591
Fig. 20.29 Procedure 4: Thinned skin flap with fat removed
Fig. 20.28 Procedure 3: As much fat is removed from the skin flap as
possible apart from the area surrounding the perforators
Reconstruction of Amputated Foot Stump: Free Abdominal Perforator Flap (Level of Difficulty: 4)
592
Fig. 20.31 Procedure 6: Use of an arch support for several months
after surgery is desirable
Fig. 20.30 Procedure 5: The deep inferior epigastric blood vessels are
pulled into subcutaneous tunnel up to the proximal tarsal tunnel and
end-to-side anastomosis conducted for the arteries and side-to-side
anastomosis conducted for the veins. A drain is inserted in the sur-
rounding area
20 Reconstruction of Dorsum and Amputated Foot Stump
593
Tips
Visual care is required, and lifestyle guidance is also crucial.
The skin flap area has no sensory function so no pain is felt even if the area is injured. Photo is case of burn from a
heater.
Reconstruction of Amputated Foot Stump: Free Abdominal Perforator Flap (Level of Difficulty: 4)
594
Free Anterolateral Thigh Flap (Level of Difficulty: 5)
Information
Vascular pedicle Descending branch of lateral circumflex femoral artery; possible to secure 15–20 cm
Size If there is a premise of primary closure, normally a length of 20 cm and width of 8–10 cm. If there is premise of
closing using a skin graft, half of the skin of the lateral thigh can be elevated.
Advantage Has thickness (2–3 mm diameter) and long vascular pedicle and it is possible to obtain thin and large skin
flaps. Can be harvested in supine position
Disadvantage The position of the perforators of the descending branch of the lateral circumflex femoral blood vessels
are not constant, so the final shape may not match the design of the skin flap pre-surgery. It is safer to design the skin
flap after determining the perforators that are to be harvested. Also, elevation of the skin flaps can be difficult due to
the path of the perforators, and advanced skill is required. Severing the nutrient branch to the rectus femoris muscle
can cause myonecrosis.
Caution In order to avoid twisting of the vascular pedicle, it is preferable if two perforators are secured
20 Reconstruction of Dorsum and Amputated Foot Stump
595
Operation Procedures
Fig. 20.33 Procedure 2: The perforators are dissected. If they emerge
from the intermuscular septum they are easy to dissect, however if they
penetrate the vastus lateralis muscle, the perforators must be dissected
with care, with a small amount of muscle tissue left around the
perforators
Fig. 20.32 Procedure 1: The position of the perforators as measured
by Doppler measurement are indicated on the skin prior to surgery. A
longitudinal incision is made to the anterior surface of the thigh, and
when the area beneath the fascia lata is detached and turned over later-
ally, it is possible to confirm the perforators penetrating the intermuscu-
lar septum between the rectus femoris muscle and vastus lateralis
muscle or the vastus lateralis muscle itself. Once the position of the
perforators can be confirmed, the design of the skin flap is finished, and
an incision is made and the fascia lata detached
Note Two perforators are secured to prevent twisting.
Free Anterolateral Thigh Flap (Level of Difficulty: 5)
596
Fig. 20.34 Procedure 3: The required amount of the descending
branch of the lateral circumflex femoral blood vessels are dissected
proximally and harvested. If possible the donor site is temporarily
sutured closed. If not possible then a skin graft is conducted
Fig. 20.35 Procedure 4: Using this skin flap it is possible to cover
large skin defects that extend across the entire dorsum. The vascular
pedicle is long so anastomosis is performed with the posterial tibial
blood vessels at proximal to the tarsal tunnel
20 Reconstruction of Dorsum and Amputated Foot Stump
597
Fig. 20.36 Procedure 5: Final image. Good skin texture compared
with the plantar skin
Free Anterolateral Thigh Flap (Level of Difficulty: 5)
598
Free Scapular Flap (Level of Difficulty: 4)
Information
Vascular pedicle Dissected and harvested from circumflex scapular artery to subscapular artery. Length of vascular
pedicle 10 cm and diameter 2 mm
Size The size of a scapular flap that can be sutured closed is around 20 cm long with a width of 8–10 cm, and this can
be combined with a flap of longitudinal length 1.5–20 cm and width 10 cm
Advantage Has thickness. Technique is simple and has stable blood flow. It is possible to create a large flap
Disadvantage Can require change of position.
