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cast immobilization, application of external fixation, and open reduction with internal fixation [14,39] .

Donor site morbidity
Donor site morbidity profiles can have a significant impact on the surgical decision-making process.
Limited donor site morbidity has been described following MFC flaps when compared to vascularized free
fibula flap and iliac crest bone graft. Multiple systematic reviews have been performed to elucidate the true
incidence of complications associated with these vascularized bone graft donor sites. The donor site
morbidities based on vascularized bone graft are outlined in Table 1.

[46]
Ling et al. performed a systematic review of the literature and calculated weighted mean incidences for
early and late donor site complications following free fibula flap. Early complications included infection
(1.1%), dehiscence (7.0%), necrosis (7.3%), delayed wound healing (17.4%) and skin graft loss (8.1% partial
graft loss, 4.7% complete graft loss). Of note, the incidence of wound healing complications was higher in
donor sites that were skin grafted compared to those that were closed primarily (19.0% vs. 9.9%). The most
common late complication was a limited range of motion of the ankle (11.5%) followed by altered sensation
(7.0%), persistent pain (6.5%), claw toe (6.1%), ankle instability (5.8%), reduced muscle strength (4.0%), gait
[46]
abnormality (3.9%), and dorsiflexion of the great toe (3.6%) . Compartment syndrome of the lower leg is
rare, however severe, complication following vascularized free fibula flap - a rate of 3% was reported in a
[47]
recent meta-analysis by Gu et al. in the setting of mandibular reconstruction.

Early and long-term donor site morbidities following vascularized iliac bone flap for mandibular
reconstruction were evaluated by Gu et al. in a 2021 systematic review and meta-analysis. The most
[47]
common donor site morbidities were late complications - chronic altered sensation (43%), pain (26%), and
[47]
gait disturbance (20%) . The altered sensation is likely related to injury to the lateral femoral cutaneous
nerve with resulting lateral thigh numbness/tingling. The reported early donor site morbidities (wound
infection, dehiscence, and hernia) ranged from 3% to 16% . The iatrogenic hernia is a rarely reported
[47]
complication (3% in the previously cited meta-analysis) and is thought by some authors to correlate with
the size of the flap [47,48] . Donor site morbidity has been compared in the craniomaxillofacial literature
between free fibula flaps and vascularized iliac bone grafts. The fibula group had less immediate post-
operative pain and returned to unaided walking faster, while patients who underwent iliac bone graft had a
higher incidence of altered sensation and gait abnormality .
[49]
A systematic review of the literature evaluating donor site morbidity following vascularized bone grafts
from the distal femur by Giladi et al. found a low rate of donor site complications. The most commonly
[50]
reported donor site morbidities included persistent knee pain (which commonly lasts up to 3 months), and
temporary altered sensation (parethesias or sensitivity) - < 2% of patients in the included studies had
permanent altered sensation. The authors suggest that sensory changes could be related to saphenous nerve
injury associated with osteocutaneous flap harvest. There are no reports in the literature of post-operative
knee instability or limitations to knee range of motion. Secondary procedures were performed in 2.5% of
patients included for review (6 flaps); procedures included: hematoma evacuation, seroma evacuation,
wound debridement, and open reduction and internal fixation of femur fracture . Post-operative femur
[50]
[22]
fracture has been reported in two patients in the literature .
CONCLUSIONS
Vascularized bone grafts may be required for the reconstruction of bone defects in the setting of lower
extremity trauma. Indications include bony defect greater than 6 cm, fracture non-union, and previously
failed reconstruction with non-vascularized bone grafts [12-14] . Single-stage and two-stage approaches have