Preoperative vascular assessment of the lower limb for harvest of a fibular flap: the views of vascular surgeons in the United Kingdom

Sexual Dimorphism of the Nutrient Foramen of the Fibula and Its Importance in Vascularised Bone Grafting: A Descriptive Cross-Sectional Study

Background

Vascularised fibular bone grafting is widely used in many reconstructive surgeries to repair bony defects. It is very essential for the nutrient blood supply to be conserved in the vascular bone graft. Understanding the sexual differences of the fibular nutrient foramen can help operating surgeons make appropriate changes in their clinical methodologies according to the sex. The present study was done to evaluate the sexual dimorphism of fibular nutrient foramen and its clinical importance in the adult central Indian population.

Methods

This descriptive cross-sectional study was done on 136 dry adult central Indian human fibula bones of known sex (male: 68 and female: 68). The presence of nutrient foramen, their numbers, relation with fibular surfaces, and distance from the styloid process were assessed and were then clinically correlated.

Results

In males, single-nutrient foramen and double-nutrient foramina were seen in 92.65% and 7.35% of fibula, respectively. Whereas in females, single-nutrient foramen and double-nutrient foramina were seen in 95.59% and 4.41% of fibula, respectively. The position of the nutrient foramen and the fibular length showed significant sexual variation.

Conclusions

This study concludes that among both sexes, the single fibular nutrient foramen in the middle third segment was the most prevalent. Compared to the female population, the male population demonstrated a broader location of the nutrient foramen.

Influence of preoperative imaging on fibula free flap harvesting

INTRODUCTION

The fibula free flap (FFF) is the gold standard for the reconstruction of large maxillofacial defects. Magnetic resonance angiography (MRA) seems to supersede digital subtraction angiography (DSA) as the reference in preoperative evaluation, being non-invasive and having equivalent diagnostic results. The aim of this study was to assess the impact of preoperative MRA versus DSA on the viability of FFF and its success rate.

MATERIAL AND METHODS

A total of 216 patients, who underwent mandibular or maxillary FFF reconstruction from January 1995 to January 2011, were retrospectively included in the study. Of them, 101 patients underwent preoperative DSA and 115 underwent MRA. Recorded criteria were as follows: age, sex, tobacco consumption, defect etiology, preoperative vascular assessment, donor-site choice and flap failure. The DSA group was compared to the MRA group.

RESULTS

The harvested side was switched in 15.7% of cases with preoperative MRA versus 4% with DSA. Our success rate was higher (96.1%) with MRA than with DSA (88.1%) (P<0.05). More atherosclerotic patients (P=0.004) were diagnosed through MRA. MRA and DSA showed similar results in anatomical variation detection.

CONCLUSION

MRA is less invasive and more effective in atherosclerosis detection than DSA. Therefore, donor-site switching was more frequent in the MRA group, which led to a better success rate. MRA should replace DSA as the reference in preoperative assessment.

Color Doppler Sonographic and Cadaveric Study of the Arterial Vascularity of the Lateral Upper Arm Flap

OBJECTIVES

To determine the importance of adequate preoperative assessment with color Doppler sonography to assist in the successful transfer of lateral upper arm flaps by studying the lateral upper arm flap with color Doppler sonography and analyzing the anatomic features of the radial collateral artery.

METHODS

A clinical case-control study was performed. The radial collateral artery was studied with color Doppler sonography in 15 healthy volunteers. The origins, courses, variations, and locations of the perforators of the radial collateral artery were recorded. The results and data from the color Doppler sonographic investigation were compared with an anatomic study that was performed on 22 adult cadaveric upper limb specimens.

RESULTS

The volunteer group (14 of 15 volunteers) and the cadaveric group (19 of 22 upper arm specimens) clearly showed that the branch pattern of the arterial supply was as follows: brachial artery → deep brachial artery → radial collateral artery → posterior radial collateral artery → myocutaneous perforator. Variations in the origin of the radial collateral artery were identified in 1 volunteer bilaterally and in 3 upper arm specimens. The diameters of the artery and vein measured at the distal insertion of the deltoid and the origin of the deep brachial artery were not significantly different between the volunteer and cadaver groups (P > .05). Due to the difference in measuring methods, the length of the vascular pedicles was significantly different between the groups (P < .05).

CONCLUSIONS

Color Doppler sonography can facilitate the preoperative assessment of the origin, course, variations, and locations of the radial collateral artery and therefore may increase the success rate of lateral upper arm flap transfer.

Factors influencing the necessity for preoperative vascular imaging before harvesting a vascularized fibular flap

OBJECTIVE

This study was carried out to identify groups of patients who would benefit from this angiography. The angiographic images of a random group of patients were studied; the correlations between the vascular state of the lower extremities and vessel pathology were investigated; and the possible links of these findings with certain medical conditions were explored.