Not possible to reconstruct sensory function
Indication For large skin defects
20 Reconstruction of Dorsum and Amputated Foot Stump
599
Operation Procedures
Fig. 20.37 Procedure 1: Deformation of great toe due to scar contrac-
ture of the medial left foot
Fig. 20.38 Procedure 2: All scarring in the medial foot resected. The
bone of the deformed great toe is cut and corrected and fixed using a
steel wire. The posterial tibial blood vessels are identified
Free Scapular Flap (Level of Difficulty: 4)
600
Fig. 20.40 Procedure 4: The skin flaps are combined to cover a large
skin defect area, and anastomosis of the subscapular blood vessels is
performed to the posterial tibial blood vessels. A continuous suction
drain is inserted subcutaneously to the flap donor area, and then closed
Fig. 20.39 Procedure 3: The bi-lobed scapular flap with subscapular
blood vessels is secured
Refer to Section of “Reconstruction of the plantar forefoot: Bi-lobed
scapular flap” in Chap. 19
20 Reconstruction of Dorsum and Amputated Foot Stump
601
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_21
Reconstruction of Dorsum of Toes
Basic Principles
The most common cause for covering the dorsum of the toes is the great toe. In the case that
tendon and bone are exposed, either a muscle fl ap or skin fl ap is required, however the easi-
est method with a stable blood supply is a reverse muscle fl ap using the extensor digitorum
brevis muscle fl ap.
Selectable Flaps and Surgical Procedures
Reverse fl ow extensor digitorum brevis muscle fl ap • Artifi cial dermis and skin graft • Skin
graft with negative pressure wound therapy
The diffi culty level of each surgical procedure is shown subsequent to
the procedure title (e.g., Level of Diffi culty: 2). The levels range from 1
to 5, with level 1 indicating a preliminary level and level 5 indicating a
very advanced level.
21
602
Information
Vascular pedicle Lateral tarsal blood vessels (branches from the dorsal artery beneath the extensor retinaculum)
Size 4.5 × 6 cm
Advantage Blood fl ow is stable, it is not bulky and there is no loss of function due to harvesting. Suitable for covering
exposed tendons or bone of the dorsum. The vascular pedicle is beneath the extensor retinaculum of the ankle, and
some distance from the area requiring covering, so in many cases is not damaged.
Disadvantage Size of muscle fl ap is small. Requires skin graft
Caution Incision is made slightly medial along the dorsal artery. The connection branch between the dorsal artery and
plantar artery must be left intact
Reverse Flow Extensor Digitorum Brevis Muscle Flap (Level of Diffi culty: 3)
21 Reconstruction of Dorsum of Toes
603
Operation Procedures
Fig. 21.1 Procedure 1: Case of necrosis of great toe due to
amputation
Fig. 21.2 Procedure 2: Skin defect area present on dorsal part of great
toe due to debridement
Reverse Flow Extensor Digitorum Brevis Muscle Flap (Level of Diffi culty: 3)
604
Fig. 21.4 Procedure 4: While gradually dissecting the dorsal pedis
vessels (including the deep peroneal nerve) in a distal direction, the
extensor digitorum brevis muscle is isolated from the layer beneath the
extensor digitorum longus muscle tendon. Distally, the tendenous areas
from the great toe to 4 th toe are cut, and dissection is performed on the
lateral dorsum off the periosteum. An island muscle fl ap with a thick
vascular pedicle (lateral tarsal blood vessels) can now be elevated
Fig. 21.3 Procedure 3: An incision is made in line with the path of the
dorsal blood vessels, and then the retinaculum of extensor is opened up
several more centimeters proximally, enabling confi rmation of the lat-
eral tarsal artery that branches from the dorsal artery to the extensor
digitorum brevis muscle
Note Without dissecting the small lateral tarsal artery, around 2 cm of
the surrounding thick vascular pedicle should be retained. Dissection is
not made at the extensor digitorum longus muscle (subcutaneous) layer.
