Safe Zones for Cerclage Wiring of the Humeral Diaphysis.

Cerclage wiring of the humeral diaphysis entails particular danger to the radial nerve and the deep brachial artery. We sought to delineate safe zones for minimally invasive cerclage wiring of the humeral diaphysis, specifically in relation to the radial nerve and accompanying vasculature. Cerclage wires were percutaneously inserted into three groups of fresh-frozen cadaveric humeri. Group 1-proximal midshaft humerus at 30% of humeral height (n = 4); Group 2-midshaft spiral groove at 45% of humeral height (n = 4); and Group 3-distal midshaft humerus at 60% of humeral height (n = 4). Subsequently, an extensive surgical exploration of the arteries and nerves around the humerus was performed, noting any disturbance to the vessels or nerves and measuring the distance from the cerclage wire to the radial nerve. Neurovascular structures were injured in 75% of specimens when the cerclage wire was inserted at the level of the spiral groove. Both posterior structures, e.g. the radial nerve and the deep brachial artery, and medial structures, e.g., the median nerve and brachial artery, were incarcerated. Application of the cerclage at 30% or 60% of humeral height did not cause neurovascular injury. Minimally invasive application of the cerclage wire at the spiral groove, which is at 45% of humeral height, is likely to cause injury to neurovascular structures. Application of the cerclage at the proximal or distal midshaft humeral areas is associated with less risk of such injury. Clin. Anat. 33:552-557, 2020. © 2019 Wiley Periodicals, Inc.

What about limb long bone nutrient canal(s)? - a 3D investigation in mammals.

The nutrient arteries, located in the long bone diaphysis, are the major blood supply to long bones, especially during the early phases of growth and ossification. Their intersection with the central axis of the medullary area corresponds to the ossification center, and their opening on the outer bone surface to the nutrient foramen. Nutrient arteries/foramen have essentially been analyzed in humans, and only to a much lesser extent in a few mammals. Some studies have taken measurements of the nutrient foramen; others have investigated the shape and orientation of the nutrient canals, although only partially. No studies have analyzed the nutrient canal in three dimensions inside the bone and the relationships between nutrient foramen, nutrient canal, growth, and physiology require further investigation. The current study proposes to investigate in three dimensions the shape of the nutrient canal in stylopod bones of various mammals. Qualitative and quantitative parameters are defined to discuss the diversity in, for example, morphology, orientation, and diameter encountered, resorting to two different datasets to maximize differences within mammals and then analyze variation within morphologically and phylogenetically closer taxa. This study highlights a strong intraspecific variation for various parameters, with limited biological signal, but also shows trends. It notably provides evidence that canals are generally more numerous and relatively thinner in less elongated bones. Moreover, it shows that the growth center is located distally in the humerus and proximally in the femur, and that the canals are essentially oriented towards the faster growing end, so that the nutrient foramen does not indicate the location of the growth center. This result seems general in mammals but cannot be generalized outside of Mammalia. Further analyses of the features of nutrient arteries in reptiles are required to make comparisons with the trends observed in mammals.

Novel multimodal MRI and MicroCT imaging approach to quantify angiogenesis and 3D vascular architecture of biomaterials.

Quantitative assessment of functional perfusion capacity and vessel architecture is critical when validating biomaterials for regenerative medicine purposes and requires high-tech analytical methods. Here, combining two clinically relevant imaging techniques, (magnetic resonance imaging; MRI and microcomputed tomography; MicroCT) and using the chorioallantoic membrane (CAM) assay, we present and validate a novel functional and morphological three-dimensional (3D) analysis strategy to study neovascularization in biomaterials relevant for bone regeneration. Using our new pump-assisted approach, the two scaffolds, Optimaix (laminar structure mimicking entities of the diaphysis) and DegraPol (highly porous resembling spongy bone), were shown to directly affect the architecture of the ingrowing neovasculature. Perfusion capacity (MRI) and total vessel volume (MicroCT) strongly correlated for both biomaterials, suggesting that our approach allows for a comprehensive evaluation of the vascularization pattern and efficiency of biomaterials. Being compliant with the 3R-principles (replacement, reduction and refinement), the well-established and easy-to-handle CAM model offers many advantages such as low costs, immune-incompetence and short experimental times with high-grade read-outs when compared to conventional animal models. Therefore, combined with our imaging-guided approach it represents a powerful tool to study angiogenesis in biomaterials.

