Donor Leg Morbidity and Function after Fibula Free Flap Mandible Reconstruction

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Abstract
The purpose of this study was to determine the donor leg morbidity and function after removal of the fibula free flap for mandible reconstruction. In the past 24 months, 29 consecutive patients underwent a total of 30 fibula free flap mandible reconstructions. A muscle-sparing technique was used to harvest the fibula flap, and the proximal 6 cm and distal 8 cm of fibula were left intact. Patients included 20 men and 9 women; their mean age was 58.8 years (range 29 to 82 years); the mean length of fibula removed was 14.5 cm (range 8 to 25 cm); osteocutaneous flaps were used in 27 patients (90 percent); and 16 patients (53 percent) required skin grafts to the donor leg. Donor leg morbidity and function were determined by patient questionnaire, physical examination, and isokinetic testing, with the opposite, unoperated leg serving as a control. Immediate postoperative morbidity occurred in 5 patients (17 percent) (infection, wound separation, or partial graft loss); none required additional surgery for donor complications. Patient questionnaires were completed by all patients at an average of 7.3 months after surgery. Patients were able to ambulate pain-free an average of 5.1 weeks (range 2 to 32 weeks) postoperatively and were all fully able to engage in all daily and recreational activities. Most (21 patients, 72 percent) were free of any donor pain, and the remainder (28 percent) had only occasional mild discomfort. Other complaints included ankle stiffness (41 percent), mild ankle instability (10 percent), and transient peroneal motor (7 percent) or sensory (28 percent) loss, which resolved in all patients. Isokinetic testing was performed in 11 representative patients an average of 8.4 months after their fibula flap harvest. There were no significant differences between operated and control legs in the range of motion of the knee or in ankle eversion/ inversion. However, donor legs had significantly less range of motion in ankle flexion/extension (29 percent decrease; p = 0.003) than controls. All strength measurements at the knee and ankle revealed a significantly decreased strength in the donor leg compared with the unoperated control leg. These values ranged from a low of 14 percent (p = 0.02) decrease in knee flexion/extension strength to a high of 49 percent decrease (p = 0.002) in ankle eversion strength. While these decreases were significant, the questionnaire results indicate they were not severe enough to have an impact on patients' daily activities. There was no correlation between any subjective or measured patient morbidity and patient age, length of fibula harvested, or the use of a skin graft. This study demonstrates that there is a measurable morbidity associated with harvest of the free fibula flap which nearly all patients will tolerate well and should not alter lifestyle but which is detectable with isokinetic testing. Patients should be apprised of this morbidity, and strategies to further minimize this morbidity are presented. (Plast. Reconstr. Surg. 96: 146, 1995.)

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