The role of the periosteal and intraosseous blood supply to the femur and the proximal tibia was investigated to improve the operating technique for transplantation of allogenic vascularized femoral diaphyses and knee joints in humans. Altogether 48 limbs were injected with gelatin, red latex milk, or Revertex and macroscopically prepared; 41 limbs were studied for the variation and division of the truncus profundo-circumflexus. In 200 femurs and 200 tibias the location of the nutrient foramen was determined. The arteries supplying the periosteum of the distal femur and the proximal tibia have defined nutritive areas. The following technique should be followed: If the femoral artery alone is prepared as the vascular pedicle, the optimal section for resection of the femur in knee joint transplantations is 6 to 12 cm above the level of the femur condyles and 5 to 7 cm below the tibial plateau. For the transplantation of femoral diaphyses, the deep femoral artery can be used if the lateral femoral circumflex artery is protected. The Proximal line of resection is defined between the greater and lesser trochanter. For shorter grafts one must consider the number and location of nutrient foramens. For longer grafts the distal branches of the femoral artery must be respected as the intraosseous blood supply reaches distally down to the level of about 8 cm above the femoral condyles. In all these operations of the variation of the truncus profundo-circumflexus and the trifurcation of the popliteal artery must be considered.
The periosteal and endosteal blood supply of the human ulna and radius was investigated by anatomical dissection. The main artery concerned is the anterior interosseous artery. It supplies the diaphysis of ulna and radius; its branches feed the distal one-fourths of both the ulna and the radius. The proximal one-fourth of the ulna is supplied by the ulnar artery, the ulnar recurrent artery and the recurrent interosseous artery. Periosteal branches of the common interosseous artery, the ulnar artery and the recurrent interosseous artery supply the proximal one-fourth of the radius. In both bones the main branch of the nutrient artery has an ascending course. The anterior interosseous artery, as the main artery of the periosteal and endosteal supply of the human ulna and radius, is important in transplantation and reconstruction, especially with a view to reducing the rate of pseudarthrosis. When osteosynthesis is planned so-called LC-DC plates should be chosen to preserve the periosteal branches. When a vascularized bone graft is taken from the forearm the vascularization of the remaining bones has to be considered. The vascularity of this area allows various options in grafting.
The blood supply of the periosteum of the human tibia was investigated by anatomical dissection of 12 lower extremities which were filled with injection mass. By division of the tibia into 4 segments (proximal and distal fifths; proximal and distal diaphysis) a general supplying system of the periosteum was found. The proximal fifth of the tibial periosteum is nourished by branches of the arteriae recurrentes tibiales anterior et posterior and the aa. inferiores medialis et lateralis genus. At the proximal diaphysis (next three tenths of the tibia) periosteal branches arise from the aa. tibialis anterior and posterior, whereas the distal diaphysis is nourished exclusively by semicircular vessels of the a. tibialis anterior which twine around the bone and merge with each other at the facies medialis. Concerning the periosteal blood supply of the distal fifth of the tibia, two different types were found. In two thirds of the cases the lateral side was nourished by branches of the a. tibialis anterior, which are supported by vessels from the a. fibularis. In one third the latter branch was absent so that the rami periostales arising from the a. tibialis anterior nourished the lateral aspect of the distal tibia alone. The dorsal region was supplied in all cases by rami of the a. fibularis and a. tibialis posterior. On the medial side the periosteal nourishment is ensured only by anastomosis. Branches of the a. tibialis anterior supply the facies lateralis and facies posterior where it is supported by vessels of the a. tibialis posterior and in a minor region of rami of the a. fibularis (distal) and a. poplitea (proximal). Both the facies lateralis and facies posterior are nourished by direct branches which arise from the main arteries of the lower leg, whereas the facies medialis is supplied only by capillary anastomosis. The a. tibialis anterior is the artery of great importance concerning the arterial supply of the periosteum and the outer aspect of the cortex of the tibia. The autonomous region of this vessel is the periosteum of the distal diaphysis. It is known that this region has the highest incidence of congenital and acquired pseudarthrosis. Therefore an osteo- or corticotomy should be avoided in the distal diaphysis.
The proximal third of the humerus is fed by the anterior and posterior circumflex arteries of the axillary artery. They construct a fine anastomoses network at the humeral head as well as longitudinal anastomoses to the diaphysis. The middle third of the humerus is maintained by the rami musculoperiostales originating in both the brachial artery and the deep brachial artery. These periosteal vessels are formed both horizontally and vertically. The distal third of the humerus is mainly supplied by the horizontal anastomoses of the collateral arteries. The inner part of the bone is normally penetrated by just one nutrient artery entering the nutrient canal below the middle of the humerus.
The vitality of a graft in a vascularized allogenic knee joint transplantation in humans will depend strongly on maintaining the arterial blood supply to the bone. As can be demonstrated in injected specimens on cadavers, only periostal aa. are important to ensure the blood supply of the human knee joint. The main arteries have defined nutritive areas. According to our results access to the vessels should most probably be conducted from the dorsal side of the knee. During the explantation the popliteal a. should be ligated proximally as high up as possible and distally just above its trifurcation. The articular branch of the descending genicular a. of both the donor and the recipient can be ligated because of a rich anastomotic network. The medial and lateral inferior genicular aa. of the donor should be ligated ventrally as far forward as possible. One should, above all, preserve the medial inferior genicular a. of the donor in order not to endanger the medial part of the distal segment of the graft. If an operation is to be performed according to the results of our anatomical studies, vascularized allogenic knee joint transplantations should be successful from an anatomical point of view.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.