Akio Minami, Hiroyuki Kato,

Naoki Suenaga, and Norimasa Iwasaki

DISTALLY-BASED FREE
VASCULARIZED TISSUE GRAFTS IN
THE LOWER LEG

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ABSTRACT
In the field of orthopaedic surgery, the lower leg is often treated by free vascularized tissue grafts. In
performing these grafts for reconstruction of the lower leg, the anterior tibial artery and its venae comi-
tantes are frequently selected as anastomosing recipient vessels. However, due to the deep location of
the anterior tibial vessels, it is extremely difficult to accomplish antegrade microsurgical anastomoses
between the donor vessels and the anterior tibial vessels. This technical difficulty often leads to the pos-
sibility of immediate postoperative arterial and venous occlusion. To resolve this problem, the idea of a
reverse-flow island flap has been applied to the free vascularized tissue grafts for reconstruction of the
lower leg, based on both artery and vein reconstructed with retrograde blood flow.
To evaluate clinical outcomes of the procedure mentioned, the postoperative results of 14 patients
were reviewed. The free vascularized grafts consisted of seven vascularized fibular grafts with peroneal
flaps, six vascularized latissimus dorsi myocutaneous flaps, and one vascularized groin flap. Venous con-
gestion of the flap was not observed and all flaps survived. Bone union was obtained in seven patients
treated with vascularized fibular grafts. There were no serious postoperative complications. Distally-
based free vascularized tissue grafts in the lower leg are useful procedures in reconstruction of massive
bone defects and osteomyelitis of the tibia, and for skin defects on the anterior aspect of the lower leg.

There have been great advances in reconstruc-
tive procedures for bone and soft-tissue defects
since the introduction of microvascular surgery. In
the field of orthopaedic surgery, the lower leg has of-
ten been treated with free vascularized tissue grafts.
The tibia and skin of the lower leg are frequently in-
volved in trauma and infection. In particular, there
are many cases with massive bone defects and os-
teomyelitis of the tibia, and skin defects on the ante-
rior aspect of the lower leg. '"5
In performing free vascularized tissue grafts for
reconstruction of the lower leg, the anterior tibial
artery and its venae comitantes are frequently se-
lected as anastomosing recipient vessels. Accord-
ingly, the donor artery and veins are anastomosed to
these vessels located in the anterior aspect of the
lower leg. However, the anterior tibial vessels proxi-
mal to the distal third of the lower leg are located
deeply just on the interosseous membrane and also
close to the anterolateral cortex of the tibia. Due to
the deep location of the anterior tibial vessels, it is
extremely difficult to accomplish antegrade micro-
surgical anastomosis between the donor vessels and
the anterior tibial vessels. This technical difficulty
leads to the possibility of immediate postoperative
arterial and venous occlusion. To avoid the difficul-
ties associated with the anterior tibial vessels, some
microsurgeons would use the posterior tibial vessels
anastomosing end-to-side to the artery.
To resolve this problem, the concept of a re-
verse-flow island flap has been applied to free vascu-
larized tissue grafts for reconstruction of the lower 495

Microsurgical Unit, Section of Hand Surgery, Department of Orthopaedic Surgery, Hokkaido University School of Medicine, Sapporo,
lapan Reprint requests-. Dr. Minami, Dept. of Orthopaedic Surgery, Hokkaido University School of Medicine, Kita-15-Jo, Nishi-7-Chome,
Kita-Ku, Sapporo 060, Japan Accepted for publication June 28, 1999 Copyright© 1999 by Thieme Medical Publishers, Inc., 333 Seventh
Avenue, New York, NY 10001, USA. Tel.: +1 (212) 760-0888, x!32. 0743-684X/1999/1098-8947(1999)15:07:0495-0500:JRM00573X.
 JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 15, NUMBER 7 OCTOBER 1999

leg, based on both artery and vein reconstructed with lease of these vessels should be avoided to prevent
retrograde blood flow. We report the clinical results damage to the communicating branches of the venae
of this technique. comitantes. The proximal portion of the vascularized
tissue is placed at the recipient site in a retrograde
direction. After obtaining stability of the bone and
PATIENTS AND METHODS flap, the vascular bundles of the peroneal vessels of
the fibula, the thoracodorsal vessels of the latis-
This study evaluated 14 patients, 11 males and simus dorsi myocutaneous flap, or the superficial il-
three females. Their ages at the time of surgery iac circumflex vessels of the groin flap are positioned
ranged from 18 to 71 years, with an average of 48 on the distal third of the lower leg.
years. Follow-up periods averaged 40 months (range: Before anastomosis of the vessels, a clamp on
24 to 57 months). Patients followed less than 2 years the anterior tibial artery is temporarily used to con-
were excluded. The pathogeneses of diseases were: firm the vasculature of the foot. Then, the anterior
bone defect or pseudarthrosis of the tibia after tibial artery and its venae comitantes are severed. If
trauma in four patients; osteomyelitis of the tibia the marked valve of the venae comitantes of the an-
with bone defect in six (three patients with skin de- terior tibial artery is observed in the adjacent distal
fects and three without); and massive skin defects on part of the suture site, the position of the anastomo-

