I tool for non-randomised studies. Results are visualised using the robvis tool34

Study Characteristics

Eighty-three individual patients were identified, with a mean age of 35.07 ± 12.16 (range: 18–65) years. There were more males (n = 68, 83.95%) than females (n = 13, 16.05%).22–36 Study characteristics are shown in Table 3 and Supplementary Table 1.

Table 3.

Study characteristics

Author Year Country Study design Intervention (%) Follow-up duration in months (mean, range) Group comparator Total number of patients Mean age (range) Female ratio
Atkins et al. 1999 United Kingdom Case series IVFT NR N/A 4 39 (24–53) 0.75
Chung and Chung 1998 Korea Case series PVFG 38 (31–48) N/A 5 38 (25–51) 0
Chung et al. 2011 South Korea Case series IVFT with free flap grafting 40.8 (27.6–56.4) N/A 9 30.5 (18–43) 0.2
He et al. 2022 China Case series PVFG (22.2%), FVFG (77.8%) 21.78 (12–60) N/A 9 33.2 (21–49) 0
Hierner and Wood 1995 United States Case series FVFG (50%), FVFG with soft tissue flap (50%) NR Iliac crest graft 2 NR NR
Iamaguchi et al. 2019 Brazil Case series FVFG NR N/A 3 32.3 (24–42) 0.33
Jeng and Wei 1997 China Case series FVFG with latissimus dorsi/rectus abdominis flap NR N/A 5 44.2 (32–62) 0
Jeng et al. 2001 Canada Case series PVFG 31.33 (23–48) N/A 3 38 (30–46) 0.33
Kaplan et al. 1998 Turkey Case series FVFG with skin graft NR Other bone grafts 2 24 (24–24) 0
Karami et al. 2019 Lebanon Cohort FVFG with osteo(+/–myo)cutaneous flap 14.5 (5.8–25.6) N/A 12 37.9 (20–62) 0.16
Lee et al. 2012 South Korea Case series FVFG NR Other bone grafts 1 58 0
Li et al. 2017 China Case series FVFG 15 (12–18) N/A 3 33.3 (22–58) 0.33
Ozaksar et al. 2012 Turkey Case series FVFG with skin flap 79.3 (18–216) N/A 19 34.3 (18–47) 0.1
Qi et al. 2016 China Case series FVFG 45 (24–66) N/A 2 39.7 (28–47) 0.5
Yokoyama et al. 2001 Japan Case series FVFG with skin flap (75%), FVFG (25%) NR Callus distraction 4 40 (18–65) 0
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FVFG, free vascularised fibular graft; IVFT, ipsilateral vascularised fibular transport; NR, not reported; PVFG, pedicled vascularised fibular graft

On average, where reported, the length of follow-up was 41.07 ± 45.05, ranging from 5.8 to 216 months. All studies used fibula flaps for vascularised tibia reconstructions; however, the techniques described varied, including the ipsilateral vascularised fibula transfer (IVFT), the free vascularised fibular graft (FVFG) and the pedicled vascularised fibular graft (PVFG) approaches, along with composite flaps including other tissues such as skin and/or muscle.

Ipsilateral vascularised fibula transfer reconstructs the tibia by transporting the fibula of the injured limb into the tibial defect through external fixation, whilst preserving the blood vessels, compared to free vascularised fibular grafting, which requires surgical microvascular anastomosis.25–27 Another option is the use of the ipsilateral fibula on its vascular pedicle with internal fixation (PVFG).26,28,30 The FVFGs involve the separation of the bone from its native blood supply and its reattachment to vessels at the recipient site.22–24,28,29,31–36 The choice for either technique used depended on a variety of factors such as the condition of soft tissues in the injured limb.

