Introduction and Purpose: Since its introduction by Taylor in 1975, the microvascular free fibula transfer has become gold standard in osseous reconstructions requiring vascularized bone transfer. Various modifications of the free fibula have been described in the literature. A series of 76 free vascularized fibula transfers during a 7-year period was reviewed. Data was retrospectively analyzed with respect to type of procedure and outcome, general surgical complications, as well as general and flap related ('specific') complications.

Methods: The patient age ranged between 14 and 82 years (median 52), with a gender distribution of 41 male and 35 female patients (n = 76 patients). The range of follow-up was between 1 and 67 months (median 9). Reconstructions included the mandible in 36 cases, 19 upper extremity and 19 lower extremity cases respectively, and 2 spine fusions. The fibula graft lengths varied between 5 and 18 cm. For mandibular reconstructions up to 3 osteotomies were required, while in extremity and spine reconstructions no osteotomies were needed. A skin island with the bone (osteo-septo-cutaneous fibula) was utilized in 67 cases. One arterial microvascular anastomosis was performed in all cases. A single venous microanastomosis was performed in 39 times, whereas two venous anastomoses were done in 37 cases. The pedicle (artery and vein) had to be elongated using vein grafts in 8 patients.

Results: Of all 76 free fibula flaps, 47 cases healed uneventful (62%), in 29 patients one or more postoperative complications occurred (38%). Interestingly, 53% of all extremity reconstruction cases had at least one of these listed complications, whereas in the maxillofacial cases the complication rate was only 25%. Complete osseous consolidation at the time of evaluation was confirmed in 58 patients (76%). A complete flap failure occurred in 4 patients (5%).

Conclusion: Complication rates reflect the complexity of the procedures and seem to be strongly related to the underlying disease and predisposing medical risk factors. Time will tell if advances, e.g. in the field of tissue engineering will replace autologous vascularized bone transfer in the future.