The Vascular Supply to the Lateral Compartment of the Leg with Emphasis on Fibular Graft Harvesting

doi:10.21203/rs.3.rs-4673479/v1

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Research Article

The Vascular Supply to the Lateral Compartment of the Leg with Emphasis on Fibular Graft Harvesting

https://doi.org/10.21203/rs.3.rs-4673479/v1

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Purpose

The aim of this study is to determine the exact locations of vascular pedicles that supply the fibularis longus and brevis, to identify the morphometric features of those vessels in the lateral compartment of the leg, and to indicate the branching points of the pedicles from the main arteries.

Methods

The popliteal arteries of 40 lower limbs from 20 adult cadavers (12 males, eight females) were injected with colored latex bilaterally. Following dissection, the branches were counted, and the distances between the apex of the head of the fibula and the branching points of pedicles from the anterior tibial, fibular, and posterior tibial arteries that supply the fibularis longus and brevis were measured.

Results

In all cases, a single artery coursing in the lateral compartment of the leg was identified; it was a branch of the anterior tibial artery and it supplied the proximal and middle thirds of the fibular muscles anteriorly. The mean distance between the origin of this artery and the apex of the fibular head was 8.65 cm. Its mean length was 10.9 cm and the mean number of its branches was 4.7. In all specimens, the fibular artery supplied the proximal and distal portions of the fibular muscles posteriorly.

Conclusions

In this study, the morphometric properties and branching patterns of the axial pedicle of ATA, which runs longitudinally in the lateral compartment and branches to the FL and FB, are described in detail for the first time. We propose that this artery be named the lateral fibular artery. If this nomenclature is accepted, the fibular artery can be renamed the posterior fibular artery.

fibular muscles

fibular graft

anterior tibial artery

lateral fibular artery

posterior tibial artery

axial pedicle

fibularis brevis graft

Fibular grafts and myocutaneous fibular flaps are used for reconstruction of lower limb traumas and facial bone defects such as mandible defects (1–3). Fibularis longus (FL) and brevis (FB) muscle grafts are also the most commonly used grafts for foot and leg defects because of their proximity to those regions (4). In particular, the FB muscle is preferred as a pure muscle flap or an osteomuscular flap that is harvested with a vascularized bone segment. It is used for reconstructing muscle or bone defects in the distal part of the lower limb, and for Achilles tendon reconstruction (4–9).

While these grafts and flaps are preferred for reconstruction owing to such advantages as compatibility with the length of the fibula and ease of bone union, there is a risk of complications such as postoperative necrosis of the fibular muscles (10, 11). The vascular pattern of the FL and FB is important for suitability and post-operative success of flap harvesting. There are several accounts of the vasculature patterns of the FL and FB in the literature. The main textbooks of anatomy and of plastic and reconstructive surgery indicate that these muscles are supplied by branches of the fibular (FA), anterior tibial (ATA), and posterior tibial (PTA) arteries (12, 13). Although some previous studies have shown that the PTA gives branches to the fibular muscles, information about the branching pattern and distribution of these vessels is lacking (2, 14, 15). Shortness or congenital absence of the FA, ATA and PTA and their branches can be problematic for the donor sites, the free fibular flap, or both (16). Identification of vessel variations with imaging techniques prior to fibular flap harvesting is a good operation strategy (17). However, some authors consider the use of imaging procedures before the operation controversial (16).

Although fibular grafts are frequently used for reconstructions in the face and foot-ankle regions, and muscle-tissue lesions have been reported after graft surgeries, there is no consensus in the guidelines and the literature about the vascular patterns of these muscles. Reliable knowledge of the vessels supplying this region would guide surgeons before and during the operation. Therefore, the aim of this study is to determine the exact locations of the vascular pedicles that supply the FL and FB, and to identify the branching pattern and the course of these vessels in the lateral compartment of the leg.

Forty lower limbs from 20 adult cadavers (12 males, eight females) with a mean age of 65 years (range 38–93) were dissected. The popliteal arteries of the specimens were filled with colored latex. The length of the leg was measured between the apex of the fibular head and the tip of the lateral malleolus. After the skin, soft tissue, and the deep fascia of the leg had been excised, the ATA in the anterior compartment and the FA and PTA in the posterior compartment were identified. Their branches were counted and their lengths measured. The distances between the apex of the head of the fibula and the branching points of branches of the ATA, FA, and PTA that supply the FL and FB were measured. The leg was examined in three parts of equal length, proximal, middle, and distal. The branching points of each artery were recorded in relation to those parts and the vascular pattern of the fibular muscles was determined.

