Risk Factors for Early and Late Donor-Site Morbidity After Free Fibula Flap Harvest

SURGICAL ONCOLOGY AND RECONSTRUCTION

Risk Factors for Early and Late Donor-Site Morbidity After Free Fibula Flap Harvest Peng Li, MD,* Qigen Fang, MD,y Jinxing Qi, MD,z Ruihua Luo, MD,x and Changfu Sun, MDk Purpose:

This article reports on the incidence of donor-site complications and identifies predictive factors for early and late donor-site complications.

Materials and Methods:

From January 2007 through December 2012, 45 patients underwent free fibula flap reconstruction and their medical records were reviewed. They were asked to complete a questionnaire on the operated leg and they were evaluated for ankle stability and ambulatory status.

Results:

One patient (2.2%) developed a complication owing to a hematoma, but no other patients had any complications. During the risk factor analysis, no domain was found to be statistically associated with early morbidity; late dysfunction was noted in 20 patients (57.1%), and of these cases, at least 2 symptoms were found in 10 patients (50%). The most common complication was numbness followed by toe contracture and abnormal ambulatory movement. During the risk analysis, the following domains affected late donor-site morbidity: harvested fibula length, operation time, and follow-up time. Furthermore, in cases with complications, patients with the osteocutaneous fibula flap complained more than patients with the osseous flap (P = .07).

Conclusion:

Early donor-site morbidity was uncommon, but late morbidity occurred frequently. Harvested fibula length, operation time, and follow-up time were statistically linked to postoperative function. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-4, 2015

The free fibula flap has been widely used for mandibular reconstructions since it was first introduced in 19751 and donor-site morbidity remains a major concern. Previous studies have addressed this topic,2-6 but it remains controversial, especially with regard to predictive factors for perioperative complications and postoperative function outcomes.2,3,6 Momoh et al4 found that preoperative chemotherapy could induce perioperative donor-site complications and Shindo et al5 reported that a history of heavy smoking was statistically associated with an increased incidence of early donor-site complications. This article presents the incidence of donor-site complications based on the

authors’ experience and identifies predictive factors for early and late donor-site complications that have rarely been evaluated before.

Materials and Methods The China Medical University (Shenyang, China) institutional research committee approved the study and all participants signed an informed consent agreement. This was a retrospective study. Patients who underwent free fibula reconstruction from January 2007 through December 2012 were included in the study

*Resident, Department of Head Neck and Thyroid Surgery,

kDepartment Head, Department of Oral Maxillofacial Surgery,

Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou,

School of Stomatology, China Medical University, Shenyang, China.

Henan, China. yResident, Department of Head Neck and Thyroid Surgery,

Address correspondence and reprint requests to Dr Fang: Department of Head Neck and Thyroid Surgery, Affiliated Tumor

Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou,

Hospital of Zhengzhou University, No 127, Dongming Road, Jin-

Henan, China.

shui District, Zhengzhou, Henan, People’s Republic of China;

zDepartment Head, Department of Head Neck and Thyroid

e-mail: [email protected]

Surgery, Affiliated Tumor Hospital of Zhengzhou University,

Received September 29 2014

Zhengzhou, Henan, China.

Accepted January 25 2015

xProfessor, Department of Head Neck and Thyroid Surgery,

Ó 2015 American Association of Oral and Maxillofacial Surgeons

Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, Henan, China.

0278-2391/15/00108-1 http://dx.doi.org/10.1016/j.joms.2015.01.036

1

2

RISK FACTORS FOR DONOR-SITE MORBIDITY

and their medical records were reviewed. Early donorsite complications were complications (including partial necrosis, hematoma, etc) that occurred during the perioperative period; late complications were complications (including pain, numbness, weakness, etc) that occurred during follow-up. Patients were asked to be available for follow-up at 1, 3, 6, 12, 24, and 48 months after surgery. During each follow-up visit, the patient was questioned and examined carefully. Patients were asked to complete a questionnaire (Table 1) about the operated leg; they also were evaluated for ankle stability and ambulatory status. The study consisted of 45 patients (23 male and 22 female). The mean age was 47.2 years (range, 17 to 74 yr). Twenty-one patients (46.7%) had received a primary school or middle school education, and the remainder had received a high school or university education. Fourteen patients (31.1%) had a history of smoking and 12 (26.7%) had a history of alcohol abuse. Primary diagnoses were benignity in 20 cases (44.4%) and malignancy in 25 (55.6%). Six patients (13.3%) had an osseous fibula flap and 39 patients (86.7%) had an osteocutaneous fibula flap. The size of the skin paddle in the osteocutaneous flaps varied from 2 to 60 cm2, and the mean length of the harvested fibula was 15.4 cm (range, 8 to 21 cm). In all cases, primary closure was performed at the donor sites. The mean operation time was 10 hours (range, 6.3 to 15.5 hours). The volume of suction drainage ranged from 68 to 614 mL. The mean postoperative hospital stay was 11.9 days (range, 7 to 27 days). Five patients died of disease and there was no follow-up information for 5 patients. Therefore, 35 patients (18 male and 17 female) were included in the late donor-site morbidity evaluation. Dissection of the fibula flap was performed as described previously.1,4,7 During the operation, 5 cm of proximal bone and 7 to 8 cm of distal bone were left in situ to preserve knee and ankle stability. When an osteocutaneous flap was needed, a perforator dissection was performed through the soleus and flexor hallucis longus muscles. All donor sites were closed primarily after carefully evaluating the wound tension. The c2 test and bivariate correlation analysis were used to assess the risk factors for early and late donor-site complications. All statistical analyses were performed using SPSS 13.0 (SPSS, Inc, Chicago, IL). A P value less than .05 was considered significant.