STUDY DESIGN

Three experienced observers independently evaluated the angiograms of 185 patients. The status of all 3 vessels of the lower extremities (anterior tibial artery, posterior tibial artery, and peroneal artery) was evaluated. The patients' gender, age, drinking and smoking habits, and medical conditions were documented.

RESULTS

We found a significant correlation between pathology of the arteries of the lower extremity and blood cholesterol level, blood pressure, coronary heart disease, diabetes mellitus, and age.

CONCLUSIONS

We suggest that preoperative vascular imaging be carried out in patients with comorbidities to reduce the potential for flap failure and to minimize donor site complications.

Preoperative imaging for perforator flaps in reconstructive surgery: a systematic review of the evidence for current techniques

BACKGROUND

Although preoperative imaging of perforator vasculature in planning microvascular reconstruction is commonplace, there has not been any clear demonstration of the evidence for this practice, or data comparing the many available modalities in an evidence-based approach. This article aims to provide an objective, evidence-based review of the literature on this subject.

METHODS

The evidence supporting the use of various modalities of imaging was investigated by performing focused searches of the PubMed and Medline databases. The articles were ranked according to the criteria set out in March 2009 Oxford Centre for Evidence-Based Medicine definitions. Endpoints comprised objective outcome data supporting the use of imaging, including flap loss, unplanned returns to theater, operative time reduction, and surgeon-reported stress.

RESULTS

The objective high level of evidence for any form of preoperative perforator imaging is low with only small number of comparative studies or case series investigating computed tomographic angiography (CTA), magnetic resonance angiography, handheld Doppler, color duplex, and classic angiography. Of all modalities, there is a growing body of level 2b evidence supporting the use of CTA.

CONCLUSION

While further multicenter trials testing hard outcomes are needed to conclusively validate preoperative imaging in reconstructive surgery, sufficient evidence exists to demonstrate that preoperative imaging can statistically improve outcomes, and that CTA is the current gold standard for perforator mapping.

Preoperative three-dimensional reconstruction in vascularized fibular flap transfer

OBJECTIVE

The objective of this study was to investigate the added value of preoperative computerized tomographic angiography (CTA) and three-dimensional reconstruction of the lower limb in vascularized fibular flap transfer.

METHODS

Eighteen patients who underwent mandibular or maxillary reconstruction with a vascularized fibular flap were studied retrospectively by image analysis. The original DICOM data of preoperative CTA were analysed and applied to the reconstruction of the lower limb using SimPlant Pro software (version 11.04).

RESULTS

The course of the peroneal artery in 17 patients was the same except for one patient. The peroneal artery originates from the posterior tibial artery. The original external diameters of the peroneal artery were 2.99 ± 0.64 mm. The perpendicular lengths from fibular head to the origin of the peroneal artery and to the fibular perforator vessel were 42.88 ± 8.84 mm and 174.55 ± 25.62 mm, respectively.

CONCLUSION

The course of peroneal artery was relatively invariable, its original external diameter was thick. Preoperative CTA and three-dimensional reconstruction of the lower limb, which are noninvasive, accurate and direct-viewing methods, play an important, preoperative role in vascularized fibular flap transfer for lower limb vascular assessment.

Raising the osteocutaneous fibular flap for oral reconstruction with reduced tissue alteration

Raising the osteocutaneous fibular flap offers excellent possibilities for oral reconstructive surgery but is associated with specific donor-site risks. Moreover, with inadequate surgical technique, flap-specific complications can occur, such as loss of the skin paddle or inadequate pedicle length. A flap-raising technique has been used to decrease surgical damage but provide maximal pedicle length. Sixty-six osteocutaneous fibular flaps were raised by the lateral approach with the following modifications: 1) flap-raising was carried out without a tourniquet, 2) only the amount of bone needed was removed, leaving the rest of the fibula intact, 3) only a minimal muscle cuff was included, and 4) the complete pedicle was dissected along the posterior intermuscular septum without opening the interosseous membrane and without touching the deep flexor muscles proximal to the osteotomized fibular segment. The skin paddle was placed distally in the leg, perfused by only 1 perforator in most cases. Medical records were analyzed and patients were examined postoperatively for up to 32 months to evaluate the above-mentioned complications. Of the 66 reconstructions, 44 were performed in a previously operated or irradiated neck. Three flaps and 1 skin paddle were lost. The most common donor-site complications were temporary wound-healing disturbances of the skin graft (n = 17) and transient pain or sensory alterations (n = 12). No compartment syndrome, ankle instability, or need for walking aids was recorded. A hammertoe deformity developed in 1 patient. On average, pedicle length was 9 cm and flap-raising took 130 minutes. In conclusion, maximal pedicle length and minimal bone and muscle resections can be achieved with a small number of donor-site complications. The skin paddle is highly reliable based on only 1 perforator. Perforators can be precisely controlled when raising the flap in the perfused leg.