21 Reconstruction of Dorsum of Toes
605
Fig. 21.5 Procedure 5: The dorsal artery is temporarily clamped in the
proximal position, and confi rmation made of reverse blood fl ow
Fig. 21.6 Procedure 6: The dorsal artery is ligated and cut proximally
and the muscle fl ap is elevated with reverse fl ow. The dorsal artery
should be detached up to the communicating branch with the plantar
artery to prevent it from folding over on itself
Note The deep peroneal nerve is severed and electrocauterization
conducted on the amputation stump.
Reverse Flow Extensor Digitorum Brevis Muscle Flap (Level of Diffi culty: 3)
606
Fig. 21.8 Procedure 8: A split-thickness skin graft is conducted on top
of the muscle fl ap. Light pressure is applied using cotton and dressing
Fig. 21.7 Procedure 7: The exposed bone area is covered using the
muscle fl ap, and a bolster suture is performed to pull the muscle fl ap
into the subcutaneous layer. A drain tube is inserted in the donor area
which is then closed
21 Reconstruction of Dorsum of Toes
607
Fig. 21.9 Procedure 9: The plaster splint is removed after 2 weeks.
(Part of photos reproduced from: Hirase Y, et al.: Indication and prac-
tice of reverse fl ow extensor digitorum brevis muscle fl ap transfer. Ann
Plast Surg 51:273–277, 2003)
Reverse Flow Extensor Digitorum Brevis Muscle Flap (Level of Diffi culty: 3)
608
Column
In the doctor ’ s offi ce
Naho had cleft hand in both hands. Her father also had cleft hand. Both her parents had come to get their DNA tested
because they were concerned about the genetics of their next child.
“What do you plan to do once you get the DNA results? Would you terminate the pregnancy?”
The young parents wouldn’t say.
“That would be like saying Naho shouldn’t exist, wouldn’t it?” mumbled the doctor half to himself. “If you say you
wouldn’t have this next child because it has a disability, wouldn’t that mean that Naho wouldn’t have been born either?”
“Would you love your husband more if he didn’t have a disability? Probably not, right?”
“Just because Naho has a disability, it doesn’t make her any less valuable in your eyes does it? Or would she be more
precious to you if she didn’t have a disability?”
Naho’s mother had black panda circles around her eyes where the tears had smudged her mascara.
“My wife has a nose just like her father. Every time I see her father, it reminds me that my wife is this man’s daughter.
So if your next child has a disability, then you should take pride in them, and say ‘this is my child.’”
Naho’s young father put his head in his hands and cried his heart out.
“Nurse - take down the sign that says plastic surgery. From now it will say ‘Be grateful for yourself - Surgery’” shouted
the doctor to hide the embarrassment of his tears, and placing both hands in his pockets, he strutted off.
Why, even an old man wants a chance to have his say every now and then!
It was a warm spring afternoon when that story drifted into my offi ce.
21 Reconstruction of Dorsum of Toes
609
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_22
Nerve Graft and Nerve Transfer
Basic Principles
Only certain nerves are capable of being harvested. For nerves for the fi nger, because only
thin and comparatively short nerves are required for nerve transplant, the cutaneous nerve
of the forearm and the posterior interosseous nerve can be used.
In cases requiring reconstruction using long or thick nerves, the sural nerve can be used.
The sural nerve can be folded up and used as a cable graft for reconstructing thick nerves.
In the distal 2/3 of the lower leg, the sural nerve runs above the calf, and apart from muscle
perforators of the posterior tibial artery, also obtains blood fl ow from the peroneal artery
fascial branch. Therefore one advantage to harvesting the calf fascia as a vascular pedicle
fascial fl ap, is it’s possible to harvest the fi bula fl ap and sural nerve at the same time.