Results EARLY DONOR-SITE MORBIDITY

A hematoma was reported for 1 patient, with no long-term consequences. No other complications, such as partial necrosis or compartment syndrome,

Table 1. INFORMATION ELICITED BY THE QUESTIONNAIRE

Question

Answer

1. Do you feel pain in your operated leg? 2. Do you feel numbness in your operated leg? 3. Do you feel weakness of the operated leg when walking or performing daily activities? 4. Do you feel edema in your operated leg? 5. Do you feel cold in your operated leg?

yes or no yes or no yes or no

yes or no yes or no

Li et al. Risk Factors for Donor-Site Morbidity. J Oral Maxillofac Surg 2015.

were noted. In the risk factor analysis, no domain was found to be statistically associated with early morbidity (Table 2). LATE DONOR-SITE MORBIDITY

Dysfunction was noted in 20 patients (57.1%), and of these cases, at least 2 symptoms were found in 10 patients (50%; Fig 1). The most common complication was numbness, followed by toe contracture and abnormal ambulatory movement. In the risk analysis, late donor-site morbidity was affected by the following domains: harvested fibula length, operation time, and follow-up time. No statistical association was noted with age (<60 vs >60 yr; Table 2). Furthermore, patients with complications tended to complain more

Table 2. RISK FACTORS FOR DONOR-SITE MORBIDITY

Domain Age Gender Education Smoking Alcohol Diagnosis Systemic disease Flap type Fibula length Operation time Suction drainage Postoperative hospital stay Follow-up time

Early Morbidity Late Morbidity .094 1.000 .467 .311 .267 .444 .200 .133 .489 .603 .090 —* —*

.060 .845 .241 .451 .266 .486 .422 1.000 .041 .006 .932 .779 <.001

* The domain was not calculated. Li et al. Risk Factors for Donor-Site Morbidity. J Oral Maxillofac Surg 2015.

LI ET AL

FIGURE 1. Late donor-site morbidity of the patients. Li et al. Risk Factors for Donor-Site Morbidity. J Oral Maxillofac Surg 2015.

if they had an osteocutaneous fibula flap compared with patients with an osseous flap (P = .07).

Discussion A study by Sieg et al8 reported that 21% of patients had prolonged and complicated wound healing caused by soft tissue infection or wound dehiscence in the donor area. Zimmermann et al9 observed that wound healing was complicated in 16 patients (38.1%). Similarly, a review article by Ling and Peng10 reported that the most common problem was delayed wound healing. However, in the present study, the early donor-site dysfunction rate was only 2.2%, and there was only 1 complication (a hematoma in 1 patient). These results could be explained in part by the following reasons: first, all donor sites in the present study were closed directly and Ling and Peng10 reported that abnormal surgical wounds were more common when skin graft closure was used; second, only 9 patients (20%) had systemic diseases, which negatively affect wound healing; third, no patients received preoperative chemotherapy and only 14 patients (31.1%) had a history of smoking, and chemotherapy and smoking have been linked to an increase in donor-site complications.4,5 The authors did not find 1 particular factor that was related to early donor-site complications, although this might be due to the low complication rate. Many studies have investigated late donor-site morbidity. Momoh et al4 noted that 26 patients (17%) reported long-term morbidity after fibula flap harvesting and no patients developed knee instability, weakness, or decreased range of motion. Patel et al11 reported that only 8% of patients reported some discomfort. However, in the present study, the incidence of late morbidity was as high as 57.1%, which is consistent with that described by Shindo et al.5 This variation might be because different methods were used to evaluate dysfunction; alternatively, it could be that even minor abnormalities after fibula flap reconstruction can considerably affect daily life. A study by Bodde et al3 reported that fibula harvesting

