Combined osteocutaneous microvascular flap procedure for extensive bone and soft tissue defects in the tibia.

Recent experience with bone healing seems to advocate vascularized bone grafts in cases of large bone gaps or significant scarring, following irradiation, in the presence of low-grade infection, and in congenital pseudarthrosis of the tibia. When extensive bone and skin replacement are needed, the microvascular procedures currently available may not meet specific reconstructive requirements. To augment the advantages of the vascularized fibular graft for tibial substitution (strength, straightness, length, and predictability of vascular supply) with the benefits of free skin, muscle, or musculocutaneous flaps, separate on-demand harvesting of these tissue units and their microvascular combination can be useful in selected cases. In a study of 4 patients, the vascularized fibula was combined with a free latissimus dorsi flap. The procedure was facilitated and shortened by connecting the peroneal vessels to branches of the thoracodorsal or to the scapular circumflex artery and vein outside the operative field. The main supporting vessels of the combined composite tissue block were then anastomosed only to one pair of vessels in the leg.