Vascular pedicle nerve transplants are said to recover quickly, however if blood fl ow is not
properly reconstructed, scarring of the soft tissue surrounding the nerve can occur, and this
can impede the regeneration of the nerve, so care is required.
Nerve transfer is an option as a surgical method, however in the current day where vas-
cular pedicle nerve transplants are now possible, it is chosen in extremely limited cases.
Selectable Flaps and Surgical Procedures
a) Non-vascularized nerve graft
• sural nerve
• cutaneous nerve of forearm
• posterior interosseous nerve
b) Vascularized nerve graft
• sural nerve
• radial nerve
c) Nerve transfer
• ulnar nerve
• radial nerve
The diffi culty level of each surgical procedure is shown subsequent to
the procedure title (e.g., Level of Diffi culty: 2). The levels range from 1
to 5, with level 1 indicating a preliminary level and level 5 indicating a
very advanced level.
22
610
Information
There are various reports on locations where nerves can be harvested, however the following three types are practical
with small loss from the donor site. Indication varies according to the thickness of the reconstructed nerve
1. Cutaneous nerve of the forearm
2. Posterior interosseous nerve
3. Sural nerve
For fi ngers, either the cutaneous nerve of the forearm or the posterior interosseous nerve is suitable; for the palm
area, the sural nerve is more practical. In order to reconstruct a thick nerve, several thin nerves are bundled together
and used as a cable graft
Non-vascularized Nerve Graft (Level of Diffi culty: 3)
22 Nerve Graft and Nerve Transfer
611
Operation Procedures
Fig. 22.2 Procedure 2: Due to resection of the neuroma, a loss of
around 20 mm of nerve occurred
Case 1
Fig. 22.1 Case 1: Procedure 1: An amputation neuroma is present on
the radial digital nerve of the thumb
Non-vascularized Nerve Graft (Level of Diffi culty: 3)
612
Fig. 22.4 Procedure 4: The proximal and distal ends of the harvested
cutaneous nerve of the forearm are reversed and transferred to the
thumb
Fig. 22.3 Procedure 3: A small incision is made in the middle of the
medial forearm, and after detaching the antebrachial fascia, it becomes
possible to confi rm the thin cutaneous nerve of the forearm. The
required length of this nerve is severed and harvested
22 Nerve Graft and Nerve Transfer
613
Case 2
Fig. 22.6 Case 2: Procedure 1: Harvesting of posterior interosseous
nerve: A small incision is made beneath the 4th compartment of the
dorsal wrist joint, enabling confi rmation of the posterior interosseous
nerve rising up between the radius and the ulna. Around 20 mm of this
1 mm diameter nerve can be harvested
Fig. 22.5 Procedure 5: It is sutured under an optical microscope using
a 9-0, 10-0 nylon suture
Non-vascularized Nerve Graft (Level of Diffi culty: 3)
614
Case 3
Fig. 22.8 Case 3: Procedure 1: A 2 cm nerve defect was present fol-
lowing resection of an amputation neuroma on the median nerve on the
left hand
Fig. 22.7 Procedure 2: This can be used for the reconstruction of the
fi nger nerves of the distal fi ngertips
22 Nerve Graft and Nerve Transfer
615
Fig. 22.9 Procedure 2: An incision is made to the left lateral Achilles
tendon above the posterosuperior lateral malleolus, enabling confi rma-
tion of the sural nerve running beneath the subcutaneous fat. The
required amount is harvested
Note One method of harvesting this involves making multiple small
horizontal incisions every few centimeters, but because it is easily dam-
aged, the author chooses to harvest using a longitudinal incision.
Non-vascularized Nerve Graft (Level of Diffi culty: 3)
616
Fig. 22.10 Procedure 3: Because the sural nerve is thin, when transfer-
ring to the median nerve, several lengths are bundled together for use as
a cable graft. Therefore it is necessary to harvest the necessary length of
sural nerve, with care taken that the distal end is marked and sutured to
the proximal end of the median nerve
Fig. 22.11 Procedure 4: Three sural nerves are bundled together and a
cable graft is conducted
Note The blue points marked on the transplanted nerve in the photo
show that the distal ends of the transplanted nerve are sutured to the
proximal ends of the median nerve. When conducting a cable graft it is
also possible to bundle the transplanted nerves before they are trans-
ferred, however the suturing of nerves located in the middle can become
diffi cult, so it is better to carefully suture one nerve at a time.