The data obtained were analyzed using SPSS (Statistical Package for Social Sciences) for Windows (Version 26, IBM Corp., Armonk, NY, USA). Student’s t-test was used to compare the parameters and Pearson’s correlation test was used to analyze the relationships between groups.

The FL and FB were supplied by pedicles branching from three main arteries, the FA, ATA and PTA. The mean lengths of the leg and vascular branches were 32.6 ± 2.4 cm and 2.2 ± 0.54 cm, respectively.

The ATA had 3.25 ± 1.1 and 2.25 ± 0.8 branches to the FL and FB, respectively, on average. These branches supplied the FL and FB through their medial aspects.

In all specimens, an axial pedicle of the ATA supplied the fibular muscles in the proximal and middle thirds through their anterior aspects (Figs. 1 and 2). The mean length of this pedicle was 10.9 ± 2.14 cm and the mean number of branches arising from it was 4.67 ± 1.2. The mean distance between the origin of the pedicle and the apex of the fibular head was 8.65 ± 1.2 cm.

The pedicle coursed in the proximal and middle parts of the lateral compartment of the leg, accompanied by the superficial fibular nerve (Fig. 3).

The FA supplied the fibular muscles through their posterior aspects. The mean numbers of branches to the FL and FB were 4.5 ± 0.9 and 2.67 ± 0.65, respectively (Table 1). In 15% of the specimens, the PTA had 1.37 ± 0.49 branches to the FB in the distal part of the leg (Fig. 4).

Table 1

Distribution of the vascular branches in the proximal, middle and distal thirds of the leg length
Mean number of branches
	Proximal 1/3	Middle 1/3	Distal 1/3	Total
ATA_FL	1.97 ± 0.67	0.95 ± 0.69	1.09 ± 0.3	3.25 ± 1.1
ATA_FB	-	2 ± 0.6	0.68 ± 0.48	2.25 ± 0.81
ATAp_FL	1.08 ± 0.27	1.85 ± 0.67		2.88 ± 0.85
ATAp_FB	-	1.95 ± 0.6	0,7 ± 0.47	2.25 ± 0.81
FA_FL	2.15 ± 0.48	1.68 ± 0.53	1 ± 0.28	4.5 ± 0.91
FA_FB	-	1.88 ± 0.33	1.10 ± 0.31	2.68 ± 0.66
PTA_FB	-	-	1.38 ± 0.49	1.38 ± 0.49
ATA: anterior tibial artery; FA: fibular artery; PTA: posterior tibial artery; FL: fibularis longus; FB: fibularis brevis.

Mean number of the vascular branches for each muscle in the proximal, middle and distal thirds of the leg length was indicated in Table 2. The most common patterns of branching in each third of the leg were identified. In the proximal 1/3, while the ATA had two branches and its pedicle had one branch supplying the FL through its anterior aspect, the FA had two branches supplying the FL through its posterior aspect. In the middle 1/3, the pedicle of ATA had two branches supplying the FL and FB through their anterior aspects, and the FA had two branches supplying those muscles through their posterior aspects. In the distal 1/3, while the ATA had one branch supplying the FB through its anterior aspect, the FA had one branch supplying each of the FL and FB through their posterior aspects. In addition, the PTA had one branch supplying the FB through its posterior aspect (Fig. 5).

Table 2

Distribution of the number of vascular branches for each muscle in the proximal, middle and distal thirds of the leg length
	FL		FB
	ATA	FA	ATA	FA
Proximal 1/3	3.05	2.15	-	-
Middle 1/3	2.8	1.68	3.95	1.88
Distal 1/3	1.09	1	1.38	1.10
ATA: anterior tibial artery, FA: fibular artery; FL: fibularis longus; FB: fibularis brevis.

The mean distances between the branching points of the vascular branches to the apex of fibular head in the three parts of the leg are given in Table 3.

Table 3

Mean distances between the branching points of the vascular branches of the fibularis longus and brevis and the apex of fibular head in three equal parts of the leg. The distances are given in cm ± standard deviation.
	Proximal 1/3*	Middle 1/3*	Distal 1/3*
ATA_FL	6.96 ± 1.65	17.42 ± 3.71	24.5 ± 1.72
ATA_FB	-	19.62 ± 1.93	24.39 ± 1.02
ATAp_FL	10.55 ± 0.57	13.63 ± 1.51	-
ATAp_FB	-	18.82 ± 1.71	-
FA_FL	4.89 ± 1.76	18.05 ± 2.77	25.43 ± 5.06
FA_FB	-	17.64 ± 1.47	23.54 ± 1.41
PTA_FB	-	-	27.37
ATA: anterior tibial artery, FA: fibular artery; PTA: posterior tibial artery; FL: fibularis longus; FB: fibularis brevis.

