A comparison of skin and muscle for cortical revascularization

Summary

The purpose of this project was to compare the ability of skin and muscle to revascularize cortical bone segments in the canine distal limb. A model mimicking severe combined soft tissue and orthopaedic injury with bone devascularization involving the canine metatarsus was developed. Soft tissue defects were reconstructed with a reverse saphenous conduit flap or a free trapezius muscle flap. Cortical bone blood flow was determined by the radiolabeled microsphere method at 21 days post-reconstruction. In addition cortical porosity, the amount of fluorescent labelled intracortical new bone, and the maximum depth of periosteal new bone were determined. Significant differences were not detected between skin and muscle reconstructions for any of the measured parameters of cortical revascularization. The mean values for cortical bone blood flow were higher than expected from previous studies, and did not correlate with subjective assessments of adhesion quality between bone and reconstructive tissue onlay. The reverse saphenous conduit flap, and the free trapezius muscle flap, may respectively provide superior blood supply to underlying bone than local random pattern skin and local pedicled muscle. The reverse saphenous conduit flap has a robust and reliable vascular supply, unlike that to random pattern skin. The free transfer of muscle maintains a vigorous blood supply, and has shown improvements in blood flow over pedicled muscle. Blood flow to both tissue types may be favourably affected by the denervation associated with transfer, causing arteriolar vasodilation and reductions in vascular resistance. In this model, comparable revascularization of cortical bone at 21 days was seen beneath reverse saphenous conduit flaps and free trapezius muscle flaps. However, a role for endosteal revascularization cannot be excluded.

Cortical revascularization by skin and muscle reconstruction was compared at 21 days in a canine metatarsal model. Significant differences in cortical bone blood flow were not detected