22 Nerve Graft and Nerve Transfer
617
Vascularized Free Sural Nerve Graft (Level of Diffi culty: 5)
Information
Vascular pedicle Peroneal blood vessels
Size Can harvest 20 cm of the sural nerve from the proximal 1/3 of the lower leg to the ankle, with fascial blood fl ow
from the peroneal blood vessels
Advantage Can obtain a long nerve that can be used for the reconstruction of a thick nerve by folding and using for a
cable graft. Because it is vascularized, the nerve recovery is said to be fast and good quality.
Disadvantage Due to harvesting of the sural nerve, a 3 cm square area on the lateral dorsum becomes desensitized,
however this is rarely a problem
Caution If proper blood fl ow is not established, scarring will occur in the soft tissue, such as the fascia surrounding
the nerve, and it can actually hinder regeneration of the nerve.
Vascularized Free Sural Nerve Graft (Level of Diffi culty: 5)
618
Fig. 22.12 Procedure 1: Formation of amputation neuroma on the
median nerve
Fig. 22.13 Procedure 2: After resection of the neuroma, 4 cm of
median nerve lost
Operation Procedures
Fig. 22.14 Procedure 3: Patient is placed in either lateral recumbent
position or abdominal position. The perforators are confi rmed using
Doppler measurement from the central posterior border of the fi bula,
and the fi bula fl ap designed
22 Nerve Graft and Nerve Transfer
619
Fig. 22.17 Procedure 6: While opening up the margin around the cru-
ral fascia, the proximal end and distal end of the sural nerve are cut
along with the small saphenous vein. Pulling the soleus muscle down-
ward while turning over the calf fascia from the rear enables the perfo-
rators that were confi rmed from the anterior margin of the fl ap to be
confi rmed from the rear also. Going deeper and detaching more fascia
containing perforators, it is possible to confi rm the peroneal blood ves-
sels that run inside the fl exor hallucis longus muscle attached tightly to
the rear surface of the fi bula
Fig. 22.16 Procedure 5: A wide area is dissected above the crural fas-
cia, exposing the sural nerve from the proximal 1/3 of the lower leg to
the ankle. Using the small saphenous vein that accompanies the sural
nerve as a guide, a 20 cm length of sural nerve is secured
Fig. 22.15 Procedure 4: An incision is made in the anterior margin of
the fl ap and the fl ap is dissected with the independent fascia of the pero-
neal muscle included. It is then possible to confi rm the perforators ris-
ing up from the posterior margin of the fi bula through the thin fascia.
While retaining this, the peroneal muscle is detached in the anterior
direction
Vascularized Free Sural Nerve Graft (Level of Diffi culty: 5)
620
Fig. 22.18 Procedure 7: The calf fascia containing the sural nerve,
together with a monitoring fl ap (fi bula fl ap) can be elevated with the
perforators from the peroneal blood vessels. The peroneal blood vessels
are completely isolated from the fi bula with only a small amount of the
fl exor hallucis longus muscle attached, and the necessary length secured
Fig. 22.20 Procedure 9: The peroneal artery is placed in between the
radial artery and fl ow through type is used with anastomosis conducted
to both ends. Anastomosis of the small saphenous vein and the peroneal
artery comitant vein to the cutaneous vein of the forearm and the radial
artery comitant vein is conducted. The sural nerve is cut into 4 cm
lengths, being careful not to damage the fascial blood fl ow, folded into
3 layers, and transplanted to the median nerve as a cable graft
Fig. 22.19 Procedure 8: The vascular pedicle crural fascia is harvested
with fi bula fl ap attached. The small saphenous vein and sural nerve are
included in the crural fascia
Note The photo shows two fi bula fl aps harvested together.