The leading cause of the bone defects treated was segmental bone injuries, high-energy trauma, such as traffic accidents and industrial accidents, followed by blast injuries and gunshot wounds.23–25,27,28,34–36 All studies but four did not use a comparator group. Patient comorbidities were only reported in two studies and included smoking (n = 10, 66.7%), diabetes mellitus (n = 3, 20%) and cardiovascular disease (n = 2, 13.3%).22,23

Patient and Treatment Characteristics

Most of the studies (n = 13, 80%), with the exception of two, conducted an ipsilateral transfer, whilst 89.7% (n = 35) of fibulas were transferred using a single-barrel approach (Table 4).25–27,32,34,35 Typically, non-fractured fibulas were used for reconstruction; whilst Chung and Chung and Qi et al. used fractured fibulas for treating tibial defects in four (80%) and one (50%) patients, respectively.26,35

Table 4.

Patient and injury characteristics

Author, year Ipsilateral flap (%) Grade of fracture Size of defect in cm (mean, range) Single barrel (%) Double barrel (%) Concurrent infection (%) Graft size in cm (mean, range) Right leg injured (%) Fractured fibula (%) Time between injury and flap in months (mean, range) Number of procedures before flap (mean, range) Polytrauma (%)
Atkins et al., 1999 100% Gustilo IIIb 14.75 (12–18) 100% 0% 75% NR NR 0% NR NR 0%
Chung and Chung, 1998 100% Gustilo IIIb 8.75 (6–11.5) 100% 0% NR NR NR 80% NR NR 0%
Chung et al., 2011 100% Gustilo IIIb 5.35 (4–8) NR NR 80% NR 50% 0% 4.3 (2–6) 1 0%
He et al., 2022 77.78% “Extensive composite defects” NR 66.7% 33.3% 0% 18.22 (9–25) 44.4% 0% NR NR 0%
Hierner and Wood, 1995 NR “Segmental bone defects” 8.5 (3–14) NR NR NR NR NR NR NR 4.5 (0–9) NR
Iamaguchi et al., 2019 NR “Segmental bone defects” 11.03 (6.8–14) NR NR NR NR NR 0% NR NR 0%
Jeng and Wei, 1997 NR Gustilo IIIb 10.8 (8–15) NR NR NR NR 20% 0% NR NR 0%
Jeng et al., 2001 100% Gustilo IIIb 10 (8–12) 66.7% 33.3% Wound infection: 33.3% NR 33.3% 0% NR NR 66.7%
Kaplan et al., 1998 NR Gustillo IIIb (50%)Gustillo IIIc (50%) 15.5 (15–16) NR NR NR NR 100% 0% 5.6 (2.8–8.4) 3 (2–4) 0%
Karami et al., 2019 NR “Composite defects” 13.3 (9–17) 100% 0% Infected: 35.7% Contaminated: 28.6% NR NR NR 0.29 (0–0.5) 1 0%
Lee et al., 2012 NR Gustilo IIIb 7 100% 0% NR NR NR 0% 0.2 NR NR
Li et al., 2017 0% “Composite defects” 6 (5–7) 100% 0% NR NR 66.7% 0% 0.1 (0–0.3) NR 0%
Ozaksar et al., 2012 NR Gustilo IIIb (89.5%)Gustillo IIIc (10.5%) 10.1 (6–18) NR NR NR NR 10.5% 0% NR NR 0%
Qi et al., 2016 0% “Large segmental defects” NR 100% 0% 50% NR 100% 50% 4.5 (3–6) NR 0%
Yokoyama et al., 2001 NR Gustillo IIIb 7.3 (6–8) NR NR 100% 14.3 (12–20.5) NR 0% 17.75 (4–41) 3.8 (2–5) 0%
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NR, not reported

Most tibia fractures were Gustilo IIIb (n = 50, 60.2%), though some studies described the fractures without specific grading. Defect sizes ranged from 4 to 22.5 cm. Only two studies reported mean graft sizes: He et al. (16.92 cm, 9–22.5 cm) and Jeng et al. (15.5 cm, 15–18 cm). Single-barrel techniques, when reported, were the most common (Table 4).25–27,30,32

Concurrent infections at presentation were significant, and the number of procedures performed prior to flap application was variable (Table 4).

Effectiveness Outcomes

Reported union rates ranged from 60 to 100%. We calculated the weighted average union rate across 58 patients to be 93.08% (95% CI: 86.56, 99.61). Three studies reported primary union duration: The time taken for the initial healing of the bone at the graft site.24,29,33 Six studies reported total time for union, which ranged from 3 to 20 months.25–27,29,30,36 Time for full weight-bearing ranged from 4 to 13 months (Table 5).26,27,29,30,32,34 Graft hypertrophy was reported in four studies, with three observing it in all flaps and one observing it at a rate of 80%.25,27,29,30

Table 5.

