Vascularized fibular graft transposition to upper femur avoiding microsurgery

Torres, Luciano Ruiz; Paganotti, Fernanda Bogdanovics; Gaiarsa, Guilherme Pelosini; Teng, Hsiang Wei; Soro Neto, Francisco Perez; Viola, Dan Carai Maia; Souza, Fabiano Inácio de; Yuhara, Clécio Seiji; Mattar Júnior, Rames; Gaia, Leonardo Franco Pinheiro

doi:10.1590/S1413-78522010000400008

Abstracts

OBJECTIVE: The study describes a new and simple way to transplanttranspose a vascularized fibular graft from the fibula to the femur diaphysis without the need for microsurgery, demonstrates a successful clinical case with good results with regards to vascularization and osseous consolidation, and speculates about other applications of this flap procedure in reconstructive surgery. METHODS: A stalked vascularized fibular bone graft was transferred without microsurgery. The bone reached the proximal diaphysis of the femur. Communication between the lateral gastrocnemius arterial system and fibular artery through a skin flap and it's perforating arteries allowed good vascularization to the graft. The concept of "perforating artery-to-perforating artery" was established with their vascular territories intersecting the skin island flap. RESULTS: The patient operated on healed without infection. Bone scintigraphy showed periosteal bone vascularization. CONCLUSION: The Cutaneous Gastrocnemius-Fibular Flap is a new weapon for the reconstructive surgeon. It´s practical and reliable, and its reduced surgery time and its principle of construction will be applicable to the creation of other flaps.

Bone transplantation; Surgical flaps; Fibula; Muscle; Skeletal

OBJETIVO: O estudo descreve uma maneira nova e simples de transplantar o enxerto ósseo vascularizado da fíbula pro fêmur diafisário sem necessidade de microcirurgia, demonstra o caso clínico operado com bom resultado quanto a vascularização e consolidação óssea e, por último, especula sobre possíveis outras aplicações dentro da cirurgia reconstrutiva. MÉTODOS: A fíbula vascularizada é transportada até o fêmur sem necessidade de microcirurgia, alcançando até sua metáfise proximal através das comunicações das perfurantes do músculo gêmeo lateral com as septais fibulares via retalho de pele póstero-lateral da perna que intersecciona os dois sistemas. RESULTADOS: O paciente operado evoluiu sem infecção. Cintilografia esquelética precoce demonstrou vascularização óssea. CONCLUSÃO: O retalho gêmeo fibular é nova arma no arsenal do cirurgião. Sua técnica é factível, reprodutível, seu tempo cirúrgico reduzido e o princípio de construção com ponte através de ilhas de pele e perfurantes poderá ser aplicado na construção de novos retalhos.

Transplante ósseo; Retalhos cirúrgicos; Fíbula; Músculo esquelético

ORIGINAL ARTICLE

^ILIM 41 - Laboratory of Medical Investigation of the Musculoskeletal System of the Department of Orthopedics and Traumatology of HC/FMUSP

^IIHospital Municipal Moysés Deutsch, São Paulo, SP

Mailing address

ABSTRACT

OBJECTIVE: The study describes a new and simple way to transpose a vascularized fibular graft from the fibula to the femur diaphysis without the need for microsurgery, demonstrates a successful clinical case with good results with regards to vascularization and osseous consolidation, and speculates about other applications of this flap procedure in reconstructive surgery.

METHODS: A stalked vascularized fibular bone graft was transferred without microsurgery. The bone reached the proximal diaphysis of the femur. Communication between the lateral gastrocnemius arterial system and fibular artery through a skin flap and it's perforating arteries allowed good vascularization to the graft. The concept of "perforating artery-to-perforating artery" was established with their vascular territories intersecting the skin island flap.

RESULTS: The patient operated on healed without infection. Bone scintigraphy showed periosteal bone vascularization.

CONCLUSION: The Cutaneous Gastrocnemius-Fibular Flap is a new weapon for the reconstructive surgeon. It´s practical and reliable, and its reduced surgery time and its principle of construction will be applicable to the creation of other flaps.

Keywords: Bone transplantation. Surgical flaps. Fibula/transplantation. Muscle, Skeletal.

INTRODUCTION

Small posttraumatic bone defects can be treated by conventional bone grafting. However, the superiority of the consolidation potential of the vascularized bone graft when compared with the conventional autologous graft and bone substitutes, as well as its lower postoperative resorption, is firmly established in literature^1-3 and in our field.^4-6

The resistance to unfavorable and previously infected environments of a vascularized live tissue is also superior to that which demands revascularization by the adjacent bed.^1,7

Since its first description by Taylor,⁸ the microsurgical transplantation procedure of the vascularized fibula has been considered of high technical demand, in our opinion comparable to Grade 4 of the classification of dissection of skin flaps.⁹

Fibular dissection involves opening of all the leg compartments. The pedicle of the fibular artery, in general, can only be elongated up to its origin in the tibiofibular trunk. Proceeding with its elongation implies ligation of the posterior tibial artery and risk of devascularization or hypovascularization of the lower limb. The ideal positioning of the vascularized bone graft is also difficult, often requiring the use of vascular loops due to the bone depth and short extension of the fibular pedicle.

