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Wee et al. Plast Aesthet Res 2019;6:12 I http://dx.doi.org/10.20517/2347-9264.2019.02 Page 3 of 12

Figure 1. Radiograph showing severely comminuted humerus fracture secondary to gunshot wound

Table 1 Characteristics of techniques for long bone reconstruction
Reconstructive Options for Segmental Bone Defects
Suggested Minimum # of
Technique Soft tissue component Strengths Limitations
Maximum Length operations
Corticocancellous < 6 cm 1 No Single operation, Small defects with adequate soft
bone graft quick recovery tissue coverage
Cortical bone graft 4-9 cm 1 No Single operation, Small to medium defects with
medium size adequate soft tissue coverage,
defects resorption and fracture with
longer grafts
Induced membrane 1-25 cm 2 No Technically Medium to large defects with
simple operation adequate soft tissue coverage.
Two stages. Time to weight
bearing 6-18 months.
Distraction 6-25+ cm 2 No Early partial One mm/day, soft tissue restricts
osteogenesis weight bearing distraction, joint contracture
Free fibula 6-30 cm 1 Multiple soft tissue Large soft tissue Fibula often injured in lower
options (skin, component, can extremity trauma, soft tissue
muscle, and chimeric shape the bone contiguous with bone, iatrogenic
configurations) injury to another extremity

defects and 3 pelvic defects. Successful union or bone healing was observed in 26 of 27 cases, with the
following complications noted: 2 cases of delayed soft tissue wound healing and 1 case of complete resorption
of a fibula bone flap requiring salvage with an expandable megaprosthetic and additional soft tissue flap
coverage.

RESULTS
The following are examples of cases performed within the case series mentioned above. Free fibula grafts in
extensive trauma:

Case 1. A 38-year-old male presented after high-velocity gunshot wound (GSW) to his right arm, resulting in
a severely comminuted fracture of his humerus [Figure 1]. He had segmental bone loss of the humerus and
complete segmental loss of his radial nerve. The only realistic treatment option in this case was the induced
membrane technique or a free vascularized fibular graft. We proceeded with the fibular graft as it provided
immediate stability and the ability to begin early gentle range of motion of the humerus [Figures 2A and B].
Anastomosis was performed to a muscular branch off of the brachial artery. This patient is now one year out