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the anterior aspect of the lower leg in four patients. sis should be changed to a more proximal or distal
The free vascularized tissue grafts consisted of seven location, i.e., suturing of the vein should be per-
vascularized fibular grafts with peroneal flaps, six formed far from the valve of the vein. Microsurgical
vascularized latissimus dorsi myocutaneous flaps, anastomosis is performed under the operating mi-
and one vascularized groin flap. croscope. First, the artery of the donor tissue is anas-
The method of harvest of the vascularized fibula tomosed to the proximal end of the distal anterior
has been described in several papers. 1256 Recently, tibial artery. After accomplishment of the arterial su-
we have employed the vascularized osteocutaneous ture, venous return from the donor material is con-
fibular graft to cover associated skin defects or to firmed. Thereafter, donor veins are anastomosed to
monitor the vasculature of the fibula.16 Harvesting of the proximal end of the distal venae comitantes of
the latissimus dorsi myocutaneous flap and groin the anterior tibial artery.
flap was done according to previous reports.47-9
The entire length of the fibula for the graft was
determined according to the length of the bone de- RESULTS
fect, which ranged from 15.5 to 28 cm and averaged
20 cm. The fibula was folded into divided fragments In cases using free vascularized fibular grafts,
in one of seven cases.10 In two patients, the distal the peroneal flap survived in all patients. No partial
tibiofibular joint was stabilized by inserting screws. necrosis of the flap was observed. Subsequent bone
The size of the flap associated with vascularized union was obtained in all patients. The time periods
fibulas in five patients averaged 3.3 X 9.4 cm (range: between vascularized fibular graft procedures to
1.5 to 6.0 X 5 to 15 cm). The size of the latissimus bone union ranged from 12 to 20 weeks, with an aver-
dorsi myocutaneous flap averaged 12.3 X 23.3 cm age of 16 weeks. In cases using latissimus dorsi my-
(range: 8 to 25 X 17 to 40 cm). The single groin flap ocutaneous and groin cutaneous flaps, all flaps sur-
measured 6 X 1 5 cm. vived uneventfully after the procedure. No venous
Postoperative vasculature was checked by ob- congestion of the flap was found. Partial necrosis at
servation of the skin color of the flap. In cases of free the distal and proximal triangular edges of the flap
vascularized fibular graft, anteroposterior, lateral, were observed in two flaps; however, no additional
and oblique plain x-rays were obtained every 2 weeks treatment was required.
after the procedure. Establishment of bone union There were no vascular impairments suggesting
was determined when continuity of the bone trabec- arterial or venous thromboses in the early postopera-
ulae was confirmed in even one among several views. tive period. No venous congestion was observed in
Tomograms were also taken in cases in which diffi- any flap, including peroneal, latissimus dorsi myocu-
culty of determining union in the plain x-rays was taneous, or groin flaps. No recurrence of osteo-
evident. myelitis was observed as a delayed postoperative
SURGICAL TECHNIQUES. Before performing the complication. Subsequent fractures of the grafted
procedure, arteriography is necessary to confirm the fibula following bone union occurred in two patients
existence of at least two arteries among the three (14 percent). Both patients had no history of trauma.
main arteries in the lower leg. The anterior tibial ves- The periods between the establishment of bone
sels are released in the small area of the distal third union and the occurrence of fracture in these two pa-
of the leg. During this procedure, extensive distal re- tients were 3 and 4 months, respectively. Both frac-
496
 DISTALLY-BASED FREE VASCULARIZED TISSUE GRAF IN LOWER LEG/MINAMI, KATO, SUENAGA, IWASAKI

tures obtained bone union uneventfully with a 2-

month cast immobilization. There were no other
postoperative complications. \
\

DISCUSSION

The reverse-flow island flap has become a com-

mon procedure in reconstructive microvascular sur-
gery,511"16 and it is also one of the most versatile re-
r\
constructive procedures used in the lower extremity.
Sawaizumi et al.17 first reported seven patients un-
dergoing lower-limb reconstruction that incorpo-
rated free and composite flap transfers with anasto-
mosis and retrograde flow to the anterior and
posterior tibial vessels. All cases had complete flap
survival. In our series, this concept was extensively