Also in relation to vascularized bone grafts, other flaps allow their osteocutaneous form: lateral arm flap associated with the humerus, antebrachial (Chinese) flap with radial segment, ulnar artery flap with ulnar segment, parascapular flap with lateral edge of the scapula, serratus anterior flap with ribs, large dorsal flap with rib/scapula, trapezial flap with scapula, inguinocrural flap with iliac crest, osteocutaneous medial femoral condyle flap, second metatarsal associated with dorsal flap of the foot. Almost all of these are performed in the microsurgical form for the thigh. The exception is the iliac crest flap that can be pediculated on the deep iliac circumflex artery in rotation for femoral head in the treatment of osteonecrosis, yet it does not reach the diaphyseal region of the femur.

As regards muscular flaps, Ger^15,16 popularized the concept of covering a defect with transposition from a local muscle then grafting with partial skin. Orticochea¹⁷ first described the transplantation of skin adjacent to the muscle on the lower limb. McCraw et al.¹⁸ then McCraw and Dibbel¹⁹ demonstrated that the skin adjacent to the muscles receives its vascular supply from perforating branches of the vessels that irrigate the muscle. McCraw et al.²⁰ Morris,²¹ Mathes and Nahai,²² Salibian and Menick²³ and Cheng et al.²⁴ further expanded the limits for use of the musculocutaneous gastrocnemius flap for defects in the distal third of the leg and thigh.

The most refined study of the physiology of flaps based on perforating pedicle, in the last decade^25-28, allowed the use of new local flaps in an island called propeller flaps. In these, the dissection of a perforating pedicle in an eccentric region of the flap allows its rotation, up to 180 degrees, reaching the targeted defect, with a large quantity of tissues perfused by a single perforating vessel.^29,30 The idea that a cutaneous artery pierces the muscle and reaches the homogeneous vascular mesh of the skin, allowing the irrigation of large areas, became clearer. These perforating arteries can also be irrigated in a reverse manner, when there is the performance of ligation of the origin of a perforating pedicle that entered the skin of a flap already irrigated by another source. In this manner it is possible to add part of the muscle adjacent to this perforating artery at the skin island flap, generating chimeric flaps.^31-33

Nevertheless, different from muscular tissue, the application of the same principle to the use of vascularized bone tissue with considerable mobility of its pedicle and of this in relation to the skin/muscle portion taken is not described in the medical literature examined.

The aim of this study is to describe a new and simple way of transplanting the vascularized bone graft from the fibula to the femur diaphysis without the need for microsurgery and to speculate about other possible applications in reconstructive surgery.

MATERIAL AND METHOD

We conducted a prior anatomical study of the perforating vessels of the medial gastrocnemius muscle.³⁴ In the subsequent clinical experience, increasingly larger skin islands were lifted from the flap without presenting damage. Accordingly, the muscle becomes, for the most distant defects, a "carrier" of vascularized skin. Once familiarized with the irrigation power of a perforating vessel of the gastrocnemius muscle, we also begin to use the lateral head of this muscle. This muscle has smaller proportions than the medial head and leads to an even lower plantar flexion deficit, within the global structure of the triceps surae. It is, however, able to associate the same quantity of skin necessary for the defects, easily reaching the middle third and the transition from the middle to the proximal third on the lateral side of the thigh.

In a study of the perforating branches of the fibular artery, Yoshimura et al.³⁵ differentiated musculocutaneous and septomusculocutaneous perforating branches, travelling between soleus and fibular, but emitting muscular branches and pure septocutaneous vessels, with a greater probability of finding septal vessels in the distal third of the leg and others in the proximal and middle third.

We then proposed the removal of the lateral head of the gastrocnemius muscle in a musculocutaneous manner where the skin island formed an intersection with the emergence of the distal fibular artery perforating branches. (Figure 1) The largest of these perforating branches is dissected unscathed up to the fibular pedicle and this is removed together with the fibular segment, with ligation of the fibular pedicle proximal and distal to the ressecated bone. (Figure 2) Thus the skin irrigated by perforating arteries of the lateral head of the gastrocnemius muscle reversely supplies the fibular pedicle that enters the fibula, reaching the femur diaphysis, with the possibility of rotation of this fibular perforating artery in relation to the skin. (Figure 3)

CLINICAL CASE

The patient is a 23-year old male student, with infected pseudoarthrosis of the right femur after trauma. He previously underwent 14 surgical treatments without obtaining success in the cure of the infection and bone consolidation. (Figures 4 and 5)