Recent updates of surgical techniques and applications of free vascularized fibular graft in extremity and trunk reconstruction

Successful free vascularized bone transfers have revolutionized the limb salvage and musculoskeletal reconstruction. The free vascularized fibula remains the mainstay in bone reconstruction combines the benefits of blood supply, biological potential, and callus formation with its unique biomechanical characteristics offering a supreme candidate for various dissolvable issues. Especially in conditions where there was lack of other applicable method and the free vascularized fibular graft was introduced as the only alternative. Extensive traumatic bone loss, tumor resection, femoral head osteonecrosis and congenital defects have been managed with exceptional results beyond expectations. The present manuscript updates several issues in application of free vascularized fibular graft in extremity and trunk reconstruction. It also highlights tips and pearls of surgical technique in some crucial steps of harvesting the vascularized fibular graft in order to offer a vascularized bone with safety and low donor site morbidity.

Management of venous thrombosis in fibular free osseomusculocutaneous flaps used for mandibular reconstruction: clinical techniques and treatment considerations

Background

Mandibular reconstruction by means of fibula transplants is the standard therapy for severe bone loss after subtotal mandibulectomy. Venous failure still represents the most common complication in free flap surgery. We present the injection of heparine into the arterial pedicle as modification of the revising both anastomoses in these cases and illustrate the application with a clinical case example.

Methods

Methods consist of immediate revision surgery with clot removal, heparin perfusion by direct injection in the arterial vessel of the pedicle, subsequent high dose low-molecular weight heparin therapy, and leeches. After 6 hours postoperatively, images of early flap recovery show first sings of recovery by fading livid skin color.

Results

The application of this technique in a patient with venous thrombosis resulted in the complete recovery of the flap 60 hours postoperatively. Other cases achieved similar success without additional lysis Therapy or revision of the arterial anastomosis.

Conclusion

Rescue of fibular flaps is possible even in patients with massive thrombosis if surgical revision is done quickly.

An unreported variation of the course of peroneal artery during fibula flap harvest

We describe a previously unreported anatomical variant of the peroneal artery that was found both on preoperative angiography and at operation to be related to the fibula only in its distal third. In contrast to previously reported variations, the artery began descending on the medial aspect of the fibula about 26cm from the fibular head.

CT angiography of peripheral arterial disease

Lower-extremity computed tomographic (CT) angiography (ie, peripheral CT angiography) is increasingly used to evaluate patients with peripheral arterial disease. It is therefore increasingly important for all vascular specialists to become familiar with the strengths and limitations of this new technique. The aims of this review are to explain the principles of scanning and injection technique for a wide range of CT scanners, to explain and illustrate the properties of current image postprocessing tools for effective visualization and treatment planning, and to provide an overview of current clinical applications of peripheral CT angiography.

Occult stenosis of the common carotid artery complicating mandibular reconstruction with a fibular free flap

An unsuspected severely stenosed common carotid artery that compromised a free flap for mandibular reconstruction is described. To our knowledge no one has advocated the assessment of the carotid tree before transfer of free tissue. We suggest that patients with several risk factors for peripheral vascular disease should have colour flow duplex imaging of the carotid system if transfer of free tissue is being considered.

Posterior Tibial Artery Flap in Poliomyelitis Patients with Lower Extremity Paralysis

BACKGROUND

Poliomyelitis is a disease that can render affected individuals incapacitated to a variable degree. A normal lifespan is expected and therefore the patients deserve every effort at curative cancer resection and reconstruction. Those with lower extremity paralysis rely heavily on their upper limbs and torso for ambulation; therefore, their compromised limbs may be a better donor site for flaps.

METHODS

All poliomyelitis patients with lower extremity paralysis over a 20-month period who underwent head and neck reconstruction were selected for a retrospective review. Perioperative complications were noted and outpatient follow-up was performed.

RESULTS

Three patients underwent reconstruction of defects using the posterior tibial artery flap. Two patients required reconstruction of a buccal defect and one patient required soft palate reconstruction. All patients healed without complications and none required reexploration. At a mean follow-up of 10 months, there was no incidence of donor limb vascular compromise, cold intolerance, or long-term paresthesias.

CONCLUSIONS

The posterior tibial artery free flap has been used successfully in the past; however, its popularity has been limited because of sacrifice of the posterior tibial artery. Nevertheless, in patients with lower extremity paralysis, this flap may fulfill the requirements of a thin, pliable flap with minimal hair that has a long pedicle and a reliable blood supply. Most importantly, the use of this flap obviates the need to use flaps that fulfill the same requirement, such as forearm flaps, that would be taken from patients' functioning limbs.