Free vascularized fibular flap for clavicle reconstruction: A systematic review with a new case

Published:October 18, 2022DOI:



      Due to the rarity of the need for claviculectomy and the subsequent clavicle reconstruction, currently there is no consensus on the reconstructive approach for the clavicle. The clavicle is an essential bony structure that is necessary for optimal upper limb anatomical and physiological functionalities.


      This study analyzes the reconstructive approach, vascular anastomosis, complications, and long-term outcome of clavicle reconstruction using a free vascularized fibular flap through a systematic review of the literature and a case report from our institution.


      A comprehensive literature search was executed in the Ovid MEDLINE, Embase, and Google Scholar databases. The search strategy was designed to capture the concept of cases that underwent clavicle reconstruction after necessary claviculectomy with sufficient clinical information for detailed analysis. Using the final included articles, we analyzed and summarized the outcomes associated with clavicle reconstruction using free fibular osteocutaneous flap.


      A review of 179 articles yielded 11 publications with 26 cases that had detailed clinical information. We presented an additional case from our institution database. The systematic review of 27 cases revealed that clavicle nonunion due to various causes accounted for 73.08% of the cases for claviculectomy and the eventual reconstruction with a free fibular flap. The mean follow-up period in this study is 29.54 months with the range of 3 to 120 months. A total of 92.31% of the cases showed evidence of complete osseous consolidation.


