Free vascularized fibular graft (FVFG) was firstly reported in 1977 for reconstruction of long bone defect after resection of bone tumor. Since then, the FVFG has become a popular biological reconstructive option for limb-sparing surgery after resection of the malignant bone tumors.

Vascularized bone grafts don’t undergo resorption by creeping substitution due to their intact vascularity. FVFG can incorporate into the adjacent host bone directly via bone union similar to the process of healing of fractures. Due to the viability of FVFG, the structural integrity is well preserved until the bony union is achieved. Furthermore, soft tissue structures like skin, fascia, and muscle may be harvested concomitantly with the fibula and used for more complex soft tissue reconstruction.

FVFG can be used in three forms of reconstructive options:

(1) Single vascularized fibular graft which is mainly indicated for reconstruction of areas with lighter stress loads as in upper extremity reconstruction, segmental defects of the mid-tibia, and intercalary defects in pediatric patients.

(2) Vascularized double-barreled fibula which can be indicated for areas with intermediate stress loads such as femur and pelvis. This technique can provide the double volume of a fibular graft for the same length of the defect with the same number of the microvascular anastomosis.

(3) In combination with an allograft or devitalized autograft such as pasteurized or irradiated autograft.

Despite these advantages, the fibula has small cross-sectional area and is weaker than the originally resected long bone, particularly the femur. The sufficient fibular thickness to allow full weight-bearing is achieved several years after the surgery as the fibula needs a long time to undergo hypertrophy through processes of pressure transport, microfractures, and callus formation.

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Journal of Orthopedic Oncology

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