Successful treatment of pathologic femoral shaft fracture associated with large arteriovenous malformations using a 3-dimensional external fixator and teriparatide: a case report.

BACKGROUND: Arteriovenous malformations (AVMs) are rare congenital vascular lesions associated with early quiescence, late expansion, and, ultimately, infiltration and destruction of local soft tissue and bone. The extremities are a common location. Incidence of bony involvement by AVM has been reported as high as 31%. However, there are few reports on management of pathologic fracture associated with AVM. Teriparatide is a recombinant parathyroid hormone (PTH) analogue consisting of the 1-34 fragment of PTH. Recently, some reports have shown the ability of teriparatide to improve fracture healing. Here, we present a case of pathologic femoral shaft fracture associated with large AVMs that was treated successfully by external fixation and teriparatide. CASE PRESENTATION: A 68-year-old Japanese woman, previously diagnosed as having large AVMs, sustained a right femoral shaft fracture due to a fall. At the time of admission, she presented with massive swelling and venous varicosities of the right thigh. Plain radiography of the right thigh revealed femoral shaft fracture with bony erosion and calcification of soft tissue. We planned closed reduction and intramedullary nailing with a unilateral external fixator following embolization of the feeding artery. However, closed reduction using the fracture table was difficult. When we attempted open reduction, massive bleeding (1000 mL) after incision of subcutaneous tissue occurred. Finally, we carefully applied a Taylor Spatial Frame. Fracture displacement was corrected successfully and bony union was obtained with administration of teriparatide 15 months after the initial surgery. The patient is able to walk using 1 cane. CONCLUSION: We present the first report of pathologic fracture associated with large AVMs that achieved bony union using a 3-dimensional external fixator and teriparatide.

Management of traumatic bone defects: Metaphyseal versus diaphyseal defects.

Although bone defects after trauma appear in different locations and forms, many clinicians have adopted a single strategy to deal with any defect. In this overview, a distinction is made between metaphyseal, or cancellous defects, and diaphyseal, or cortical defects. The treatment goals and background of these two types of defects are discussed in order to describe the difference in strategy and hence the difference in treatment method.

Neovascularization of osteoporotic metaphyseal bone defects: A morphometric micro-CT study.

PURPOSE: Neovascularization is essential for bone regeneration in fractures. This study aimed to investigate the microvascular morphology and distribution in the non-injured femur and the neovascularization of the metaphyseal critical size defect in a small animal model of osteoporosis. MATERIALS AND METHODS: Female rats (n=7) were ovariectomized (OVX) and received a multideficiency diet. Three months after OVX, a 5mm wedge shaped critical size defect was cut at the distal femoral metaphysis and stabilized with a T-shaped mini-plate. After six weeks, the animals were euthanized, and femora were removed and decalcified for micro-CT measurement of fracture neovascularization. RESULTS: No fracture healing was observed along the critical size defects. In the non-injured bone, micro-vessel distribution showed a specific pattern, thereby enabling a differentiation between epi-, meta- and diaphysis. Micro-CT based morphometry revealed a significant reduction of the vascular volume fraction as well as the vascular thickness (p<0.001) in the critical size defect compared to the intact contralateral femur. Blood volume related vascular surface (vascular surface/volume) increased significantly (p<0.001). Connectivity density and tissue volume related vascular surface (vascular surface density) did not change significantly. CONCLUSIONS: Micro-CT based vascular morphometry demonstrated differences between epi-, meta- and diaphysis in the non-injured bone as well as differences between the critical size defect and the non-injured metaphysis. As angiogenesis is a crucial prerequisite that precedes osteogenesis, our results may influence further evaluation of osteoconductive or osteogenic biomaterials in this small animal model of osteoporosis.