Fig. 22.21 Procedure 10: The fi bula fl ap is sutured to the surrounding
area as a monitoring fl ap and then surgery brought to a close. A plaster
splint is applied for 2 weeks
22 Nerve Graft and Nerve Transfer
621
Nerve Transfer (Level of Diffi culty: 3)
Information
A pedicled nerve maintains good blood fl ow without necrosis of the core in cases of thick nerve transplants, doesn’t
require blood vessel anastomosis, and shows good axon regeneration. However, this involves the use of major nerves,
and is only indicated in special cases of crushing or neuroparalysis.
Application of pedicled nerve transfer to the forearm include reconstruction of the median nerve using a pedicled
ulnar nerve, and transfer of the paralyzed distal end of a median nerve or ulnar nerve from the interosseus to the dorsum
of the hand, and suturing to the proximal radial nerve.
Nerve Transfer (Level of Diffi culty: 3)
622
Operation Procedures
Fig. 22.22 Procedure 1: Due to a partial amputation crushing injury to
the wrist, the medial/ulnar nerve and radial/ulnar artery were ruptured.
Anastomosis was conducted on the arteries and the nerves were sutured,
however paralysis of the medial/ulnar nerve did not improve. On re-
opening the wound 6 months later, a 4 cm length of scarring was present
on the medial nerve. The artery was patent
Fig. 22.23 Procedure 2: Scarring of the ulnar nerve and an amputation
neuroma were also confi rmed
22 Nerve Graft and Nerve Transfer
623
Fig. 22.24 Procedure 3: However there was no damage in the ulnar
nerve at the proximal rupture area, and the branch heading to the area
surrounding the nerve from the ulnar artery was retained
Fig. 22.26 Procedure 5: Here, the ulnar blood vessels and ulnar nerve
were elevated as one group, and using the branch heading to the skin, a
small skin fl ap was elevated as a monitoring fl ap
Fig. 22.25 Procedure 4: The branch heading to the skin from the ulnar
artery was also confi rmed
Note (Branch to nerve⇒, branch to skin➡)
Note (Branch to nerve⇒, Branch to skin➡)
Nerve Transfer (Level of Diffi culty: 3)
624
Fig. 22.27 Procedure 6: The ulnar nerve is elevated together with the
ulnar blood vessels. Confi rmation made that there is no change in the
blood fl ow to the monitoring fl ap due to reverse blood fl ow, even when
a clamp is applied to the proximal area of the ulnar artery
Fig. 22.28 Procedure 7: The ulnar nerve is cut from the proximal end,
and the vascular pedicled ulnar nerve fl ap with reverse fl ow is elevated
Fig. 22.29 Procedure 8: Being careful not to damage the blood ves-
sels, the ulnar nerve is cut and folded into 2 layers, and transplanted to
the median nerve as a cable transplant (➡)
Note (Ulnar blood vessels ⇒, Ulnar nerve➡)
Here, if there is insuffi cient reverse blood fl ow to the monitoring fl ap,
the blood vessels should be cut and it should be used for a normal fl ow
pedicled free nerve transplant.
22 Nerve Graft and Nerve Transfer
625
Fig. 22.30 Procedure 9: The wrist wound was closed using the moni-
toring fl ap. A skin graft is conducted on the donor area
Nerve Transfer (Level of Diffi culty: 3)
627
© Springer Japan 2017
Y. Hirase, Practical Techniques in Flap Surgery, DOI 10.1007/978-4-431-56045-6_23
Transplantation of Bone and Joints
Basic Principles
Historically, areas that can be used for harvesting of vascular pedicled bone transplants
include the ribs, scapula, ilium, radius, femur and fibula; however, the easiest of these to use
are the fibula and the scapula. If a long bone of 7–8 cm or greater is required, then the fibula
can be combined with a latissimus dorsi musculocutaneous flap or scapular flap, and in
cases where only a small amount of bone but a large amount of soft tissue is required, the
scapula is selected.
The PIP joint of the second toe is used for reconstructing PIP joints of the finger.
