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Application for ESRA Abstract Prizes:Background and Aims The free fibula flap is a versatile option for reconstructing bone defects. Its success depends on meticulous perioperative planning due to microvascular complexity and dual surgical fields. This case highlights perioperative strategies supported by current evidence.Methods A 36-year-old male with diaphyseal humeral pseudoarthrosis after multiple surgeries for a blast-related fracture underwent a 7 cm free fibula flap transfer from the right leg. Simultaneous donor and recipient site surgeries were performed under general anesthesia and dual ultrasound-guided blocks: a popliteal-sciatic block (20 mL levobupivacaine 0.25%) in supine position for the donor site, and a supraclavicular continuous block (20 mL levobupivacaine 0.25% plus lidocaine 1% reinforcement boluses) for the recipient site. The 10-hour procedure involved 1L blood loss, managed with tranexamic acid, fibrinogen, and transfusion. Hemodynamic and gasometric monitoring ensured stability without vasopressors. A Doppler probe was used for flap monitoring. Postoperative continuous analgesia via catheter and PCA was effective, avoiding opioid rescue. Doppler signals remained stable, and the patient was discharged without complications.Results Free flap failure ranges from 1–5%, especially in trauma and early postoperative periods. Preoperative optimization of hemoglobin, glucose, and nutrition, and maintaining perfusion and oxygenation delivery intra- and postoperatively, are essential. General anesthesia is preferred for complex surgeries, while regional blocks may enhance perfusion via sympathetic blockade, though evidence is limited. Hemodynamic control, cautious use of vasopressors and tranexamic acid, goal-directed fluid therapy, early thromboprophylaxis, and monitoring are crucial.Abstract P315 Figure 1Removal of osteosynthesis material, bone resection of pseudoarthrosis margins, circular external fixation, steinmann intramedullary nailing and cement spacerAbstract P315 Figure 2Ultrasound image of supraclavicular catheter, posterolateral plane approach, between the upper and middle trunkAbstract P315 Figure 3Free fibula flap placement on bone defectConclusions Free flap reconstruction requires multidisciplinary planning and precise perioperative care. Further evidence is needed regarding regional anesthesia and transfusion strategies in microsurgery.