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applied to free vascularized tissue grafts.
In free vascularized tissue grafts in the lower
leg, there are four patterns based on the blood flow-
direction of the artery and vein. Both artery and vein
may have antegrade blood flow (pattern A, Fig. 1). Al-
though both artery and vein may have antegrade
blood flow, both may also be kinked or looped (pat-
tern B, Fig. 2). The artery may have retrograde blood
flow, but the vein has antegrade blood flow (pattern
C, Fig. 3). Or both artery and vein may have retro- Figure 2. Pattern B. Both artery and vein have ante-
grade blood flow, but both are kinked or looped. (A =
artery; V = vein)

grade blood flow (pattern D; Fig. 4). Although the di-

rections of blood flow of the vein in patterns B and C
are antegrade, kinking and looping of the anasto-
mosed vein may lead to thrombosis. Therefore, we
prefer to promote retrograde flow of the artery and
it A vein, as in pattern D.
In a reverse-flow island flap, arterial flow is cer-
tainly supported by the anastomosis of the other ar-
teries distally; whenever there are more than two ar-
teries in the lower extremity, there are no arterial
problems. Because venous blood passes through the
venae comitantes in a reverse-flow fashion, there re-
mains a problem with the valves inside the veins that
may be resistant to reverse flow. For reverse venous
drainage, communicating branches between the two
venae comitantes and the collateral branches of the
venae comitantes take part in the reverse flow,14 and
the valves inside the veins are hypothesized to be-
come incompetent.18
The anatomy of the venous system in the pedicles
of the radial forearm and anterior tibial reverse-flow
flaps was investigated in fresh cadavers, and their
drainage pathways were observed in a radiographic
perfusion study.19 The venous system was found to
Figure 1. Pattern A. Both artery and vein have ante- consist mainly of three types of veins: venae comi-
grade blood flow. (A = artery; V = vein) tantes, communicating veins between the venae comi-
497
 JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 15, NUMBER 7
> :s I >• is
Figure 3. Pattern C. The artery has retrograde
blood flow but the vein has antegrade blood flow. (A = retrograde blood flow. (A = artery; V = vein)
artery; V = vein)
tantes, and vasa vasorum. Valves were identified in all
three types of vein. In all the venous systems, including
the vasa vasorum, there was no route of reverse flow
that did not pass directly through the valves. Valve in-
competence was demonstrated in the radiographic
perfusion study. However, valve incompetence did not
occur in all the valves, and a difference in valve resis-
tance against reverse-flow pressure existed. Veins with
relatively weak valve resistance played a role in the
drainage pathway. Another anatomic study20 sup-
ported the existence of these three venous systems in
the pedicles of anterior tibial reverse flow flaps.
The degree of valve resistance and the location
of anastomoses of the communicating veins with the
venae comitantes will affect flap survival. The base of
the pedicle of the anterior tibial reverse-flow flap is
usually located in the distal third of the lower leg.
Valves with strong resistance at the site where the
three venae comitantes become two are in the pedi-
cle, and there are additionally few or no connecting
veins in the distal third of the pedicle.21
Satoh et al. reported that 25 reverse-flow island
flaps were clinically applied to soft-tissue defects in
the lower leg (10 peroneal, eight anterior tibial, and
seven posterior tibial flaps).22 Anterior tibial flaps
498
OCTOBER 1999
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Figure 4. Pattern D. Both the artery and vein have
were likely to become congested, with engorgement
of the comitant veins. Four of eight flaps with ve-
nous anastomoses survived completely. Two of four
flaps without venous anastomosis survived, and the
other two flaps necrosed. The flap became con-
gested 3 to 4 days postoperatively and completely
necrosed. These authors suspect that venous prob-
lems may have caused the necrosis. In elevating a
reverse-flow island flap in the lower leg, they there-
fore proposed the anastomosis of one of two venae
comitantes to a superficial vein near the recipient
site, if there is venous congestion or beading of the
veins.
In our study, all distally-based free vascularized
tissue grafts in the lower leg completely survived
without any compromising event. Distally-based free
vascularized tissue grafts in the lower leg are useful
procedures for reconstruction of massive bone de-
fects and osteomyelitis of the tibia, and for skin de-
fects on the anterior aspect of the lower leg.
The authors thank Kiyoshi Kaneda, M.D., Professor in
the Department of Orthopaedic Surgery, Hokkaido Univer-
sity School of Medicine, Sapporo, Japan, for his sugges-
tions and advice during this investigation.
 DISTALLY-BASED FREE VASCULARIZED TISSUE GRAFT IN LOWER LEG/MINAMI, KATO, SUENAGA, IWASAKI
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