Background: Significant osseous defects or osteonecrosis, precipitated by open fractures, infections, or neoplastic conditions, represent infre- quent yet critical medical conditions. The free vascularized fibular graft (FVFG) is a challenging but straightforward, reliable surgical intervention for the reconstruction of defects across various anatomical regions. This study aims to compare, quantify, and demonstrate the FVFG's versatility. The utilization of a single- or double-barrel approach, contin- gent on the defect's characteristics, optimizes length conservation or enhances the stability of extensive defects. Methods: We retrospectively evaluated patients who underwent the FVFG procedure, employing either a single-or double-barrel technique, at our medical center during the period from August 2017 to May 2023. The inclusion criterion was the presence of substantial osseous defects (bone loss in straight bone over 8-10 cm or multi-level spine resection), precipitated by trauma, neoplasms, non-union fractures or infections. Results: Our study encompassed eight male patients, with an average age of 31 years, ranging from 10 to 56. Each patient underwent osseous resection due to osteomyelitis (n=2), tumor excision (n=4), or pseudar- throsis (n=2) resulting from previous trauma, followed by a free fibula flap as part of the FVFG procedure. When fibula was simultaneously prepared already during tumor resection (n=2), there was a significant reduction in the overall operation time. Postoperative assessment re- vealed that full osseous integrity without any graft failure was restored in all patients, and the same number of patients regained independent ambulatory ability. Surgical complications were observed in one patient, who exhibited wound healing post-reconstruction, all of which were rectified through subsequent surgical intervention. Conclusion: Diverse osseous defects in complex cases can be recon- structed by using the FVFG, thereby restoring maximal reconstructive capacity, expedited union compared to non-vascularized bone, and ac- ceptable donor site morbidity. FVFG remain a reliable solution for diverse defects. Moreover, in cases requiring complex tumor defects, careful preoperative planning and an interdisciplinary treatment are essential for successful treatment.
