Download the blood supply of the osteocutaneous free fibular graft

THE
BLOOD
SUPPLY
OSTEOCUTANEOUS
A.
FREE
J. CARR,
D.
From
the
A.
OF THE
FIBULAR
MACDONALD,
Nuffield
N.
Orthopaedic
GRAFT
WATERHOUSE
Centre,
Oxford
The use of an osteocutaneous
free fibular graft as a single-stage
reconstructive
procedure
for composite
loss is increasingly
common.
Detailed
anatomical
study in cadavers
of the blood supply to the graft
demonstrates
cutaneous
arteries
arising from the peroneal
artery and then passing along the posterior
surface
of the lateral
intermuscular
septum. These vessels pierce the crural fascia and then ramify to supply the skin.
Knowledge
of the vascular
anatomy
of the skin overlying
the fibula is essential
to the success of the graft.
tissue
Vascularised
in
the
bones
grafting
the
fibular
grafts
management
have
of
than
traditional
(Taylor,
Miller
advantage
suitable
which
of
successful
methods
and Ham
of non-vascularised
1975). The fibula
being
a compact
loss
long
from
bone
long
the deep
fascia
was
included.
vessels
pierce
the deep
fascia
has
subcutaneous
layer,
establishing
leg deep
to the fascia
(Haertsch
and
for
can
is
microvascu!ar
be combined
also
supplied
anastowith
a
by the
and Yan
1983;
Harrison
skin flap allows
treatment
1986).
of cases
with
a simultaneous
skin defect.
The blood
supply
to the skin consists
of two main
types of artery : first, those which
are terminal
branches
of arteries
secondly,
supplying
other
tissues
such
as
direct
cutaneous
arteries
which
pass
individual
the
muscles,
skin,
century
as
(Ristic
It is the
must
often
along
described
and
direct
by
Morain
branches
be included
fascial
in
1983)
of the
muscle;
between
planes,
Manchot
and
the
to reach
nineteenth
by Salmon
peronea!
in the osteocutaneous
(1936).
artery
fibu!ar
flap
which
if the
skin is to remain
viable
(Carriquiry,
Costa
and Vasconez
1985). These
vessels
were originally
observed
in studies
of the communicating
veins
of the legs although
their
potential
(Linton
long
significance
1938). It was
skin
flaps
was
not
recognised
could
be raised
realised
at that
by Pont#{233}n(1981)
in the
lower
time
that
The
direct
cutaneous
and then
ramify
in the
a surgical
1981).
plane
in the
is
The peroneal
artery,
vessels
to the fibula,
is of
sufficient
calibre
to be used
mosis.
A free fibular
graft
fasciocutaneous
flap
which
(Chen
ofa
more
bone
for early
weight-bearing.
provides
the nutrient
peroneal
artery
The incorporation
proved
extensive
MATERIALS
This study
to 72 years
AND
METHODS
was carried
out on 16 fresh cadavers,
aged 59
(mean
63 years)
and excluded
all those
with
diabetes
or evidence
of peripheral
vascular
disease.
The
popliteal
artery
was exposed
through
a longitudinal
posterior
incision.
It was cannulated
and flushed
at 100
to 1 50 mmHg
with one litre of normal
saline
at 37#{176}C
for
two to three hours.
then tied proximally
The origin
of the
and cannulated.
peroneal
artery
was
In eight
cadavers
30 ml of 100% w/v barium
sulphate
and 10% gelatin
at
37#{176}C
were injected
and in the remaining
eight
cadavers
30 ml of indian
ink were injected,
both at a pressure
of 100
to 1 50 mmHg.
Radiographs
were taken
of the leg using
Kodak
Industrex
C film. Exposures
were made
in the
post-mortem
room from a mobile
unit at I 50 mA and 50
kV for I .0 second
and the films processed
by hand.
In the
ink-injected
was raised
leg a flap of skin, approximately
on the lateral
aspect
of the leg,
deep
fascia.
The
dissected
free,
the
branches
identified
lateral
intermuscular
peroneal
artery
and
and their position
and
10 x 1 5 cm,
including
the
septum
was
its cutaneous
size recorded.
leg provided
FINDINGS
A. J. Carr,
FRCS,
Nuffield
Orthopaedic
England.
Research
Registrar
Centre,
Headington,
D. A. Macdonald,
FRCS,
Glasgow
Western
Infirmary,
N. Waterhouse,
Mount
Vernon
Requests
for
FRCS,
Hospital,
reprints
Lecturer
in Orthopaedic
GI 1 6NT,
Scotland.
FRCS
Ed,
Northwood,
should
©
70-B, No. 2, MARCH
1988
OX3
7ND,
Surgery
Senior
Registrar
in Plastic
Surgery
Middlesex
HA6 2RN,
England.
be sent
1988 British
Editorial
Society
030l-620X/88/2043
$2.00
J Bone Joint Surg [Br] 1988:70-B:
VOL.
Oxford
to Mr
of Bone
3 19-21.
A.
and
J. Carr.
Joint
Surgery
The peroneal
approximately
artery
arises
2 to 3 cm
popliteus
muscle,
descends
posterior
along
its
and
flexor
calcaneal
posterior
anastomose
arteries.
branches
surfaces
with
it
from
below
the posterior
the lower
passes
towards
medial
hallucis
border,
longus
which
ramify
on
of the
calcaneum.
the
anterior
and
tibial
border
the
fibula
artery
of the
and
between
tibialis
and
divides
into
the lateral
and
These
vessels
posterior
tibial
319
A. J. CARR,
320
D. A. MACDONALD,
N. WATERHOUSE
between
uppermost
the
superficial
posterolateral
the posterior
tibial
and deep
venous
systems.
vessel
often
originated
artery
in halfofthe
cadavers
The
from
studied;
it corresponds
to the circumflex
fibular
artery
described
in Gray’s
Anatomy
(Warwick
and
Williams
1973).