Effectiveness outcomes

Author, year Union (%) PUT (months) TFU in months (mean, range) TFFWB in months (mean, range) Graft hypertrophy QoL assessment tool Average QoL score Functional outcome
Atkins et al., 1999 100% NR 3–8.75 NR 100% NR NR Adequate ROM of the foot, reduced compared to other side
Chung and Chung, 1998 60% 5.5 6 (3–11) 9 (4–13) NR Occupation status Return to original work (40%), Re-employed (20%) Limited ROM of the ankle without significant impairment
Chung et al., 2011 100% NR Proximal: 5.2 (4–7)Distal: 6.7 (5–8) 10.2 (8.2–12.1) 100% NR NR Restricted ROM of knee (40%), reduced ROM ankle (100%), able to walk without assistance (100%), satisfied with surgery (100%)
He et al., 2022 100% NR 8 (median) NR NR NR NR NR
Hierner and Wood, 1995 NR NR Proximal: 7.5 months, Distal: 5.5 months 15.3 100% NR NR NR
Iamaguchi et al., 2019 NR NR NR NR NR NR NR Mobilising without help (66.67%), mobilising with crutches (33.33%)
Jeng and Wei, 1997 100% NR NR NR NR NR NR NR
Jeng et al., 2001 100% NR 8 (5–10) 11.7 (10–13) 80% Occupation status Return to original work (67%), retired (33%)
Kaplan et al., 1998 100% NR NR 5 (4–6) NR NR NR NR
Karami et al., 2019 91.6% NR NR NR NR NR NR NR
Lee et al., 2012 NR 12 NR NR NR Puno et al. 97% NR
Li et al., 2017 100% NR NR 9 NR Description of function Satisfactory (100%) NR
Ozaksar et al., 2012 Distal: 100%, Proximal: 84.2% Distal: 4.37 (3.68–5.52) Proximal: 4.6 (3.68–5.52) NR NR NR SF-36, Occupation status Cannot extract for population of interest Could extract for population of interest, Foot drop (5%)
Qi et al., 2016 100% NR 3 NR NR Description of function Excellent (100%) NR
Yokoyama et al., 2001 75% NR 20 5.86 NR Puno et al. Mean: 69.5 corresponding to Poor (50%), Fair (25%), Good (25%) NR
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NR, not reported; PUT, primary union time; TFU, time for union; TFFWB, time for full weight bearing

The revision rates for tibia flap reconstructions across studies ranged from 0 to 40%.23,26–28,31,32,35,36

Patient-reported Outcomes

Pain scores were only reported by Qi et al., who mentioned that all patients were pain-free post-surgery.35 Scores or descriptors relating to patient's quality of life (QoL) were reported in six studies using different tools such as the SF-36 questionnaire or the scale by Puno et al. and were predominantly positive (Table 5).26,30,33–36

Functional outcomes varied significantly across studies, with different ankle range of movement reported (Table 5).22,25–27

Complications

Overall, safety outcomes such as flap survival and complication rates varied across studies (Table 6). Flap survival was reported in nine out of 15 studies, with seven reporting 100% survival, whilst Iamaguchi et al. reported a lower flap survival rate of 67% and in Hierner and Wood this was 50%.22,23,27–32,34,35

Table 6.

