SRS149 - Recycling flap pedicle for secondary free fibular transfer in complex upper limb reconstruction

Composite upper limb trauma with simultaneous loss of bone, tendon, and soft tissue poses one of the greatest challenges in reconstructive surgery. Successful outcomes often require staged reconstruction and meticulous vascular planning, particularly when recipient vessels are limited. This report describes the first documented use of pedicle recycling in the upper limb. A 76 year old woman sustained complex forearm trauma following a dog bite, with segmental radial loss, tendon disruption, and soft-tissue degloving. Initial reconstruction combined fixation with a non-vascularised fibular allograft and dorsal coverage using an anterolateral thigh (ALT) free flap, but the allograft did not achieve union, progressing to pseudoarthrosis. At secondary reconstruction, the descending branch of the lateral circumflex femoral artery pedicle originally supplying the ALT flap was divided and reused to vascularise a free fibular flap. The ALT flap survived independently, confirming neovascularisation, while the fibular transfer achieved osseous union. At 12-month follow-up, radiographs confirmed cortical continuity, the ALT flap remained well contoured, and the patient regained functional grasp and release, restoring independent hand use in daily activities. This case demonstrates that pedicle recycling is feasible in the upper limb, a technique only rarely reported in lower limb salvage. Its successful application here highlights the importance of preserving pedicle integrity at the index procedure and reinforces pedicle reuse as a practical option for staged or vessel-depleted reconstructions. Crucially, this approach delivered not only durable union and stable coverage but also restoration of meaningful hand function.