An Anatomic Study of Vascularized Fibular Grafts

Chinese Journal of Traumatology 2008; 11(5):279-282 . 279 .

An anatomic study of vascularized fibular grafts

ZHU Yue-liang 朱跃良*, XU Yong-qing 徐永清, YANG Jun 杨军, Li Jun 李军 and LAN Xiu-fu 兰秀夫

Objective: To study the applied anatomy of the vascu- arcuate arteries were constantly located between the distal lar and muscular innervations related to vascularized fibular half of the 1/4 segment and 2/4 segment of the fibula. The grafts. muscular branch of the superficial peroneal nerve passed Methods: Thirty-four cadaveric lower extremities were through the surface of the periosteum in the 2/4 segment of dissected for this study. The observations included fibular the fibula. length, fibular nutrient artery, arcuate arteries, and innerva- Conclusions: The most proximal osteotomy point lo- tion of fibular muscles. The fibulas were averagely divided cates at the midpoint of the 1/4 segment by which it ensure into four segments and the locations of relevant vessels the maximal potential for preserving the nutrient vessels. and nerves were ascertained. The muscular branch of the superficial peroneal nerve is Results: All specimens had 1 fibular nutrient artery fragile to injury at the 2/4 segment of the fibula. and 4-9 arcuate arteries except 1 specimen which had only 1 Key words: Fibula; Grafts; Anatomy; Artery; Nerves arcuate artery. The fibular nutrient artery and the first three Chin J Traumatol 2008; 11(5):279-282

