Free composite serratus anterior and rib flaps for tibial composite bone and soft-tissue defect

Open fracture in the lower extremity often involves composite bone and soft-tissue defects. For patients with extensive segmental bone defects, vascularized fibular transfers can be utilized and are generally accepted as one of the best options for reconstruction of intercalary defects. In some cases, either bilateral tibias and fibulas are fractured or the contralateral fibula is traumatically damaged or absent, precluding free fibular transfer. If an osteocutaneous fibular flap cannot be used to manage such a defect, a composite serratus anterior and rib flap may be considered. Nine composite serratus anterior and rib flaps, with or without latissimus dorsi transfers, were performed in eight patients between August of 1993 and March of 1994. One patient sustained a left knee disarticulation and underwent reconstruction for a right tibial defect. He failed to achieve lower extremity function within 2 years and was considered a failure. One flap failed, and the patient underwent a below-knee amputation. The remaining six patients received seven composite flaps for tibial and calcaneal defects and could ambulate without assistance. Based on this review, we conclude that the composite serratus anterior and rib flap with optional latissimus dorsi muscle can be used for (1) bilateral tibial fibular fractures, (2) contralateral lower limb amputation with fillet of the amputated leg if the leg is present for harvest, (3) contralateral middle-third fracture of the fibula, (4) patients in whom iliac bone is not suitable because of either a bone defect greater than 10 to 12 cm or previous harvest of bone graft, and (5) extensive composite bone and soft-tissue defects.