There is also a method of transferring a pedicled IDIP joint to the PIP joint, but in most
cases there is a requirement that the digital arteries on both sides are patent. When harvest-
ing from the second toe, although it is possible to retain the toe when harvesting the pedi-
cled PIP joint, in cases where a large amount of bone needs to be harvested, there can often
be problems with the remaining toe after surgery, so it is better to remove the second toe,
with the consent of the patient.
Selectable Flaps and Surgical Procedures
Fibula • Scapula • Ilium • Radius • Cranium • Transfer of PIP joint of second toe
The difficulty level of each surgical procedure is shown subsequent to
the procedure title (e.g., Level of Difficulty: 2). The levels range from 1
to 5, with level 1 indicating a preliminary level and level 5 indicating a
very advanced level.
23
628
Vascularized Fibula Graft to Lower Leg (Level of Difficulty: 5)
Information
Vascular pedicle Peroneal blood vessels
Size Can harvest around 20 cm of the fibula, leaving around 5 cm each end. Can harvest a skin flap from the middle to
the distal part of the fibula with a width of 8 cm and a length of 15 cm
Anastomotic vessel Can be inserted in between the posterior tibial artery with a flow through type used with anasto-
mosis conducted at both ends, or end-to-side anastomosis conducted with the posterior tibial artery in the popliteal
region, or a side to side anastomosis conducted in the medial malleolus region.
Refer to Section of “Bone and joint transplant/Vascularized
Fibula Graft to the forearm” in Chap. 23
23 Transplantation of Bone and Joints
629
Operation Procedures
Fig. 23.2 Procedure 2: Appearance after removal of hydroxyapatite.
An 8 cm bone defect is present
Fig. 23.3 Procedure 3: The fibula flap is designed in the center of the
lower leg
Fig. 23.1 Procedure 1: With respect to chronic osteomyelitis of the
tibia following an open fracture of the lower leg, the infected bone was
debrided and sustained release antibiotic hydroxyapatite inserted into
the wound
Refer to Section of “Bone and joint transplant/Vascular pedicle free
fibular transplant to the forearm” in Chap. 22
Vascularized Fibula Graft to Lower Leg (Level of Difficulty: 5)
630
Fig. 23.6 Procedure 6: The posterior margin of the flap is opened and
with part of the soleus fascia in the flap, it is detached from the muscle
Fig. 23.5 Procedure 5: The anterior fibula is detached
Fig. 23.4 Procedure 4: An incision is made in the anterior margin of
the fibula flap, and the perforators to the flap are confirmed as emerging
from behind the bone. The peroneal muscle is pulled forward and
dissected
23 Transplantation of Bone and Joints
631
Fig. 23.7 Procedure 7: While confirming and retaining the perforators,
detachment is continued until the flexor hallucis longus muscle comes
into view
Fig. 23.8 Procedure 8: A retractor is inserted into the posterior side of
the distal fibula, and the bone is severed while protecting the vascular
pedicle
Fig. 23.9 Procedure 9: The vascular pedicle running along the poste-
rior surface of the bone is ligated, and while holding onto the bone, the
vessel running along the muscle is detached, with about 1 cm from
inside the flexor hallucis longus muscle included. The proximal end of
the bone is cut, and further dissection conducted
Vascularized Fibula Graft to Lower Leg (Level of Difficulty: 5)
632
Fig. 23.10 Procedure 10: The posterior tibial muscle is cut from the
anterior tibia. The peroneal blood vessels are detached proximally up to
the branch with the posterial tibial blood vessels, however care is taken
not to damage the sural nerve behind the head of the fibula
a
b
Fig. 23.11 (a, b) Procedure 11: The harvested pedicled fibula and flap.