Having
pierced
the deep
fascia
of the leg, the vessels
divide
to form
a plexus
of vessels
in the subcutaneous
layer
and supply
the skin (Fig. 2). The region
of skin
supplied
by the peroneal
artery
includes
a consistent
area
on
the
posterolateral
aspect
of the
leg
(Fig.
3).
DISCUSSION
Fig.
Cadaver
vessels
lateral
leg injected
of the peroneal
intermuscular
The
the
the
out
peroneal
with
artery
indian
ink to show
running
along the
sometimes
perforating
posterior
cutaneous
surface
of the
skin flap should
be designed
with its long axis in the
of the fibula.
The deep
fascia
of the leg must
be
included
with
the
skin
to preserve
the
plexus
of vessels
septum.
artery
fibula
which
enter
on
bone.
At approximately
its length
septocutaneous
laterally,
The
line
I
through
supplies
the
2
the nutrient
vessels
to
posteromedial
surface
of
to 5 cm intervals
throughvessels
arise
which
pass
the
edge
of soleus,
onto
H
the
posterior
surface
of the lateral
intermuscular
septum
(Fig.
1). These
vary in number,
from four to eight,
and
have a diameter
of0.4
to 1.5 mm. They are accompanied
by venae
comitantes
which
provide
a communication
Fig.
3
Shaded area represents
the cutaneous distribution
of the peroneal
artery.
lying within
the subcutaneous
fat.
damaged
by excessive
movement
The
cutaneous
vessels
These
vessels
of skin upon
of the peroneal
artery
may be
fascia.
pass
onto
the posterior
surface
of the lateral
intermuscular
septum,
either
directly
or through
the edge of soleus.
The vessels
may pierce
the lateral
intermuscular
septum
and run for a
short distance
on its anterior
surface.
In order to preserve
Radiograph
of a cadaver
leg in which
the
peroneal
artery
has
been
injected
with
barium
sulphate.
The
perforating
vessels
(thin arrow)
can be seen running
out to the
skin from the peroneal
artery
(thick
arrow):
these must be included
in the osteocutaneous
fibular
graft.
Reflux
of contrast
into
the
anterior
tibial
artery
can also be seen.
these vessels
a strip of soleus should
be contained
within
the fascia!
pedicle
; it is unnecessary
to include
a great
bulk of muscle
between
the skin flap and the fibula.
The
nutrient
vessels
of the fibu!a pass into the posteromedial
surface
ofthe
bone and the cuffofmuscle
included
in the
fibu!ar
graft
should
always
be thickest
at this
point
(Fig. 4). At the origin
of the peroneal
artery
a large
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
THE
BLOOD
SUPPLY
OF
THE
OSTEOCUTANEOUS
FREE
It
FIBULAR
is hoped
anatomy
of
encourage
procedure
that
the
321
GRAFT
this
study
osteocutaneous
its use
as a
in the management
tissue
loss. The
use
advantage
of allowing
the composite
graft.
of
clarifies
the
fibular
graft
single-stage
ofextensive
a skin
monitoring
flap
surgical
and
will
reconstruction
bone and soft-
has the additional
of the circulation
to
Anterior
REFERENCES
tibiol
I vessels
*-,...--
I I
. .
Carriquiry
C, Costa
septocutaneous
198:76:34-61.
Posterior
Chen
vessels
ZW, Yan
osteocutaneous
for
Cross-section
the peroneal
osteocutaneous
of the lower
leg showing
artery
(the dotted
line
fibular
graft).
lower
the cutaneous
represents
the
branches
limits
of
of
the
Ristic
Salmon
Taylor
cutaneous
This may
impossible
VOL.
70-B,
vessel
arises,
the
circumflex
branch
from the posterior
to include
in the flap.
No.
2, MARCH
1988
their
peroneal
tibial
artery
artery.
and
and
clinical
Microsurgery
surgical
leg.
plane
in
osteocutaneous
:804-7.
ligation.
Pont#{233}n
B. The
4
The
study
of fibula.
flap
RR. Communicating
Linton
Fig.
DH. The
1986:68-B
Harrison
[Br]
LO.
An
the
leg.
W.
Haertsch
P. The
1981 :34:464-9.
:;Ql
MA,
Vasconez
vessels
of
Ann
free
veins
Surg
the
fibular
anatomic
Plast
study
Reconstr
application
1983 :4 : 1 1 -6.
leg.
Br
graft.
of lower leg and
1938:107:582-93.
fasciocutaneous
flap : its use in soft
Br J Plast Surg 1981:34:215-20.
J
tissue
the
Surg
Joint
Surg
technique
defects
of the
J, Morain
WD, translators.
Carl Manchot
The cutaneous
arteries
ofthe
human
bod.
New
York,
etc: Springer-Verlag,
1983.
M.
GI,
clinical
Art#{232}resde Ia peau.
Paris:
Miller
GDH,
Ham FJ. The
extension
of microvascular
Masson,
1936.
free vascularized
techniques.
Plast
bone graft : a
Reconstr
Surg
1975:55:533-44.
be
the
Surg
of
P/act
J Bone
operative
of
Warwick
R, Williams
Longman,
1973.
PL (Eds).
Grays
Anatomy.
35th
ed.
Edinburgh: