Anatomical Study And Clinical Application Of Tibial Periosteal Flap

Objectives Cadaver legs were chosen to make an anatomic measure, to observe the origin of the blood supply of the tibial pe riosteum, the route of travel and distribution of vessel, the position of periosteum branch and its relationship and anastomosis. The aim is to provide theoretical guidanc for the clinical application of the tibial periosteal flap based on anatomy. To investigate the clinical effectiveness of tibial periosteal flap combined with autologous bone graft in repairing tibial nonunion and bone defects.Methods 1 Anatomical study: On 13 legs of fresh adult cadavers(left side 6 cases, right side 7cases) that were injected with red latex and divided into proximal, middle and distal, the origin, branch, route of travel, distribution and anastomosis of medial tibia vessels, particularly on the middle and distal tibia, were dissected and observed.2 Clinical application: From February 2006 to June 2014, 36 cases of traumatic tibial bone defects with or without skin and tissue defects had been treated. 21 cases of them were treated by tibial periosteal flap combined with autologous bone graft to repair bone defects, and cases with skin and tissue defect repaired by transfer leg flap. Through periodic review of X-ray after operation, fracture healing and complication were observed.Results 1 Anatomical study: The tibia had flat surface and thick periosteum, that were supplied by anterior tibial artery, medial inferior genicular artery, posterior tibial artery, saphenous artery and peroneal artery. In this paper, we mainly observed the posterior tibial artery. Intermusculer branch of posterior tibial artery distributed between coarse tibia and medial malleolus. A total of 4-7 branches(mean 5.3 branches each specimen) were distributed in the medial tibia. Middle and proximal tibia had less periosteal branches than the distal. In the surface of medial tibia they anastomosed into arterial network. Length of vascular pedicle ranged from 1.0-3.5cm, and caliber was from 1.0-1.4mm.2 Clinical application: All patients were followed up 20-36 months(mean, 24 months). The graft bone got healing 4-8.5 months(mean,6 months) after operation. No complication of implant loosening of fracture occurred. There was no pain and abnormal activity in the affected extremity. Weight-bearing and walking function were acquired in all cases. The length of affected leg was recovered and difference value was 1.0±0.5cm compared with uninjured side. The function of knee and ankle joint was good, and there was no complication such as infection, malunion, and equines. In 15 cases skin flaps, the donor site was sutured directly in 5 cases and covered with skin graft in 10 cases. 14 cases flaps survived in the first intention with good appearance and abundant blood supply and no ulcer and infection. 1 case of skin flap was suffered with distal necrosis which healed after dressing change. According to the Johner standard, the results were excellent in 14 cases, good in 6 cases, and fair in 1 case, and the excellent and good rate was 95.2%. Evaluating lower limbs function by using Enneking system: score were 26-30 in 16 cases, 21-25 in 3 cases, and 16-20 in 1 cases, which indicated that the average functional recovery of affected leg reach to 88.5% of the other side.Conclusions 1 Anatomical study: Periosteum in the medial tibia was thick and superficial and the position of branch was constant, which was convenient for operator to design and cut periosteal flap to repair adjacent bone defects of tibia.2 Clinical application: Tibial periosteal flap could provided recipient bone graft with adequate blood supply, which was conducive to fracture revascularizat ion and promoting bone healing. The curative effect of periosteal flap combined with autologous bone graft in the treatment of tibial bone defects and nonunion was reliable.