Table 4

The mean distances from the branching points of the most proximal and most distal muscular pedicles to the fibular head and the lateral malleolus of the fibula. The distances are given in cm ± standard deviation.
	FL		FB
	FH	LM	FH	LM
Most proximal	3.89 ± 0.75	29.75 ± 0.63	17.24 ± 2.1	16.39 ± 1.85
Most distal	24.35 ± 3.76	9.29 ± 3.88	25.68 ± 3.54	7.9 ± 3.54
FL: fibularis longus; FB: fibularis brevis; FH: fibular head; LM: lateral malleolus of the fibula.

The FL tendon graft is an ideal option for reconstructing the anterior cruciate, lateral ankle, distal tibiofibular, and spring ligaments and the Achilles tendon (18–26). FB muscular flaps are preferred for treating distal leg injuries because of their close proximity and ease of application. Muscle flaps are difficult to use on wide defects in the distal part of the leg because most of the muscles have a tendinous structure in this region. However, the FB has a muscle body in its distal part, too, so it is suitable as a flap in this region (5, 6, 15, 27).

The axial configuration flap is a solitary pedicle flap featuring a biologically recognized arterio-venous system extending along its elongated axis. Because of this axial arterio-venous system, this type of flap is exempt from the various limitations or constraints typically linked with flaps. This enables the flap to be elevated promptly, even with a lone pedicle, and with a length significantly greater than its breadth. Therefore, axial flaps including a pedicle are usually preferred to random flaps for reconstructing medium-sized and large defects (28). Ensat et al. saw the axial pedicle in random flaps from the ATA in 15 out of 17 specimens. They used the FB as a flap with this axial pedicle. In our study the axial pedicle was present in 40/40 specimens. It was accompanied by the superficial fibular nerve, as observed by Ensat et al. also found that the pedicle pierced the anterior intermuscular septum 8.56 cm distal to the tip of the head of the fibula (14). Our study gave a similar value: the branching point of the axial pedicle from the ATA was 8.65 ± 1.2 cm distal to the tip of the head of the fibula. Ensat et al. measured the average length of this pedicle at 5.5 ± 2.4 cm. The length found in our study was approximately twice theirs, 10.9 ± 2.14 cm. We suggest that this pedicle is the dominant pedicle of the FB. According to Chung et al., dominant pedicles have few anatomical variations. The presence of this pedicle in all specimens in our study supports this idea (13).

FL and FB have type 2 vascular pedicles; one dominant pedicle and some minor ones. In this type, it is essential to preserve the dominant pedicle during flap harvesting (13, 29). The FB muscle in our study had one dominant pedicle and five minor ones from the anterior tibial and fibular arteries. The FL was nourished by 11 minor pedicles from the ATA and FA and the axial pedicle of the ATA. These results confirm that the FB is type 2 while the FL has multiple segmental pedicles (type 4).

According to Ensat et al., the FB received an average of 5.1 ± 1.6 vascular pedicles per leg from the anterior tibial and fibular arteries; in the present study it received 4.67 ± 1.2. Ensat et al. harvested the FB graft with one major pedicle, which accompanied the superficial fibular nerve, but they did not characterize it exactly in terms of location, length, or number of branches (14). In our study, we found an axial pedicle that was longer than the others (10.9 cm) and accompanied the SFN. It had approximately five branches.

Villarreal et al. stated that the ATA has two main pedicles, the superior and inferior lateral perioneal vessels, which pierce the anterior intermuscular septum. The superior lateral peroneal vessel goes to the FL 26.5 cm proximal to the lateral malleolus. The inferior lateral peroneal vessel goes to the FB 22.5 cm proximal to the lateral malleolus. According to Villarreal et al., the superior and inferior lateral peroneal vessels are the most important vascular sources to the fibular muscles; in the distal third of the leg, the FA dominates in the supply. These authors did not determine the lengths or the exact courses of the branches of the vessels (2). In the present study, we found one major pedicle, which gave branches to the FL and FB, branching from the ATA 8.65 cm distal to the fibular head. The ATA had a dominant role in the proximal and middle thirds of the leg for the FL and the middle third for the FB. The ATA and FA had equal dominance in supplying the fibular muscles in the distal third (Table 2). On the basis of our observations, and in line with Villareal et al., the risk of necrosis should be less in the proximal and middle thirds of the leg because the fibular muscles are supplied by the ATA.