Morphological and Topographical Anatomy of Diaphyseal Nutrient Foramina of Dried Pakistani Fibulae.

OBJECTIVE: To study the diaphyseal Nutrient Foramina (NF) of dry Pakistani fibulae morphometrically and topographically. STUDY DESIGN: Descriptive cross-sectional study. PLACE AND DURATION OF STUDY: Anatomy Department, Allama Iqbal Medical College, Lahore, from December 2013 to April 2014. METHODOLOGY: The materials comprised 168 dried fibulae, 80 of left side and 88 of right side. Length of bone and distance of NF from the proximal end was calculated by placing bones on osteometric board. The Foramen Index (FI) was calculated by applying the Hughes formula, dividing the distance of the foramen from the proximal end (DNF) by the total length of the bone (TL) which was multiplied by hundred FI = (DNF/TL) x 100. RESULTS: Eighty five bones (96.6%) of right side and 79 bones (98.8%) of left side had a single nutrient foramen. Mean length of left fibula was 34.690 ±2.353 cms and of right fibula 34.905 ±2.198 cms. Mean foramen index was 47.651 ±7.601 on the left side and 50.283 ±11.478 on the right side. In the right fibulae, type-1 foramen was present in one (1.13%) bone, type-2 was present in 77 (87.5%) bones and type-3 was found in 10 (11.36%) bones. In the left fibulae, type-1 foramen was not found in any bone, type-2 in 79 bones (98.75%) and type 3 in only 1 bone (1.25%). CONCLUSION: This study provides important information on the topography of nutrient foramina of fibula in Pakistani population. As microvascular bone transfer is becoming more popular, such data regarding nutrient foramina will be of importance to orthopaedic surgeons.

Hyperbaric oxygen therapy improves angiogenesis and bone formation in critical sized diaphyseal defects.

Besides the use of autologous bone grafting several osteoconductive and osteoinductive methods have been reported to improve bone healing. However, persistent non-union occurs in a considerable number of cases and compromised angiogenesis is suspected to impede bone regeneration. Hyperbaric oxygen therapy (HBO) improves angiogenesis. This study evaluates the effects of HBO on bone defects treated with autologous bone grafting in a bone defect model in rabbits. Twenty-four New-Zealand White Rabbits were subjected to a unilateral critical sized diaphyseal radius bone defect and treated with autologous cancellous bone transplantation. The study groups were exposed to an additional HBO treatment regimen. Bone regeneration was evaluated radiologically and histologically at 3 and 6 weeks, angiogenesis was assessed by immunohistochemistry at three and six weeks. The additional administration of HBO resulted in a significantly increased new bone formation and angiogenesis compared to the sole treatment with autologous bone grafting. These results were apparent after three and six weeks of treatment. The addition of HBO therapy to autologous bone grafts leads to significantly improved bone regeneration. The increase in angiogenesis observed could play a crucial role for the results observed.

Multiscale, converging defects of macro-porosity, microstructure and matrix mineralization impact long bone fragility in NF1.

