Hallock G G, Anous M M, Sheridan B C
Dorothy Rider Pool Laser and Microsurgery Laboratory, Allentown, Pa.
Plast Reconstr Surg. 1993 Jul;92(1):49-54. doi: 10.1097/00006534-199307000-00007.
Large segmental long-bone defects deserve consideration for reconstruction by vascularized, straight, high-density cortical bone grafts of comparable diameter. If available, the tibial diaphysis would be an option superior to the fibula, since the latter has known limitations when a large size discrepancy exists at the recipient site. However, the former choice is unrealistic except in the most unusual circumstances, since the tibia is a nonexpandable bone required for weight bearing. In anticipation of just such a unique opportunity, we have investigated the surgical anatomy of the principal nutrient vessel of the shaft of the tibia in 53 fresh lower limb specimens. Classical descriptions of the pertinent vascular anatomy of the tibial shaft are inadequate, since the origin of its principal nutrient vessel actually may be from the popliteal bifurcation or anterior or posterior tibial vessels. In every dissection at least a single artery and vein of large caliber (both exceeding 1.5 mm in diameter in 85 percent of cadavers) were discovered entering a nutrient foramen, usually at the upper third of the tibia. Lead oxide injection studies of the nutrient artery alone in nine cadavers demonstrated no contiguous muscle or cutaneous communications. The large size of these nutrient vessels would simplify ipsilateral pedicled transfers of an autologous tibial shaft as well as facilitate microanastomoses for its distant transfer to other humeral, femoral, or contralateral tibial defects as in a salvage replantation. Once immunologic barriers have been conquered, these data should have even greater practical clinical significance for the use of vascularized tibial allografts for substitution in lieu of autogenous fibula or other conventional bone donor sites.
对于大段长骨缺损，可考虑采用直径相当的带血管蒂、直的、高密度皮质骨移植进行重建。如果可行，胫骨干是比腓骨更好的选择，因为当受区存在较大尺寸差异时，腓骨存在已知的局限性。然而，除了在最特殊的情况下，前一种选择是不现实的，因为胫骨是负重所需的不可扩张的骨头。鉴于正是这样一个独特的机会，我们在53个新鲜下肢标本中研究了胫骨干主要营养血管的手术解剖结构。关于胫骨干相关血管解剖的经典描述并不充分，因为其主要营养血管的起源实际上可能来自腘动脉分叉处或胫前或胫后血管。在每次解剖中，至少发现一条大口径的动脉和静脉（在85%的尸体中直径均超过1.5毫米）进入一个营养孔，通常在胫骨的上三分之一处。对9具尸体仅进行营养动脉的氧化铅注射研究表明，不存在连续的肌肉或皮肤交通支。这些营养血管的大尺寸将简化自体胫骨干的同侧带蒂转移，也便于进行显微吻合，以便将其远距离转移到其他肱骨、股骨或对侧胫骨缺损处，如在挽救性再植术中。一旦免疫屏障被攻克，这些数据对于使用带血管蒂的异体胫骨替代自体腓骨或其他传统骨供区将具有更大的实际临床意义。