The bone is folded in two while retaining the vascular pedicle
23 Transplantation of Bone and Joints
633
Fig. 23.14 Procedure 14: Appearance of transplanted bone fixed in
place
Fig. 23.13 Procedure 13: A continuous suction tube is inserted under
the flap and the flap is sutured
Fig. 23.12 Procedure 12: The tip of the bone is shaved, inserted into
the marrow at both ends and fixed in place with a steel wire. Side-to-end
anastomosis is conducted of the vascular pedicle to the posterior tibial
blood vessels
Vascularized Fibula Graft to Lower Leg (Level of Difficulty: 5)
634
Tips
Which to choose, free vascularized bone graft or bone transport method?
A fibula that cannot be folded in half is too thin and prone to fracture after commencement of load bearing. The
transplanted fibula can become thicker due to the fracture, but it will take another several months of treatment before
it can take a full load. In the bone transport method that uses the Ilizarov external bone fixation and extension appara-
tus, ossification and leg extension can be conducted simultaneously following resection of a nonunion section. Although
it takes time, it is a stable process, and capable of handling thick bones and soft tissue defects.
The X-ray shows a nonunion after vascularized free fibula transplant. The left X-ray shows 6 cm bone shortening
(⇨) and cutting bone for extension. The middle X-ray shows 8 cm extension (⇒). It took 90 days until the completion
of the extension and 6 months until full weight could be applied (right X-ray).
23 Transplantation of Bone and Joints
635
Vascularized Fibula Graft to Forearm (Level of Difficulty: 4)
Refer to Section of “Bone and joint transplant/Pedicled free fibula transplant to the lower leg” in Chap. 23
Information
Vascular pedicle Peroneal blood vessels
Size Can harvest around 20 cm of the fibula, leaving around 5 cm each end. Can harvest a skin flap from the middle to
the distal part of the fibula with a width of 8 cm and a length of 15 cm
Anastomotic vessel Can be inserted in between the radial artery with a flow through type with anastomosis conducted
at both ends, or end-to-side anastomosis conducted, or side-to-side anastomosis conducted.
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Operation Procedures
Fig. 23.16 Procedure 2: A 10 cm loss of bone from the radius is
recognized
Fig. 23.15 Procedure 1: With respect to osteomylitis in the radius of
the forearm, the sequestrum is resected and sustained release antibiotic
hydroxyapatite inserted
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637
Fig. 23.18 Procedure 4: An incision is made in the anterior margin of
the flap
Fig. 23.17 Procedure 3: 12 cm of bone is planned to be harvested from
the tibia, leaving 6 cm at the distal end, with a flap designed above the
bone
Fig. 23.19 Procedure 5: Turning over the skin flap that includes the
independent fascia of the peroneal muscle, it is possible to confirm the
cutaneous branch heading to the flap from the posterior border of the
fibula
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Fig. 23.20 Procedure 6: The posterior margin of the flap is cut open,
enabling confirmation of the perforators through the soleus fascia
Fig. 23.21 Procedure 7: Perforators emerging from the posterior sur-
face of the bone are dissected and the fibula flap elevated
Fig. 23.22 Procedure 8: The front surface of fibula is completely
isolated
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Fig. 23.23 Procedure 9: The bone is cut at the distal end of the fibula
Fig. 23.24 Procedure 10: The bone is cut at the proximal end of the
fibula, and the entire bone is pulled forward
Fig. 23.25 Procedure 11: The flexor hallucis longus muscle on the
posterior side of the bone is detached
Note The vascular pedicle is running through this muscle.
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Fig. 23.26 Procedure 12: The peroneal blood vessels are ligated at the
distal end of the bone
Fig. 23.27 Procedure 13: When the distal end of the bone is lifted up,
it is possible to confirm the vascular pedicle running tightly against the
posterior surface of the bone. While cutting the posterior tibial muscle,
detachment is continued toward the proximal end
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641
a
b
Fig. 23.28 (a, b) Procedure 14: The bone and skin flap is completely
detached/elevated. The tourniquet is released and if bleeding can be
confirmed from the bone and the skin flap then it is harvested
Fig. 23.29 Procedure 15: The tip of the transplanted bone is step cut
and shaved into a cone-shape ready for insertion, and then fixed in place
with steel wires
Vascularized Fibula Graft to Forearm (Level of Difficulty: 4)