      When claviculectomy is necessary, a free fibular flap can be utilized for the subsequent clavicle reconstruction to provide optimal anatomical and physiological functionality of the clavicle.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Plastic, Reconstructive & Aesthetic Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ye L.
        • Taylor G.I.
        A 10-year Follow-up of a Free Vascularized Fibula Flap Clavicle Reconstruction in an Adult.
        Plast Reconstr Surg Glob Open. 2017; 5: e1317
        • Akinsulire A.T.
        • Badmus O.O.
        • Giwa S.O.
        Giant cell tumour of the clavicle: a rare presentation of a locally aggressive tumour.
        Niger Postgrad Med J. 2017; 24: 250-253
        • Cahueque M.
        • Macias D.
        • Moreno G.
        Reconstruction with non-vascularized fibular autograft after resection of clavicular benign tumor.
        J Orthop. 2015; 12: S255-S259
        • Heidt C.
        • Ziebarth K.
        • Erni D.
        • Slongo T.
        • Joeris A.
        Four years follow-up after clavicle reconstruction in a child: a case report.
        J Plast Reconstr Aesthet Surg. 2014; 67: 1735-1739
        • Abarca J.
        • Valle P.
        • Valenti P.
        Clavicular reconstruction with free fibula flap: a report of four cases and review of the literature.
        Injury. 2013; 44: 283-287
        • Lenoir H.
        • Williams T.
        • Kerfant N.
        • Robert M.
        • Le Nen D.
        Free vascularized fibular graft as a salvage procedure for large clavicular defect: a two cases report.
        Orthop Traumatol Surg Res. 2013; 99: 859-863
        • Rodriguez Martin J.
        • Pretell Mazzini J.
        • Vina Fernandez R.
        • Marti Ciruelos R.
        • Curto de la Mano A.
        Ewing sarcoma of clavicle in children: report of 5 cases.
        J Pediatr Hematol Oncol. 2009; 31: 820-824
        • Glotzbecker M.P.
        • Shin E.K.
        • Chen N.C.
        • Labow B.I.
        • Waters P.M.
        Salvage reconstruction of congenital pseudarthrosis of the clavicle with vascularized fibular graft after failed operative treatment: a case report.
        J Pediatr Orthop. 2009; 29: 411-415
        • Kalbermatten D.F.
        • Haug M.
        • Schaefer D.J.
        • Wolfinger E.
        • Schumacher R.
        • Messmer P.
        • et al.
        Computer aided designed neo-clavicle out of osteotomized free fibula: case report.
        Br J Plast Surg. 2004; 57: 668-672
        • Erdmann D.
        • Pu C.M.
        • Levin L.S.
        Nonunion of the clavicle: a rare indication for vascularized free fibula transfer.
        Plast Reconstr Surg. 2004; 114: 1859-1863
        • Momberger N.G.
        • Smith J.
        • Coleman D.A.
        Vascularized fibular grafts for salvage reconstruction of clavicle nonunion.
        J Shoulder Elbow Surg. 2000; 9: 389-394
        • Krishnan S.G.
        • Schiffern S.C.
        • Pennington S.D.
        • Rimlawi M.
        • Burkhead Jr., W.Z.
        Functional outcomes after total claviculectomy as a salvage procedure. A series of six cases.
        J Bone Joint Surg Am. 2007; 89: 1215-1219
        • Taylor G.I.
        • Corlett R.J.
        • Ashton M.W.
        The Evolution of Free Vascularized Bone Transfer: a 40-Year Experience.
        Plast Reconstr Surg. 2016; 137: 1292-1305
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • Group P.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        J Clin Epidemiol. 2009; 62: 1006-1012
        • Spar I.
        Total claviculectomy for pathological fractures.
        Clin Orthop Relat Res. 1977; : 236-237
        • Frassica D.A.
        • Bajaj G.K.
        • Tsangaris T.N.
        Treatment of complications after breast-conservation therapy.
        Oncology (Williston Park). 2003; 17 (discussion 31-6, 41): 1118-1128
        • Fuchs B.
        • Steinmann S.P.
        • Bishop A.T.
        Free vascularized corticoperiosteal bone graft for the treatment of persistent nonunion of the clavicle.
        J Shoulder Elbow Surg. 2005; 14: 264-268
        • Ropars M.
        • Thomazeau H.
        • Huten D.
        Clavicle fractures.
        Orthop Traumatol Surg Res. 2017; 103: S53-SS9
        • Rubright J.
        • Kelleher P.
        • Beardsley C.
        • Paller D.
        • Shackford S.
        • Beynnon B.
        • et al.
        Long-term clinical outcomes, motion, strength, and function after total claviculectomy.
        J Shoulder Elbow Surg. 2014; 23: 236-244
        • Canadian Orthopaedic Trauma S.
        Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized clinical trial.
        J Bone Joint Surg Am. 2007; 89: 1-10
        • van der Meijden O.A.
        • Gaskill T.R.
        • Millett P.J.
        Treatment of clavicle fractures: current concepts review.
        J Shoulder Elbow Surg. 2012; 21: 423-429
        • Rasmussen J.V.
        • Jensen S.L.
        • Petersen J.B.
        • Falstie-Jensen T.
        • Lausten G.
        • Olsen B.S.
        A retrospective study of the association between shortening of the clavicle after fracture and the clinical outcome in 136 patients.
        Injury. 2011; 42: 414-417
        • Wessel R.N.
        • Schaap G.R.
        Outcome of total claviculectomy in six cases.
        J Shoulder Elbow Surg. 2007; 16: 312-315
        • Taylor G.I.
        • Seneviratne S.
        • Jones I.
        • White D.
        • Mah E.
        • Shayan R.
        Free vascularized fibula flap reconstruction of the clavicle combined with biceps tendon repair of the conoid ligament and customized plate stabilization of the acromioclavicular joint.
        Plast Reconstr Surg. 2009; 123 (113e-5e.)
        • Krishnan K.G.
        • Mucha D.
        • Gupta R.
        • Schackert G.
        Brachial plexus compression caused by recurrent clavicular nonunion and space-occupying pseudoarthrosis: definitive reconstruction using free vascularized bone flap-a series of eight cases.
        Neurosurgery. 2008; 62 (ONS461-9; discussion 9-70)
        • Koppert L.B.
        • van Geel A.N.
        • Lans T.E.
        • van der Pol C.
        • van Coevorden F.
        • Wouters M.W.
        Sternal resection for sarcoma, recurrent breast cancer, and radiation-induced necrosis.
        Ann Thorac Surg. 2010; 90 (1102-8 e2)
        • Abbot A.E.
        • Hannafin J.A.
        Stress fracture of the clavicle in a female lightweight rower. A case report and review of the literature.
        Am J Sports Med. 2001; 29: 370-372