ince Taylor1 firstly reported the vascularized tomical knowledge will be greatly helpful for surgeons fibular grafts, this technique has been widely to perform vascularized fibular graft operations. Sused in plastic surgery. It is effective for reconstruction of the tibia, femur, shoulder, wrist, and METHODS mandible.2-8 Chen and Yan9 completed the first free fibular graft for congenital pseudarthrosis in China. There Thirty-four lower extremities from adult cadavers has been great experience and techniques accumu- were sectioned through the middle of the thigh (17 left lated over the recent 30 years, but some details of the limbs, 17 right limbs; 12 females and 22 males). The techniques are still obscure. The survival of the vascu- specimens were provided by the Anatomy Department larized fibular grafts in the recipient site relies on blood of Kunming Medical College. The fibula length (from supply from the peroneal artery. Several recent studies the fibular head to the lateral ankle) was measured and reported the variants of the peroneal artery.10-12 Prior to divided into four segments averagely. All the specimens reaching the muscular cuff and bone, the blood must were dissected and observed. The measurement in- pass through the nutrient arteries including a fibular nu- cluded the origin and passway of the fibular nutrient trient artery and arcuate arteries. The anatomic study artery and the arcuate arteries. The observation included about these vessels has not sufficiently been reported the innervations of the peroneus brevis, the peroneus so far in the literature. The nerves innervating peroneus longus, the extensor digitorum longus and the exten- muscles are prone to injury during the harvest of muscle sor hallucis. cuff by traditional ways 13 or by muscle sparing technique,14 and reports on the relating anatomy are RESULTS rare. We believe that a fully acquisition of these ana- The fibular length was 352.3 mm ± 15.1 mm. Being divided into four segments (1/4, 2/4, 3/4, 4/4) averagely Orthopedic Department, Kunming General Hospital, in this study, each segment was 88.1 mm ± 3.8 mm in Chengdu Military Command, Kunming 650032, China (Zhu length. The fibular nutrient artery originated directly from YL, Xu YQ, Yang J, Li J) Orthopedic Department, Daping Hospital, Third Military the peroneal artery in all the specimens. The origin site Medical University, Chongqing 400042, China (Lan XF) was 80.48 mm ± 29.1 mm distal to the fibular head and *Corresponding author: Tel: 86-13577055695, E-mail: closely around the junction between the 1/4 and 2/4 [email protected] segments. Thirty-three specimens had 4-9 arcuate ar- . 280 . Chinese Journal of Traumatology 2008; 11(5):279-282 teries (Fig. 1). One specimen had single arcuate artery DISCUSSION (Fig. 2). The first arcuate artery originated 95.4 mm ± 21.6 mm distal to the fibular head from the peroneal There have been 7 reports altogether so far on fibula artery. The interval distance between the origins of the and its vascular anatomy in Chinese people.15-21 Ours first, second and third arcuate arteries were 43.2 mm ± are based on these pioneering works. These papers 16.1 mm and 38.5 mm ± 14.4 mm respectively and all confirmed that the fibular nutrient artery and the arcu- passed through the 2/4 segment of the fibula. In this ate arteries were essential to the survival of the grafted study, all the fibular nutrient artery, 97% of the first fibula. It is suggested that the fibula should be harvested arcuate artery, all of the second arcuate artery, and within the proximal 1/3 so as to preserve the nutrient 68% of the third arcuate artery passed constantly be- vessels.13 The results of this study further clarified that tween the distal half of 1/4 and 2/4 of the fibula. For the most proximal osteotomy point should be at the securing sufficient blood supply to the bone, the peri- midpoint of the 1/4 segment. Distal from this point, the osteum and muscular cuff, the most proximal osteotomy vasuclarized fibula grafts might contain the fibular nutri- point should be adjacent to the fibular nutrient artery ent artery and the first three arcuate arteries. This and arcuate arteries. The midpoint of the 1/4 segment osteotomic level is absolutely essential for patients with had the maximal potential for preserving the nutrient only one fibular nutrient artery and one arcuate artery. vessels (Figs. 3-4). Such cases are rare but do exist as showed in this study and Ding’s.21 Many reports expounded the ways Fibular surfaces could be divided into four surfaces to find the variants relating to the free fibular flap: peronea according to the muscular attachment: the extensor arteria magna, arteriosclerotic disease, and absence surface, peroneus surface, flexor surface, and tibialis of the peroneal artery,10-12 but effective ways to find pre- posterior surface. Both peroneus longus and peroneus operatively the situations of nutrient peroneal arteries brevis attached to the peroneus surface. Peroneus lon- are lacking. Accordingly, we believe that it is neces- gus attached to the 1/4 segment and the anterior half sary to define a most proximal osteotomy point for any of the 2/4 segment of the peroneus surface. Peroneus free vascularized fibula grafts, which locates at the mid- brevis attached to the posterior half of the 2/4 segment, point of the 1/4 segment of the fibula. the whole 3/4 segment and part of the 4/4 segment of the fibular surface. The oblique interval between the at- Babovic et al.22 recently reported the postoperative tachment of the peroneus longus and breveis was in- donor-site deformity. Among 100 cases, the maximum variably located at the 2/4 segment of the fibular sur- limited ambulatory distance was less than 1 000 m in face and passed anterosuperiorly to posteroinferiorly. 15 cases and difficulty in walking stairs in 6 cases, The cutaneous branch derived from the superficial pero- which is probably related to complications and func- neal nerve 99.2 mm ± 27.0 mm distal to the tip of the tions of the peroneal brevis. Vigilance and meticulous fibular head. After that, the superficial peroneal nerve manipulation are mandatory considering the relatively turned to be a muscular branch solely. There were two invariable relations between the muscular branch of the different passways of the muscular branch of superfi- superficial peroneal nerve and its surroundings in 2/4 cial peroneal nerve when it passed through the oblique segment. The nerve injury may lead to the disability of interval (Fig. 5). Whatever the passways were, the nerves the peroneal brevis and postoperative varus-valgus im- passing through the oblique interval were closely at- balance of the foot. This, as we know, has failed to give tached to the periosteum. The peroneus brevis in the 2/ enough attention before. 4 segment was thin and the nerve was fragile to injury. The anatomic relations were found to be constant be- We draw the following conclusions from this study: tween the attachment of the peroneus longus and pero- (1) The proximal osteotomy point is defined at the mid- neus brevis, the inter-muscular interval and muscular point of the 1/4 segment for preserving the nutrient ves- branch of the superficial peroneal nerve. For the mus- sels of grafted fibula.(2) The muscular branch of the cular branch of the superficial peroneal nerve at the 2/4 superficial peroneal nerve for the peroneal brevis is likely segment, the peroneus longus constituted the “roof”, to injure at the 2/4 segment of the fibula. and the peroneus brevis the “bed” (Fig. 6). Chinese Journal of Traumatology 2008; 11(5):279-282 . 281 .

Fig. 1. Normal distributions of the arcuate arteries (arrows). Fig. 2. A specimen with only one arcuate artery (arrow) and the most proximal osteotomy point. Blood supply to the fibula would be Fig. 6. The course of the superficial peroneal nerve: the muscular jeopardized if the section was distal to this artery. branch and cutaneous branch. 1: the superficial peroneal nerve, 2: the cutaneous branch, 3: the muscular branch for the peronesu brevis, 4: the peroneus longus (retracted), 5: the peroneus brevis.