Bone fragility due to osteopenia, osteoporosis or debilitating focal skeletal dysplasias is a frequent observation in the Mendelian disease Neurofibromatosis type 1 (NF1). To determine the mechanisms underlying bone fragility in NF1 we analyzed two conditional mouse models, Nf1Prx1 (limb knock-out) and Nf1Col1 (osteoblast specific knock-out), as well as cortical bone samples from individuals with NF1. We examined mouse bone tissue with micro-computed tomography, qualitative and quantitative histology, mechanical tensile analysis, small-angle X-ray scattering (SAXS), energy dispersive X-ray spectroscopy (EDX), and scanning acoustic microscopy (SAM). In cortical bone of Nf1Prx1 mice we detected ectopic blood vessels that were associated with diaphyseal mineralization defects. Defective mineral binding in the proximity of blood vessels was most likely due to impaired bone collagen formation, as these areas were completely devoid of acidic matrix proteins and contained thin collagen fibers. Additionally, we found significantly reduced mechanical strength of the bone material, which was partially caused by increased osteocyte volume. Consistent with these observations, bone samples from individuals with NF1 and tibial dysplasia showed increased osteocyte lacuna volume. Reduced mechanical properties were associated with diminished matrix stiffness, as determined by SAM. In line with these observations, bone tissue from individuals with NF1 and tibial dysplasia showed heterogeneous mineralization and reduced collagen fiber thickness and packaging. Collectively, the data indicate that bone fragility in NF1 tibial dysplasia is partly due to an increased osteocyte-related micro-porosity, hypomineralization, a generalized defect of organic matrix formation, exacerbated in the regions of tensional and bending force integration, and finally persistence of ectopic blood vessels associated with localized macro-porotic bone lesions.

[The effect of tibial transphyseal reinforcement on the growth and response of leg tissues].

Transphyseal reinforcement of right intact tibia performed with thin steel rods in six mongrel dogs at the age of six months. Contralateral segment served as control. The leg growth and blood supply studied under the created conditions for the next six months. Radiographic, physiologic (surface thermometry, photoplethysmography), and statistical methods used for studying. The significant effect of transphyseally inserted rods on the leg longitudinal growth and blood supply has not been revealed. The changes in natural shape-formation oftibial proximal and distal meta-epiphyses observed influenced by the transphyseal rods in the experiment. In order to evaluate the tissue response and the degree of the functional activity of leg bone meta-epiphyseal zones the most informative areas considered to be the following: the area of medial malleolus in the early period of physiological growth completion, and the area of the tibial lateral condyle--at the late stage.

Growth potential of different zones of the growth plate-an experimental study in rabbits.

Despite clinical efforts to treat growth disturbances only little is known about the growth potential of the different zones of the growth plate. The aim of this study was to investigate the growth potential of different zones of the growth plate. A total of 20 New Zealand White rabbits were used for this experiment. The right and left ulna of each animal were used resulting in a total of 40 ulnae. Animals were assigned into five groups. In groups I and II resection of the metaphyseal (n = 12) or the epiphyseal (n = 6) segment of the growth plate was performed. In group III resection of the growth plate and re-implantation was performed (n = 6). In group IV the growth plate was resected and re-implanted after a 180° rotation (n = 6). Animals in group V served as controls. Histologic and radiologic examinations were performed to evaluate the growth process at 1, 2, 4, and 12 weeks following surgery. In group I, III, and IV temporary growth disturbance which was compensated within a short time was observed. Resection of the epiphyseal part resulted in growth arrest of the distal ulna in combination with normal growth of the radius which led to and valgus deformity of the limb. The results of this study indicate the importance of the reserve zone for the functioning of the growth plate.

Laser-Doppler flowmetry at large interoptode spacing in human tibia diaphysis: Monte Carlo simulations and preliminary experimental results.

Laser-Doppler flowmetry (LDF) is an outstanding tool to monitor blood flow in a continuous and non-invasive way. In this work, we study LDF at large interoptode spacing applied to a human bone model (i.e. tibia diaphysis). To that aim, we first performed an extensive set of Monte Carlo (MC) simulations for 10 and 25 mm interoptode spacing. Second, we have assembled a dedicated LDF instrumentation based on an optimized industrial avalanche photo-detector. We performed LDF experimental measurements on human muscle using well-known physiological protocols, which confirmed the reliability of our instrumentation and the relevance of the LDF algorithms tested with the MC simulations. In a second set, we repeated the measurements on human tibia diaphysis. Again, the experiments corroborate the MC simulations and demonstrate the effectiveness of LDF to monitor blood perfusion in bone. The proposed technique has great potential for non-invasive neuro-vascular studies since it will certainly help to reveal the mechanisms underlying the interaction between bone/bone marrow, the circulatory system and the nervous system.