Eren et al. identified the distal FB flap for the first time, emphasizing its simplicity, usability and cost-effectiveness. According to Yang et al. and Ensat et al., respectively, the most distal pedicle of the FB is located 4.25 or 4.3 cm proximal to the lateral malleolus. Gasou et al. and Ensat et al. located the most proximal pedicles of the FB at 19 cm and 8.64 cm proximal to the lateral malleolus, respectively (14, 15, 30, 31). In the present study, the most distal and most proximal pedicles to the FB were 7.9 cm and 16.39 cm proximal to the lateral malleolus. These distances are important for avoiding injury to the pedicles and vascular complications such as necrosis by restricting the dissection to the correct level while harvesting the muscle.

Gosau et al. suggested that use of the proximal axial vessel for the FB flap was controversial, but Ensat et al. contradicted this by demonstrating that the proximal supply to this muscle predominates (14, 31). In our study, the FB received 5.83 pedicles in the middle 1/3 and 2.48 in the distal 1/3 of the leg. When the origin of the FB muscle is considered, it seems that its proximal part has more dominant vasculature than the distal. According to these results, the proximal axial pedicle seems suitable for using a vascular source in the FB flap.

Not only is wound healing affected by tobacco use and by cardiovascular and respiratory diseases, but graft features such as tissue and vessel harvesting are also important for post-operative complications. According to Shindo et al., compartment syndrome begins with tissue injury and muscle ischemia and can occur after fibula and fibular vessel harvesting (32). It can result from any injury to the muscular branches of the FL and FB (33). In harvesting of the FB, the perforators coming from the fibular artery were used mostly (5). Injury to the axial pedicle from the ATA, which has an important role in supplying the fibular muscles, could explain the necrosis of those muscles after surgery.

During graft surgeries, after a vessel source is harvested, the vascular supply to the remaining tissue is provided by anastomotic choke vessels (34). Because of the anastomoses between the perforators from the ATA and FA, ischemia and necrosis are less likely. In the absence of anastomotic vessels, removal of the FA can make the supply to the fibular muscles defective (35). In this situation, the axial pedicle of the ATA is important for ensuring continuity in the supply to the fibular muscles.

The fibular muscles are supplied mainly anteriorly by direct branches of the ATA and an axial pedicle from it that extends into the lateral compartment, and posteriorly by the FA. Knowing the exact locations of these arterial branches is important for guiding surgeons in flap operations. The pedicle from the ATA is preferable for flap harvesting of the FB muscle. In addition to the ATA and FA, any injury to this pedicle can result in necrosis after operations in the leg region.

In this study, the morphometric properties and branching patterns of the axial pedicle of the ATA, which runs longitudinally in the lateral compartment and branches to the FL and FB, have been described in detail for the first time. Knowing the characteristics of the branching points of the pedicle, and protecting the artery, are very important for maintaining the blood supply to the fibularis muscles during operations in this region. Current anatomy and plastic and reconstructive surgery books, and Terminologia Anatomica, provide no special nomenclature or terminology or detailed information about this branch, which is important for vascularization of the fibular muscles and flap harvesting. We suggest naming this artery the lateral fibular artery. If this nomenclature is accepted, the fibular artery could be renamed the posterior fibular artery.

Declaration of competing interest

The authors affirm that these potential conflicts of interest have been disclosed in the spirit of transparency and to ensure the integrity of the research process. The study was conducted objectively, and the results are reported independently of external influences. The authors are committed to upholding the highest standards of scientific rigor and ethical conduct in their research.

Ethical Statement

The procedures carried out in this study adhered to the ethical principles set forth by the institutional research committee and were in compliance with the 1964 Helsinki Declaration and its subsequent revisions. Institutional ethical clearance was not required for conducting cadaver dissections.

Author Contribution

Nihal Apaydin: Project development, Data collection, Data analysis, Manuscript writing, Manuscript editing. Aybegum Balci: Project development, Data collection, Data analysis, Manuscript writing. Simel Kendir: Data collection, Data analysis, Manuscript editing. Marios Loukas: Project development, Manuscript editing. Richard S. Tubbs: Project development, Manuscript editing. All authors read and approved the final manuscript.

Acknowledgement

We express our sincere gratitude to the individuals who generously donated their bodies to science, facilitating the advancement of anatomical research and contributing to the enhancement of patient care. The successful completion of this project would not have been possible without the invaluable contributions of these donors.

Data Availability

The data used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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The Vascular Supply to the Lateral Compartment of the Leg with Emphasis on Fibular Graft Harvesting

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