REFERENCES

1.Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg 1975;55(5): 533-544. 2.Hagan KF, Buncke HJ. Treatment of congenital pseudarthrosis of the tibia with free vascularized bone graft. Clin Orthop Relat Res 1982;(166): 34-44. 3.Weiland AJ, Weiss AP, Moore JR, et al. Vascularized fibular grafts in the treatment of congenital pseudarthrosis of the tibia. Fig. 3. The origin and passway of the nutrient arteries of the fibula J Bone Joint Surg Am 1990;72 (5): 654-662. (posterior view of the right side). Fig 4. The maximal length of the 4.Wei FC, El-Gammal TA, Lin CH, et al. Free fibula fibular shaft graft: from the most proximal to the most distal os- osteosep-tocutaneous graft for reconstruction of segmental femo- teotomy point. ral shaft defects. J Trauma 1997;43(5):784-792. 5.Wada T, Usui M, Isu K, et al. Reconstruction and limb salvage after resection for malignant bone tumor of the proximal humerus. A sling procedure using a free vascularised fibular graft. J Bone Joint Surg Br 1998;81(5): 808-813. 6.Weiland AJ, Kleinert HE, Kutz JE, et al. Free vascularized bone grafts in surgery of the upper extremity. J Hand Surg Am 1979;4(2):129-144. 7.Daniel RK, Weiland AJ. Free tissue transfers for upper extremity reconstruction. J Hand Surg Am 1982; 7(1):66-76. 8.Hidalgo DA. Fibula free flap: a new method of mandible Fig. 5. Two different types of the muscular branch of superficial reconstruction. Plast Reconstr Surg 1989; 84(1): 71-79. peroneal nerve when it passes through the interval (lateral view 9.Chen ZW, Yan W. The study and clinical application of of the right side)). Type A (left): The muscular branch runs along the osteocutaneous flap of fibula. Microsurgery 1983;4(1):11-16. the peroneus brevis side of the interval to the posterior edge and penetrates the perneus brevis where it divides into one or two 10. Clemenza JW, Rogers S, Magennis P. Pre-operative evalu- terminal branches (19 specimens,56%). Type B (right): The mus- ation of the lower extremity prior to microvascular free fibula flap cular branch directly passes through the oblique interval (15 harvest. Ann R Coll Surg Engl 2000; 82(2): 122-127. specimens, 44%). . 282 . Chinese Journal of Traumatology 2008; 11(5):279-282

11.Young DM, Trabulsy PP, Anthony JP. The need for pre- and the fibula: an anatomical study on 100 specimens. Acta operative leg angiography in fibula free flaps. J Reconstr Microsurg Anatomica Sinica 1981;12(1): 20-26. 1994;10(5): 283-287. 19.Chen YL, Sheng ZW, Bao GZ, et al. The vascular supply 12.Karanas YL, Antony A, Rubin G, et al. Preoperative CT of the fibula. Acta Anatomica Sinica 1981;12(1): 13-18. angiography for free fibula transfer. Microsurgery 2004;24(2): 20.Guo LK, Wang SK, Han XY. Arterial blood supply of the 125-127. fibula. Chin J Orthop 1982;2(3): 139-143. 13.Canale ST, eds. Campbell’s operative orthopaedics, 9th 21.Ding XZ, Wu YM. Peroneal artery, blood supply of fibula ed. St. Louis: Mosby-Year Book Inc, 1998: 3229-3232. and its clinical application-a study of 100 cadavers. Chin J Orthop 14.Graham RG, Swan MC, Hudson DA, et al. The fibula free 1982;(3):134-138. flap: advantages of the muscle sparing technique. Br J Plast Surg 22.Babovic S, Johnson CH, Finical SJ. Free fibula donor-site 2003;56(4): 388-394. morbidity: the Mayo experience with 100 consecutive harvests. J 15.Zhao MX, Chen MX, Wang QH. The perforators of the Reconstr Microsurg 2000;16(2): 107-110. fibular artery. Acta Anatomica Sinica 1957;2(1):125-129. 16.Guo F. The observation of the vascular supply of the (Received March 26, 2008) fibula. Chin J Surg 1978;26(6): 347-349. Edited by SONG Shuang-ming 17.Wu JB, Fan LY, Qing YQ. Diaphyseal nutrient foramina and artery of tibia and fibula. Acta Anatomica Sinica 1980;11(3): 234-245. 18.Wu YM, Ding XZ. The relationship of the fibular artery