Forearm reconstruction with a microsurgical free fibula flap and inguinal flap after resection of giant cell tumor

Abstract

1. INTRODUCTION:
Reconstruction of upper extremity osteocutaneous defects following wide oncologic resection with free microvascular flaps has become the treatment of choice, especially for bone defects >6 cm, or those with a poor vascular bed or evidence of chronic osteomyelitis. In larger defects, skin coverage with a secondary sequential flap can be used.
These types of defects represent a reconstructive challenge, and multiple variables must be considered during evaluation, such as the location and size of the defect, associated lesions, soft tissue coverage, and associated comorbidities, in order to restore a resistant structure with the strength necessary to maintain forearm functionality for as long as possible.

2. CLINICAL CASE:
This is the case of a 20-year-old female patient diagnosed with a giant cell tumor of the distal forearm that had been present for 13 months. Diagnostic intervention, follow-up, and treatment were postponed at her home hospital due to pregnancy, and the patient continued to experience enlargement and deformity of the right forearm. She was referred to our Institute after delivery. Tumor resection was performed by the Bone Tumor Service with distal radius involvement, and reconstructive management was achieved through plastic surgery. A microsurgical fibula flap was used to reconstruct the radial bone gap. A wrist arthrodesis with a free fibula was performed by orthopedics. Microsurgical anastomosis was performed on the radial vessels, and a right inguinal flap was dissected to provide skin coverage.

3. DISCUSSION:
Reconstruction of forearm bone defects remains a challenge for the surgeon. The decision to use a fibular flap or another alternative depends on the characteristics of the defect, the patient's needs, and the surgeon's experience. The free fibular flap is one of the most versatile options for reconstructing these defects; the length, shape, and dual blood supply of the fibula make it an ideal option for reconstruction, offering stability and potential for osseointegration. This procedure requires a thorough understanding of vascular anatomy, microsurgical techniques, and postoperative management to ensure successful results and minimize complications. The flap can be osteocutaneous in some cases, providing bone stability and simultaneous skin coverage. In contrast, in larger defects, stable skin coverage is required with fasciocutaneous flaps such as the pedicled inguinal flap or the anterolateral thigh flap.

4. CONCLUSIONS:
Oncologic reconstruction of the upper extremity requires evaluation and planning by experienced surgeons. Most cases require microsurgical flap options that can provide bone stability, such as the fibular free flap, which provides minimal morbidity at the donor site. In our case, after reconstruction and osteoarticular rehabilitation, the patient maintained functional biomechanics of the hand and forearm with stable skin coverage.