Reamed versus minimally reamed nailing: a prospectively randomised study of 100 patients with closed fractures of the tibia.

It is generally accepted that in tibial fractures the results of reamed intramedullary nailing are better than those of unreamed. However, it is not known whether the clinical effects of reaming are cumulative or if minimal reaming would induce the same beneficial effects as more extensive reaming. This international multicentre study has investigated the effects of different degrees of reaming. 100 patients with closed diaphyseal tibial fractures were prospectively randomised in two centres. Method of treatment was reamed nailing up to 12 mm inserting an 11 mm tibial nail (n: 50), and minimally reamed nailing up to 10 mm inserting a 9 mm tibial nail (n: 50). All patients included in the study had follow-up studies at 4,8,12,16,26 and 52 weeks after trauma. Sixty-six male and thirty-four female patients with an average age of 37.5 years were included in the study. Gender, age, and injury side were identical in both groups. There was no significant difference of complications in the two methods. The rate of deep wound infections was higher in the reamed group (n: 3) versus the minimally reamed group (n: 1). Union occurred earlier in the reamed group (17 wks) compared to patients with minimally reamed nailing (19 wks), and there were more patients with reamed nails in whom the fracture had healed by 16 weeks (57%) versus the minimally reamed group (43%), however, this was not statistically significant. Pain scales were similar for both groups from week 4 to week 52. A considerable number of outcome parameters including knee and ankle function, as well as the comparison of time intervals to restart certain activities, and return to work showed no significant statistical difference between the two groups. However, patients of the extensive reamed group returned earlier to running, training, and normal sports activities. This study found no significant evidence that more extensive reaming gave better results, however there seemed to be a tendency of more aggressive reaming to induce earlier fracture healing with a tendency of faster recovery times.

Nutrient Foramina in the Upper and Lower Limb Long Bones: Morphometric Study in Bones of Southern Brazilian Adults / Forámenes Nutricios en los Huesos Largos de los Miembros Superiores e Inferiores: Estudio Morfométrico en Huesos de Adultos del Sur de Brasil

The major blood supply to long bones occurs through the nutrient arteries, which enter through the nutrient foramina. This supply is essential during the growing period, during the early phases of ossification, and in procedures such as bone grafts, tumor resections, traumas, congenital pseudoarthrosis, and in transplant techniques in orthopedics. The present study analyzed the location and the number of nutrient foramina in the diaphysis of 885 long bones of the upper and lower limbs of adults: 174 humeri, 157 radii, 146 ulnae, 152 femora, 142 tibiae and 114 fibulae. The location of the nutrient foramina is predominant on the anterior aspect of the upper limb long bones, and on the posterior aspect of the lower limb long bones. The majority of the bones studied had a single nutrient foramen, which may represent a single source of blood supply. The mean foraminal index for the upper limb bones was 55.2 percent for the humerus, 35.7 percent for the radius, and 37.9 percent for the ulna, and for the lower limb bones, 43.7 percent for the femur, 32.7 percent for the tibia and 46.1 percent for the fibula. This study recorded data related to the population of Southern Brazil, providing ethnic data to be used for comparison and that may help in surgical procedures and in the interpretation of radiological images.

El importante aporte de sangre para los huesos largos se produce a través de las arterias nutricias, que penetran por los forámenes nutricios. Este suministro es esencial durante el período de crecimiento, las primeras fases de osificación y en los procedimientos como injertos óseos, resecciones tumorales, traumas, pseudoartrosis congénita y en las técnicas de trasplante en ortopedia. El estudio determina la ubicación y el número de forámenes nutricios en las diáfisis de 885 huesos largos de los miembros superiores e inferiores pertenecientes a individuos adultos. Fueron estudiados 174 húmeros, 157 radios, 146 ulnas, 152 fémures, 142 tibias y 114 fíbulas. La ubicación de los forámenes nutricios era predominante en la parte anterior de la diáfisis de los huesos largos del miembro superior y en la parte posterior de los huesos largos del miembro inferior. La mayoría de los huesos estudiados tenía un solo foramen nutricio, representando una sola fuente de suministro de sangre. El índice medio foraminal en los huesos del miembro superior fue de 55,2 por ciento para el húmero, 35,7 por ciento para el radio, y 37,9 por ciento para el ulna; en los huesos del miembro inferior fue 43,7 por ciento para el fémur, 32,7 por ciento para la tibia y 46,1 por ciento para la fíbula. Este estudio registró datos relativos a la población del Sur de Brasil, proporcionando antecedentes étnicos que además puedan servir de ayuda en los procedimientos quirúrgicos y en la interpretación de imágenes radiológicas.

