Vascularised bone transfer: History, blood supply and contemporary problems

Since the description of the free fibula flap by Taylor in 1975, many flaps composed of bone have been described. This review documents the history of vascularised bone transfer and reflects on the current understanding of blood supply in an effort to define all clinically described osseous flaps.

A structured review of MEDLINE and Google Scholar was performed to identify all clinically described bone flaps in humans. Data regarding patterns of vascularity were collected where available from the anatomical literature.

Vascularised bone transfer has evolved stepwise in concert with advances in reconstructive surgery techniques. This began with local flaps of the craniofacial skeleton in the late 19th century, followed by regional flaps such as the fibula flap for tibial reconstruction in the early 20th century. Prelaminated and pedicled myo-osseous flaps predominated until the advent of microsurgery and free tissue transfer in the 1960s and 1970s. Fifty-two different bone flaps were identified from 27 different bones. These flaps can be broadly classified into three types to reflect the pedicle: nutrient vessel (NV), penetrating periosteal vessel (PPV) and non-penetrating periosteal vessel (NPPV). NPPVs can be further classified according to the anatomical structure that serves as a conduit for the pedicle which may be direct-periosteal, musculoperiosteal or fascioperiosteal.

The blood supply to bone is well described and is important to the reconstructive surgeon in the design of reliable vascularised bone suitable for transfer into defects requiring osseous replacement. Further study in this field could be directed at the implications of the pattern of bone flap vascularity on reconstructive outcomes, the changes in bone vascularity after osteotomy and the existence of "true" and "choke" anastomoses in cortical bone.