Keywords

Revascularization - muscle - skin - bone blood flow - bone - microvascular

• REFERENCES

• 1 Anderson GI, Richards RR, Paitich B, McKee M, Schemitsch EH. Soft tissue blood flow after segmental osteotomy of the canine tibia. Ann Plast Surg 1991; 27: 49-55.
• 2 Anthony JP, Mathes SJ, Alpert BS. The muscle flap in the treatment of chronic lower extremity osteomyelitis: Results in patients over 5 years after treatment. Plast Reconstr Surg 1991; 88: 311-8.
• 3 Chang N, Mathes SJ. Comparison of the effect of bacterial innoculation in musculocutaneous and random pattern flaps. Plast Reconstr Surg 1982; 70: 1-9.
• 4 Degner DA, Lanz OI, Walshaw R. Myoperitoneal microvascular free flaps in dogs: an anatomical study and a clinical case report. Vet Surg 1996; 25: 463-70.
• 5 Fisher MD, Wood M. Experimental comparison of bone revascularisation by musculocutaneous and cutaneous flaps. Plast Reconstr Surg 1987; 79: 81-90.
• 6 Gregory CR, Gourley IM. Identification of muscle flaps in small animals. Microsurgery 1991; 12: 136-9.
• 7 Gregory CR, Gourley IM, Snyder JR, Ilkiw J. Definition of the gracilis musculocutaneous flap for distant transfer in cats. AJVR 1992; 53: 153-6.
• 8 Gross PM, Marcus ML, Hesitad DD. Measurement of blood flow to bone and marrow in experimental animals by means of the microsphere technique. J Bone Joint Surg 1981; 63-A: 1028-31.
• 9 Gunderson HJG, Bendtsen TF, Korbo L, Marcussen N, Moller A, Nielsen K, Nyengaard JR, Pakkenberg B, Sorensen FB, Vesterby A, West MJ. Some new, simple and efficient stereological methods and their use in pathological research and diagnosis. APMIS 1988; 96: 379-94.
• 10 Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures : A new classification of type III open fractures. J Trauma 1984; 24: 742.
• 11 Jaeger K, Stark GB. Clinical and experimental evidence for the improvement of perfusion from free myocutaneous flaps. In: Stuttgart DR. (ed). Microsurgical Tissue Transplantation. Chicago: Quintessence Pub. Co; 1989
• 12 Kolata RJ, Johnston DE. Motor vehicle accidents in urban dogs: a study of 600 cases. JAVMA 1975; 167: 938-41.
• 13 Kroll SS, Schusterman MA, Reece GP, Miller MJ, Evans GRD, Robb GL, Baldwin BJ. Choice of flap and incidence of free flap success. Plast Reconstr Surg 1996; 98: 459-63.
• 14 Li G, Bronk JT, Kelly PJ. Canine blood flow estimated with microspheres. J Orthop Res 1989; 07: 61.
• 15 Lorenzetti F, Salmi A, Ahovuo J, Tukiainen E, Asko-Seljavaara S. Postoperative changes in blood flow in free muscle flaps: A prospective study. Microsurgery 1999; 19: 196-9.
• 16 Lukash FN, Zingaro EA, Salig J. The survival of free nonvascularized bone grafts in irradiated areas by wrapping in muscle flaps. Plast Reconstr Surg 1984; 74: 783-8.
• 17 May JW, Gallico GG, Lukash FN. Microvascular transfer of free tissue for closure of bone wounds of the distal lower extremity. N Engl J Med 1982; 306: 253-7.
• 18 McGrory BJ, Moran CG, Bronk J. et al. Canine bone blood flow measurements using serial microsphere injections. Clin Orthop 1994; 303: 264-79.
• 19 McKee NH, Clarke HM, Nigra CAL, Manktelow RT. A study of blood flow and pressure in the vessels supplying a free flap. Plast Reconstr Surg 1982; 69: 68-73.
• 20 Melissinos EG, Parks DH. Post-trauma reconstruction with free tissue transfer analysis of 442 consecutive cases. J Trauma 1989; 29: 1095-103.
• 21 Murphy RC, Robson MC, Heggers JP, Kadowaki M. The effect of microbial contamination on musculocutaneous and random flaps. J Surg Res 1986; 41: 75-80.
• 22 Nabawi A, Gurlek A, Patrick CW, Amin A, Ritter E, Elsharaky M, Evans GRD. Measurement of blood flow and oxygen tension in adjacent tissues in pedicled and free flap head and neck reconstruction. Microsurgery 1999; 19: 254-7.
• 23 Nicoll SA, Fowler JD, Remedios AM. et al. Development of a free latissimus dorsi muscle flap in cats. Vet Surg 1996; 25: 40-8.
• 24 O’Brien BM, Morrison WA, Gumley GJ. Principles and technique of microvascular surgery. In: McCarthy (ed). Plastic Surgery. Philadelphia: WB Saunders Company; 1990
• 25 Pavletic MM, Watters J, Henry RW. et al. Reverse saphenous conduit flap in the dog. JAVMA 1983; 182: 380-9.
• 26 Pavletic MM. Introduction to myocutaneous and muscle flaps. In Vet Clin N Am Small Animal Practice 1990; 20: 127-46.
• 27 Pavletic MM. Anatomy and circulation of the canine skin. Microsurgery 1991; 12: 103-12.
• 28 Pers M, Medgyesi S. Pedicle muscle flaps and their applications in the surgery of repair. Br J Plast Surg 1973; 26: 313-21.
• 29 Philibert D, Fowler JD, Clapson JB. The anatomic basis for a trapezius muscle flap in dogs. Vet Surg 1992; a 21: 429-34.
• 30 Philibert D, Fowler JD, Clapson JB. Free microvascular transplantation of the trapezius musculocutaneous flap in dogs. Vet Surg 1992; b 21: 435-40.
• 31 Quirke TE, Sharma PK, Boss WK, Oppenheim WC, Rauscher GE. Are type IIIC lower extremity injuries an indication for primary amputation. J Trauma 1996; 40: 992-6.
• 32 Richards RR, Mahoney JL, Minas T. Influence of soft tissue coverage on the healing of cortical defects in canine diaphyseal bone. Ann Plast Surg 1986; 16: 296-304.
• 33 Richards RR, Orsini EC, Mahoney JL, Verschuren R. The influence of muscle flap coverage on the repair of devascularised tibial cortex, an experimental investigation in the dog. Plast Reconstr Surg 1987; 79: 946-58.
• 34 Richards RR, Schemitsch EH. Effect of muscle flap coverage on bone blood flow following devascularisation of a segment of tibia, an experimental investigation in the dog. J Orthop Res 1989; 07: 550-8.
• 35 Richards RR, McKee MD, Paitich CB. et al. A comparison of the effects of skin coverage and muscle flap coverage on the early strength of union at the site of osteotomy after devascularisation of a segement of canine tibia. J Bone Joint Surg 1991; 73-A: 1323-30.
• 36 Salmi AM, Tukiainen EJ, Asko-Seljavaara SL. Blood flow in muscle flaps measured by color doppler ult rasonography. Microsurgery 1995; 16: 666-72.
• 37 Schemitsch EH, Weinberg JA, McKee MD, Richards RR. The relative importance of intramedullary, intracortical, and extraosseous soft tissue blood flow to the repair of devascularized canine tibial cortex. Ann Plast Surg 1997; 38: 623-31.
• 38 Tuominen P, Asko-Seljavaara S, Svartling N. Cutaneous blood flow in the TRAM flap. Br J Plast Surg 1993; 46: 665.