3 was associated with frequent complaints according to subjective and quantitative analyses, even when the effects were minimal. In addition, most patients in the present study were younger than 50 years, and 57.1% of them had received a high school or university education; therefore, they could have a higher standard for quality of life. In this study, the most common late complication was numbness of the lateral side of the lower leg and dorsum of the foot, which is similar to that reported by Babovic et al.12 This could be because all donor sites were closed directly, and previous reports have described that sensory deficits tend to occur in patients who undergo primary closure. This dysfunction is caused by injury to the peroneal nerve. Sagalongos et al7 introduced suprafascial dissection of the fibula flap and they confirmed that donor-site morbidity was negligible compared with conventional subfascial dissection. However, their sample was relatively small and more studies are required for verification. As reported in other studies,3,6 complications, such as weakness, edema, pain, and abnormal gait, were observed in the present patients, with the exception of ankle instability; most muscles in the deep posterior muscle group originate proximal to the fibular osteotomy site, and their contribution to ankle stability is not disrupted during fibula flap harvest.13 Most surgeons are interested in risk factors associated with late donor-site morbidity, but only a few studies have described a positive outcome. Momoh et al4 observed that abnormal ambulatory status decreased with follow-up time; similarly, in the present study, patients with a longer follow-up had fewer morbidities. A report by Vittayakittipong14 showed that body mass index was associated with function: overweight and obese patients who did not undergo surgery were already limited in their daily activities and had musculoskeletal dysfunction15; therefore, their risk of disability would have increased had they undergone surgery. Furthermore, in the present study, a longer harvested fibula and longer operation time were important risk factors for morbidity. A possible explanation might be that damage increases with the length of the harvested fibula; alternatively, the longer operation time could be related to the difficulty of the dissection and the authors’ limited experience of fibula flap transfers, resulting in more soft tissue damage during the operation. Most studies have not associated flap type with donor-site dysfunction,4,14 but the authors found that patients with complications tended to complain more if they had the osteocutaneous fibula flap rather than the osseous flap (P = .07). This could be because skin paddle harvesting can result in greater skin tension, which gives rise to the slow development of pseudocompartment syndrome.

4 Some shortcomings existed in this research. First, it was retrospective so selection bias could not be avoided. Second, only 45 patients were enrolled in this study. Even as a regional cancer center, patients needing free fibula flap reconstruction always come from low-income families and cannot afford the procedure. To generate more conclusive results, a larger group of patients needs to be studied. Third, all donor sites were closed primarily, so the authors were not able to evaluate donor sites requiring skin grafts. Future studies should address whether skin grafting affects donor-site function. In summary, this study showed that early donor-site morbidity in patients was uncommon, but that late morbidity occurred frequently. Harvested fibula length, operation time, and follow-up time were statistically linked to postoperative function.

References 1. Taylor GI, Miller GD, Ham FJ: The free vascularized bone graft: A clinical extension of microvascular techniques. Plast Reconstr Surg 55:533, 1975 2. Lin JY, Djohan R, Dobryansky M, et al: Assessment of donor-site morbidity using balance and gait tests after bilateral fibula osteoseptocutaneous free flap transfer. Ann Plast Surg 62:246, 2009 3. Bodde EW, de Visser E, Duysens JE, et al: Donor-site morbidity after free vascularized autogenous fibula transfer: Subjective and quantitative analyses. Plast Reconstr Surg 111:2237, 2003

RISK FACTORS FOR DONOR-SITE MORBIDITY 4. Momoh AO, Yu PR, Skoracki RJ, et al: A prospective cohort study of fibula free flap donor-site morbidity in 157 consecutive patients. Plast Reconstr Surg 128:714, 2011 5. Shindo M, Fong BP, Funk GF, et al: The fibula osteocutaneous flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 126:1467, 2000 6. Shpitzer T, Neligan P, Boyd B, et al: Leg morbidity and function following fibular free flap harvest. Ann Plast Surg 38: 460, 1997 7. Sagalongos OS, Valerio IL, Hsieh CH, et al: Qualitative and quantitative analyses of donor-site morbidity following suprafascial versus subfascial free fibula flap harvesting. Plast Reconstr Surg 128:137, 2011 8. Sieg P, Taner C, Hakim SG, et al: Long-term evaluation of donor site morbidity after free fibula transfer. Br J Oral Maxillofac Surg 48:267, 2010 9. Zimmermann CE, Borner BI, Hasse A, et al: Donor site morbidity after microvascular fibula transfer. Clin Oral Investig 5:214, 2001 10. Ling XF, Peng X: What is the price to pay for a free fibula flap? A systematic review of donor-site morbidity following free fibula flap surgery. Plast Reconstr Surg 129:657, 2012 11. Patel J, Burnham R, Martin T, et al: Complications related to the composite fibula flap and its acceptability to patients as a donor site. Br J Oral Maxillofac Surg 50:S39, 2012 12. Babovic S, Johnson CH, Finical SJ: Free fibula donor-site morbidity: The Mayo experience with 100 consecutive harvests. J Reconstr Microsurg 16:107, 2000 13. Garrett A, Ducic Y, Athre RS, et al: Evaluation of fibula free flap donor site morbidity. Am J Otolaryngol 27:29, 2006 14. Vittayakittipong P: Donor-site morbidity after fibula free flap transfer: A comparison of subjective evaluation using a visual analogue scale and point evaluation system. Int J Oral Maxillofac Surg 42:956, 2013 15. Wearing SC, Henning EM, Byrne NM, et al: Musculoskeletal disorders associated with obesity: A biomechanical perspective. Obes Rev 7:239, 2006