The medical team performed aggressive debridement of all the devitalized tissue (Figure 6), installation of uniplanar external fixator and raising of the lateral gastrocnemius flap with extensive skin island involving the posterior and lateral sides of the leg and including fibular perforating artery of the distal 1/3 of the leg. This was dissected and removed with the bone graft of the fibula and segment of fibular vessels adjacent to the bone. (Figure 7) Flap positioning rotation was performed with a propeller on the fibular perforating vessel in order to position the largest portion of bone at the femoral pseudoarthrosis site, not involving any tension or difficulty. (Figure 8) For technical ease the bone was positioned at the pseudoarthrosis focus without osteosynthesis.

The patient received broad-spectrum antibiotics. The flap donor area received a partial skin graft removed from the same thigh with dermatome or Blair knife.

RESULTS

Effective success was achieved in overcoming the infection and integrating the skin flap to the coverage of the ulcer and of the unstable tegument. (Figure 9) The skin graft was integrated to the donor area of the flap on the leg.

Early skeletal scintigraphy showed a tenuous area of hyperconcentration of the radiopharmaceutical sidelong to the femur that corresponds to periosteal uptake of the fibular graft. (Figure 10) This was corroborated by the intra-operative finding that showed clear filling of the fibular vessels and abundant periosteal bleeding from the fibula. Therefore, this should be the scintigraphic expression of a vascularized bone graft supplied only by a perforating vessel. Periosteal irrigation is prioritized to the detriment of the nutrient vessels according to the graft vascularization sources proposed by Harii³⁶. (Figure 11)

The evolution of this case demonstrated this adequate bone vascularization. The bone is consolidated and no additional osteosynthesis procedure was performed. (Figures 12 and 13) The levelling of length of the lower limbs will be performed at the expense of tibial lengthening with circular apparatus, accepting unleveling of the knees.

DISCUSSION

Georgescu³⁷ described a microsurgical dissection flap concept, yet without vascular microsurgery. The new technique falls into this didactic category. Perfect understanding of the perforating anatomy and familiarization with microsurgical technique is certainly a prerequisite for its executer, yet its reproducibility at other centers and possibility of performance in institutions where costly microscope, forceps, microsurgical clips and fine threads are not available makes way for the treatment of infected osteomyelitis and pseudoarthrosis of the tibia and of the femur.

We were asked whether the vascularized bone graft could also be taken just in the perforating vessel without its communication with the segment of fibular vessels from where it originates, thus avoiding the ligation of an important leg vessel. In effect we do not believe that the perforating vessel contains direct nutritious branches to the bone or periosteum capable of irrigating it over a sufficient area. Actually we see the adjacent skin and the perforating vessel as a conduit that performs the nutrition and drainage of the fibular pedicle that emits the nutritious branches to the bone. Therefore the ligation and the raising of a segment of the fibular pedicle in this flap are essential.

Historically, Brazilian surgeons have been active and creative in the description of new flaps: Baudet et al.³⁸ dos Santos^39,40, Nassif et al.⁴¹ Masquelet and Rinaldi,⁴² Masquelet et al.⁴³ Recalde Rocha et al.^44,45 Bertelli and Pagliei^46,47, Teng et al.^48,49 and Ishida et al.⁵⁰ With this initial report the authors aim to hoist this category with the osteomiocutaneous flap that we call gastrocnemius-fibular skin flap. Its greatest damage is aesthetic, since its large skin island is taken from the leg, which may be a problem to female patients. Functionally, the damage is undetectable. The flap is safe and the rate of success for bone vascularization should be higher as it does not depend on micro-vascular anastomoses, which are hard to monitor when in the femur, due to depth, and subject to vascular thrombosis. Nevertheless, a subsequent comparative study with a large series of cases is necessary to demonstrate such efficacy.

Its evident original application was as a rotation flap in the treatment of defective osteomyelitis. Another tissue that could be added in this actual flap is a portion of the soleus muscle or of the flexor hallucis longus at the fibula in the same fibular pedicle to obliterate any dead space. Moreover, its application is possible in the free form with anastomoses in the pedicle of the lateral sural and/or fibular artery. This would assist in "chimeric" reconstructions in a wide variety of body areas; including in reconstruction for head and neck surgery. It could also be applied as a functional muscular flap through microneuroraphy from the tibial branch to the lateral gastrocnemius muscle with motor branch of the receptor area, allowing simultaneous bone reconstruction of the humerus or of the forearm bones, functional muscle and cutaneous cover.

CONCLUSION

Due to its technical simplicity and reproducibility, we consider the gastrocnemius-fibular skin flap a promising alternative in the field of reconstructive surgery, and meriting further research for greater clinical experience.

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