Blood supply of long bone avascular necrosis of femoral head free fibula flap reconstructive surgery Osteomyelitis

1. BLOOD SUPPLY OF LONG
BONE

2. LONG BONES – THOSE THAT ARE LONGER THAN THEY ARE
WIDE
1. Humerus
2. Radius
3. Ulna
4. Metacarpals
5. Phalanges
6. Clavicle
1. Femur
2. Tibia
3. Fibula

3. BONE AND BLOOD
• Bone strictly relies on blood supply for its correct homeostasis.
• Apart from its classical role in the transport of oxygen,
nutrients and systemic factors, the blood also conveys bone cell
precursors pivotal for bone formation. At the same time, bone
cells influence blood homeostasis by regulating
haematopoiesis.
• Evidence accumulating over the years clearly demonstrates a
strong coupling of angiogenesis and osteogenesis under
physiologic conditions.
REF : BONE AND BLOOD |NADIA RUCCI & ANNA TETI |DEPARTMENT OF BIOTECHNOLOGICAL
AND APPLIED CLINICAL SCIENCES, UNIVERSITY OF L’AQUILA, L’AQUILA, ITALY|

4. SOURCES OF BLOOD
SUPPLY
• Nutrient Artery System
• Metaphyseal System
• Epiphyseal System
• Periosteal System

5. NUTRIENT
ARTERY
• Enter through an
oblique canal
situated on the
diaphysis of long
bones aka
nutrient foramen.
• It supplies
inner 2/3rd of
cortex, medullary
cavity and
metaphysis.

7. • Nutrient artery are high pressure system that branches from the
systemic arteries.
• They enter bone through cortex and eventually enter medullary cavity
where they branch into ascending & descending branches.
• These branches travel to the end of bone anastomosing
with epiphyseal and metaphyseal arteries.
• In the cortex they divide longitudinally and
radially/transversely according to the Haversian and Volkmann's
canal respectively. Thus, forming the Capillary network of Haversian
system.
• Some arterioles enter the cortical bone and anastomose with
periosteal arterial system whereas some perfuse bone marrow.

8. PERIOSTEAL ARTERIAL SYSTEM
• Periosteal vessels send small branches through Volkmann's canal in
cortex to supply about outer 1/3rd of cortex.
Extensive network of vessels covers entire length of the bone shaft.
• Anastomoses with adjacent skeletal muscles so in cases in which the
nutrient artery of muscle has been damaged, then periosteal vessels
may temporarily serve as the primary blood supply;
• Children, while periosteum is actively engaged in circumferential
bone growth, blood supply in this area is much more abundant than
it is in adult.

10. EPIPHYSEAL ARTERIAL SYSTEM
• The epiphysis has openings that permit passage of large
number of vessels into and out of the ossification centers.
• In femoral and radial heads, which are almost entirely covered
by cartilage vessels enter in region between articular cartilage &
growth-plate cartilage.
• Epiphyseal vessels are responsible for permitting longitudinal
growth to occur.

11. METAPHYSEAL ARTERIAL SYSTEM
• These arteries directly go into the metaphyses and
reinforce/anastomose with the metaphyseal branches of the
primary nutrient artery.
• Metaphyseal vessels nourish osteoprogenitor cells , which lay
down bone on cartilage matrix.
• Following the growth arrest of the cartilage plate, there is an
extensive anastomoses between epiphyseal vessels,
metaphyseal vessels, & terminal branches of Nutrient Artery.

12. GROWTH PLATE ITSELF IS AVASCULAR &
RECEIVES NUTRITION FROM 2 SOURCES.
EPIPHYSEAL ARTERIES
• Epiphyseal vessels that
supply resting, germinal,
proliferating, and upper
hypertrophic cell layers by
diffusion
METAPHYSEAL ARTERIES
• Metaphyseal vessels that
supply zone of provisional
calcification.

13. REF : UPTODATE

14. PEDIATRIC BLOOD FLOW
• In young child, epiphyseal vessels are separated from
metaphyseal vessels.
• Circulation in pediatric bone differs from adult circulation due
to requirements of growth & presence of epiphyseal plate.
• Terminal branches of nutrient artery, along with metaphyseal
vessels, approach growth plate in a parallel relationship.
• Branches are so numerous as they reach growth plate that there
is almost one vessel for each column of cartilage cells.

15. VENOUS DRAINAGE
• Long bones posses a large venous sinus.
• Long bones drains into central venous sinus ,from Central venous
sinus through nutrient vein, periosteal veins and emissery veins it
drains out.
• Metaphyseal/epiphyseal veins – drain blood from the proximal and
distal regions of the medullary cavity.
• Periosteal veins – drain blood from the ends of long bones and the
red bone marrow.
• ONLY 5-10% OF VENOUS DRINAGE IS THROUGH NUTRIENT VEIN;
REMAINING IS THROUGH PERIOSTEAL VENOUS DRINAGE

16. REF : ORTHOBULLETS

17. OSTEOMYELITIS
• Hair pin arrangement of
metaphyseal arterioles
• Circulating organisms tend to
start the infection in the
metaphyseal ends of the long
bones because of the sluggish
circulation in the metaphyseal
capillary loops.
• More common in infants and
children.

18. AVASCULAR NECROSIS OF BONE
• Infarction of bone and marrow, usually very painful.
• Most common site is femoral head (watershed zone) due to
insufficiency of medial circumflex femoral artery.
• Causes include
1. Overdose of Corticosteroids e.g. Prednisone (reason is unknown)
2. Trauma
3. Alcoholism – increase level of fat in blood due to hepatic steatosis
4. SLE, Caisson's Disease (DCS "Bends"), Gaucher's disease and
Cancer

19. REF: 30TH EDITION FIRST AID FOR THE USMLE STEP 1

20. ORTHOINFO, AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS

21. ORTHOINFO, AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS ​

22. FREE FIBULAR FLAP
The initial use of free fibular flap was limited to the
reconstruction of long bone defects of the extremities until
1989, where this flap was used for restoration of segmental
mandibulectomy defects.
The fibula is a long non-weight bearing bone of the lower
extremity with adequate cortical thickness rendering it one of the
strongest bones available for mandibular reconstruction.
HOW TO HARVEST FREE FIBULA FLAP FOR MANDIBULAR RECONSTRUCTION? PRACTICAL TIPS
AND TRICKS |CHIROM A SINGH | RAJEEV KUMAR | PIRABU SAKTHIVEL |DEPARTMENT OF
OTORHINOLARYNGOLOGY & HEAD AND NECK SURGERY, ALL INDIA INSTITUTE OF MEDICAL
SCIENCES, NEW DELHI, INDIA |

23. • Approximately 22 to 25 cm of bone can be harvested while
preserving 6 to 7 cm of bone both distally and proximally to
maintain the integrity of the ankle and knee joints as well as
the common peroneal nerve, making this donor site unique in
terms of the ability to restore total or subtotal defects of the
mandible.
• The strength of the cortical bone effectively withstands the
powerful forces of mastication when used for mandibular
reconstruction.
HOW TO HARVEST FREE FIBULA FLAP FOR MANDIBULAR RECONSTRUCTION? PRACTICAL TIPS
AND TRICKS |CHIROM A SINGH | RAJEEV KUMAR | PIRABU SAKTHIVEL |DEPARTMENT OF
OTORHINOLARYNGOLOGY & HEAD AND NECK SURGERY, ALL INDIA INSTITUTE OF MEDICAL
SCIENCES, NEW DELHI, INDIA |

24. HTTPS://WWW.MICROSURGEON.ORG/FIBULAFLAP

25. THANK YOU :)