Safety outcomes

Author, year Flap survival (%) Overall complication rate (%) Fracture rate (%) LLD(%) Amputation rate (%) Infection rate (%) Thrombosis (%) Mechanical problems (%) Haematoma (%) DSM (%) Revision rate (%)
Atkins et al., 1999 NR NR 0% NR 0% 0% NR 0% NR NR NR
Chung and Chung, 1998 NR NR NR NR NR NR NR NR NR NR 40%
Chung et al., 2011 100% 20% NR 80% NR 0% 10% Varus angulation: 10% NR NR 10%
He et al., 2022 100% 22% NR NR NR NR NR NR NR “Minimal” 22%
Hierner and Wood, 1995 50% 50% NR NR NR NR NR NR NR 0% NR
Iamaguchi et al., 2019 67% NR NR NR 0% NR NR NR NR NR NR
Jeng and Wei, 1997 100% 20% NR NR NR NR NR NR NR NR 20%
Jeng et al., 2001 100% NR 0% 33% 0% Osteomyelitis: 33% NR Screw loosening: 66.7% NR NR NR
Kaplan et al., 1998 100% 0% NR NR 0% 0% NR NR NR NR 0%
Karami et al., 2019 100% 25% 7% NR NR NR 0% 0% 0% NR 25%
Lee et al., 2012 NR NR 0% 0% 0% 0% 0% 0% 0% NR NR
Li et al., 2017 100% 33% NR NR NR NR NR NR NR “Minimal” NR
Ozaksar et al., 2012 NR Early complication: 58%Late complication: 79% 68% 21% NR 26% 27% Varus angulation: 32% NR 5.26% NR
Qi et al., 2016 100% 50% 50% NR NR 0% NR NR NR NR 0%
Yokoyama et al., 2001 NR 75% 25% NR NR Pinsite infection: 50%Septic non-union: 25% NR NR NR NR 25%
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DSM, donor site morbidity; LLR, limb length discrepancy; NR, not reported

The weighted average complication rate across 67 patients was 39.98% (95% CI: 28.25, 51.71) and ranged from 0% to 75% (Table 6). Post-operative stress fractures were reported in 35.5% (n = 16) of cases. Limb length discrepancy was reported by four studies and occurred in 38.7% (n = 12) patients.24,27,31,33 No amputations were reported in the identified studies. The weighted average revision rate across 58 patients was 20.83% (95% CI: 9.14, 32.02) and ranged from 0 to 40%.23,26–28,31,32,35,36 In the studies reporting revisions, causes for surgical re-intervention included delayed union (6.8%, n = 3), venous congestion (6.8%, n = 3), screw loosening (4.5%, n = 2) and flap necrosis (2.3%, n = 1).

Discussion

Fibular grafting is a complex procedure, often reserved for severe cases, as non-critical bone defects are managed effectively with standard fixation techniques and autogenous or allogenic bone grafts.1 However, large structural grafts carry significant risks such as fractures, infections and non-union due to their avascular nature, making fibular grafts a viable option in these instances.37,38 Given the heterogeneity of reported outcomes and the limited number of studies, no prior study has provided granular information on the effectiveness and safety of fibula flaps for the reconstruction of traumatic large bone defects. The current study, synthesising data from 15 studies, found that fibular flaps can be effective in achieving bone union and have acceptable safety profiles, with high rates of flap survival and manageable complication rates.

Effectiveness Outcomes

Flap survival was consistently high at 100%, except in studies with small sample sizes, limiting generalisability. Flap failure of these might be attributed to individual patient comorbidities such as thrombosis.22,29 In the studies reporting time for union, this ranged from 3 to 20 months, and four studies reported non-unions. A SR by McMahon et al. comparing the management of segmental tibia fractures with intramedullary nail fixation, open reduction and internal fixation, or circular external fixation demonstrated that across these techniques, time for union ranged from 4 to 7 months, with non-union reported in three studies.39 The differences in time for union and number of patients achieving union in our study may be attributed to the inclusion of only segmental open fractures, with fibula flaps often used after previous methods had failed. McMahon et al. noted that only three studies reported functional results in patients; however, due to the variability in how our studies reported outcomes, it is difficult to draw meaningful conclusions.39

Based on the studies that reported graft hypertrophy, rates ranged between 80 and 100%, highlighting the graft's effectiveness in integrating and adapting to the host environment.25,27,29,30 The free vascularised fibular graft utilises the viable bone tissue, results in greater resistance to mechanical loading and allows the graft to adapt to the mechanical properties of the application site through hypertrophy.16,40

Safety Outcomes

Complication rates varied widely. High-energy trauma fractures, such as Gustilo Type 3B and 3C, cause extensive bone and soft tissue damage, which increases the likelihood of complications. Infection rates ranged from 0 to 33%, with infected grafts often causing flap necrosis, osteomyelitis or graft resorption.41 Vascularised free fibula grafts (VFFG) have a constant vascular anatomy and a preserved blood supply, conferring resistance to infection.42–44 The use of the ipsilateral fibula retains its vascularity, so it is often a reliable option. Most of the included studies conducted ipsilateral fibula transfer, which could have contributed to the observed low infection rates.

