The Use of Serratus Anterior Artery as the Pedicle for Complex Humerus Reconstruction With a Vascularized Fibular Graft: Anatomical Study and Clinical Application in a Case Series

INTRODUCTION: Free vascularized fibular graft is an optimal option for the reconstruction of long, complex bone defects in the humerus. Previous surgeries, infection, and trauma, particularly with brachial artery revascularization, may limit the use of conventional recipient vessels. In this study, we review the use of the serratus anterior artery as a recipient vessel, the anatomical validation of its feasibility and its clinical application in a series of cases. METHODS: The anatomical study consisted of 14 dissections on 7 Thiel-embalmed cadavers. The distance from the origin of the serratus anterior pedicle to the most distal point where the artery had at least 1.2 mm of external diameter was measured, as well as to the surgical neck of the humerus. A retrospective review (2008-2024) included patients undergoing humeral reconstruction with a free vascularized fibular graft using the serratus anterior artery. Etiology, previous procedures, bone healing, complications, pain (Visual Analogue Scale, VAS), and function (quick Disabilities of the Arm, Shoulder and Hand score, quickDASH) were recorded. This study adheres to STROBE guidelines. RESULTS: The anatomical study showed that the mean pedicle length was 13.5 cm (range 11.8-15.5 cm), and in all dissections, the transposed pedicle reached distal to the humeral surgical neck. 5 patients (mean age 43 years, range 24-58 years) were included in the study. There were two posttraumatic and three post-oncologic reconstructions, with a mean of six previous surgeries. The mean follow-up was 9.7 years (range 1-17 years). All cases achieved bone union within the first postoperative year. There were two cases of postoperative complications: one case of fibular graft fracture that healed conservatively and one case of delayed healing of the fibular graft donor area. Mean VAS at last follow-up was 1.5 (range 0-4); mean quickDASH was 15.4 (range 0-32). CONCLUSION: The serratus anterior artery provides a reliable length and caliber for use as a recipient vessel for humeral reconstruction with a free vascularized fibular graft when conventional recipient vessels are not available.