Vascularized pedicled fibula flap with split periosteal overlay for ankle arthrodesis: Modification of technique and case report

Defects of the distal tibia, ranging from infectious to neoplastic origins, are difficult lesions to repair given their proximity to the ankle joint. Surgical repair options have often been limited, as ankle replacements and ankle arthrodesis generally require more tibial bone stock to achieve positive outcomes and avoid loss of function in the affected joint. Here we present a case of a distal tibial defect being reconstructed using a pedicled fibula flap and ankle arthrodesis technique that allowed for a sufficient range of mobility of the joint post-operatively. Our patient was a 52-year-old female with a history of myelodysplastic syndrome treated with a stem-cell transplant; fifteen months following the transplant, she was diagnosed with osteonecrosis of the distal tibia and calcaneus after developing severe swelling and pain in her left ankle. Despite conservative treatment measures, her symptoms continued to worsen, and ankle reconstruction was chosen as the only viable option for recovery. She underwent distal tibial reconstruction and tibiotalar arthrodesis using an ipsilateral vascularized pedicled fibular flap. The patient was ambulating well eight weeks post-op; she reported being able to painlessly bear full weight on the left ankle 14 weeks post-op. One-year post-op the patient was able to demonstrate an adequate range of motion of the affected joint, reduced relative to the unaffected limb but still allowing for suitable and comfortable ambulation. A 21-month post-op X-ray showed complete radiographic union of the distal tibia to the fibula flap and tibiotalar arthrodesis. As evidenced in our patient, an extremely positive postoperative outcome can be achieved with the utilization of this technique.