Donor site morbidity was reported as “minimal” or ranged from 0 to 5%. Our study aligns with the existing literature, indicating that significant donor site morbidity is generally low and not severe enough to outweigh the advantages of fibular grafting.26,45–47

One of the drawbacks observed is the limb length discrepancy, which was reported by four studies. However, Chung et al., who had the largest proportion of patients affected (80%), noted in their study that this averaged 0.5 cm and was not related to significant functional issues.26,48

The average post-operative rate of fractures was 35.5% (0–75%), with Ozaksar et al. attributing fractures to biomechanical loads on the fibular graft before full integration with host bone.24 In Qi et al.'s study, early weight-bearing activities may have also led to substantial mechanical stress.35 This SR agrees with previous observations that double-barrel fibula grafts reduce stress fractures.49 High fracture rates in single-barrel studies could be attributed to the insufficient use of assistive devices, inadequate fixation or graft misalignment.50

Pain scores and QoL measures for patients were scarcely reported, and no universal measure was identified. Given the procedure's physical and psychological demands, such data are crucial for understanding patient outcomes and guiding reconstructive decisions. One study measured pain using the SF-36, which includes a pain domain but is not specific to orthopaedic surgery. More accurate tools, like the numerical pain rating scale, could provide better long-term pain assessment and were measured with various tools, but only the Puno et al. questionnaire, specific to open tibia fractures, covers both subjective and objective factors.51 Future studies should consider using this tool or developing a more comprehensive questionnaire to better assess post-operative QoL and pain.

PVFGs vs FVFGs

Both PVFGs and FVFGs demonstrate high union rates and effectiveness for reconstructing large bone defects.22–24,27,30–32,35 Pedicled Vascularised Fibular Grafts have lower complication (20%) and fracture rates (0%), but higher donor site morbidity (33%) and limb length discrepancies (33%).30,31 In contrast, FVFGs, supported by a broader evidence base, have lower infection rates (0–26%) compared to PVFGs (33.33%) but higher variability in complication rates (0–79%) and higher fracture rates (up to 68%).22–24,27,32,35

Manfrini et al. compared the use of PVFGs with FVFGs for the reconstruction of massive tibia defects post-tumour resection, observing similar rates of complications, noting that PVFGs require a shorter surgical time and avoid microvascular procedures.52 Nevertheless, trauma reconstructions present different challenges from oncologic cases, so further evaluation in a trauma context is needed.

Limitations

All the included studies were retrospective, which may introduce selection bias. Furthermore, there was significant heterogeneity in the reporting of outcomes, surgical techniques and follow-up durations, complicating result aggregation and comparison. Despite the exclusion of case reports, the small sample sizes limit the statistical power of the study and the generalisability of the findings. Larger, well-designed studies are needed to draw more conclusive results. The lack of direct comparison with other techniques makes it challenging to draw conclusions about which technique is superior. Moreover, most procedures were secondary interventions following failed attempts of other techniques, potentially increasing complication rates compared to primary interventions; so, interpretation of results should be considered within this context.

Conclusion

Fibula flaps represent a viable and effective method for managing traumatic large segmental tibia defects. High rates of union and relatively high rates of complications are reported in the literature. The heterogeneity in reporting and the high bias of the included studies restrict definitive conclusions on the technique's superiority over other reconstructive methods, and therefore, future research should focus on the conduction of high-quality randomised controlled trials.

Supplementary Materials

The Supplementary table is available on the website www.stlrjournal.com

Orcid

Sevasti P Glynou https://orcid.org/0000-0001-5132-3967

Ariadni Georgiannakis https://orcid.org/0000-0002-8521-0511

Footnotes

Source of support: Nil

Conflict of interest: None

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