Structural pattern and functional correlations of the long bone diaphyses intracortical vascular system: investigation carried out with China ink perfusion and multiplanar analysis in the rabbit femur.

The intracortical vessel system of the rabbit femur has been studied after perfusion of the vascular tree with a water solution of dye (China ink) with multiplanar analysis. This method utilizes the full depth of field of the microscope objectives focusing different planes of the thick cortex. The microscopic observation even if restricted to a limited volume of cortex allowed to differentiate true 3-D nodes (54.5%) from the superimposition of vessels lying on different planes. The network model with elongated meshes preferentially oriented along the longitudinal axis of the diaphysis in his static configuration is not very different from the vascular anatomy depicted in the 2-D traditional models; however, the semi-quantitative morphometric analysis applied to the former supported the notion of a multidirectional microvascular network allowing change of flow according to the functional requirements. Other peculiar aspects not previously reported were cutting cone loops, blind-end and short-radius-bent vessels, and button-holes figures. The network design and node distribution were consistent with the straight trajectory of the secondary remodeling, with the proximal-to-distal and distal-to-proximal advancement directions of the cutting cones and with two main modes of node formation, namely bifurcation of the cutting cone and interception with pre-existing canals. The general organization of the network and its uninterrupted transformation during bone modeling and remodeling suggested a substantial plasticity of the intracortical vascular system capable to adapt itself to the changeable haemodynamic conditions.

Structural and cellular features in metaphyseal and diaphyseal periosteum of osteoporotic rats.

Despite the important physiological role of periosteum in the pathogenesis and treatment of osteoporosis, little is known about the structural and cellular characteristics of periosteum in osteoporosis. To study the structural and cellular differences in both diaphyseal and metaphyseal periosteum of osteoporotic rats, samples from the right femur of osteoporotic and normal female Lewis rats were collected and tissue sections were stained with hematoxylin and eosin, antibodies or staining kit against tartrate resistant acid phosphatase (TRAP), alkaline phosphatase (ALP), vascular endothelial growth factor (VEGF), von Willebrand (vWF), tyrosine hydroxylase (TH) and calcitonin gene-related peptide (CGRP). The results showed that the osteoporotic rats had much thicker and more cellular cambial layer of metaphyseal periosteum compared with other periosteal areas and normal rats (P < 0.001). The number of TRAP(+) osteoclasts in bone resorption pits, VEGF(+) cells and the degree of vascularization were found to be greater in the cambial layer of metaphyseal periosteum of osteoporotic rats (P < 0.05), while no significant difference was detected in the number of ALP(+) cells between the two groups. Sympathetic nerve fibers identified by TH staining were predominantly located in the cambial layer of metaphyseal periosteum of osteoporotic rats. No obvious difference in the expression of CGRP between the two groups was found. In conclusion, periosteum may play an important role in the cortical bone resorption in osteoporotic rats and this pathological process may be regulated by the sympathetic nervous system.

Host-derived neoangiogenesis with short-term immunosuppression allows incorporation and remodeling of vascularized diaphyseal allogeneic rabbit femur transplants.

The purpose of this study was to demonstrate that living bone allotransplants can incorporate, remodel, and maintain mechanical properties without long-term immunosuppression in a fashion comparable to living autotransplants. For this, viability is maintained by repair of nutrient vessels and neovascularization from implanted host-derived vasculature. Microsurgically revascularized femoral diaphysis allotransplants were transferred from young male New-Zealand-White (NZW) into 4 groups of male Dutch-Belted (DB) rabbits. Short-term immunosuppression by tacrolimus (IS, groups 4 and 5) and host-derived neovascularization (NV) from implanted fascial flaps was used to maintain viability (groups 3 and 5) as independent variables. Group 2 received neither IS nor NV. Vascularized pedicled autotransplants were orthotopically transplanted in group 1. After 16 weeks, transplants were evaluated using radiologic, histologic, biomechanical, and histomorphometric parameters. Vascularized bone allotransplants treated with both short-term IS and host-derived NV (group 5) healed in a fashion similar to pedicled autotransplants (group 1). Their radiographic scores were higher than other groups. Groups with patent fascial flaps (3 and 5) showed significantly greater neoangiogenesis than ligated controls (2 and 4). Tacrolimus administration did not affect neoangiogenesis. Elastic modulus and ultimate stress were significantly greater in autogenous bone than in allotransplanted femora. Biomechanical properties were not significantly different among allotransplants. Bone turnover was decreased with IS, but increased with NV by the implanted fascial flaps. Living allogeneic femoral allotransplants treated with short-term IS and host-derived neoangiogenesis can lead to stable transplant incorporation in this rabbit model. The combination of both factors optimizes bone healing. Transplant mineralization is improved with neoangiogenesis but diminished with IS.

The microvascular anatomy of the metatarsal bones: a plastination study.

PURPOSE: The purpose of this study was to categorize and systematize the arterial supply of the metatarsal bones and furthermore the observation of arterial lesions after frequently performed forefoot surgeries. MATERIALS AND METHODS: Twenty-two cadaver feet were analyzed by two plastination methods and the enzyme maceration method. Five forefoot surgeries were performed after arterial injections. RESULTS: The bases of the metatarsal bones were primarily supplied by dorsal and plantar arteries. The arterial supply of the metatarsal diaphysis was given by a frequently observed nutrient artery. The first plantar metatarsal artery was the main supply of the first metatarsal head. The plantar and dorsal metatarsal arteries supplied the lesser metatarsals heads. The forefoot surgeries revealed lesions of arteries in all cases. CONCLUSIONS: The plastination methods were excellent methods to analyze the arterial supply. In addition arterial damage after forefoot surgeries could be analyzed with these methods.

Vascular basis of free transfer of proximal epiphysis and diaphysis of fibula: an anatomical study.

INTRODUCTION: Transfer of proximal epiphysis and diaphysis of fibula is a treatment of bony defects in children. Although there are few reports of this procedure, different arteries or combination of arteries have been used as supplying pedicle and the reported success rates are different. This is an anatomical study to clarify the vascular anatomy of this region. MATERIALS AND METHODS: A total of 16 fresh cadavers were enrolled. An incision was made in the popliteal fossa to find the popliteal artery, which was dissected distally and the lateral inferior genicular artery, anterior tibial artery, tibioperoneal trunk and its bifurcation were located. In eight subjects popliteal artery was cannulated above the level of femoral condyles and injected by latex. In the next eight cases the same material was injected in the anterior tibial artery. The next steps of dissection were done by 4.3-loupe magnification. Lateral inferior genicular artery was dissected from its origin to the fibular head and branches of anterior tibial artery were also dissected. In three specimens, the fibula and its supplying arteries were removed after dissection and put in diluted hydrochloric acid to be opened for studying the medullary vasculature. RESULTS: This study confirms the existence of not only periosteal but also intramedullary anastomosis between artery of the neck and peroneal artery. Artery of the neck was usually a branch of anterior tibial artery and in 24% of the subjects a branch of popliteal artery. In the latter condition the pedicle would be too short to permit the surgeon to do this surgery. Therefore preoperative angiography is mandatory to identify the origin of the artery of the neck. CONCLUSION: According to these dissections, a classification system of arterial supply of proximal fibular epiphysis is introduced in this article.