Background: Lower extremity reconstruction of the tibial bone for segmental defects represents a technical challenge for the reconstructive plastic surgeon. For large tibial defects, the options are combined free tissue transfer with Ilizarov distraction osteogenesis or free vascularized bone transfer. Both have been shown to be effective but are prone to complications such as, non-union, bony exposure, ischemia of transferred flap and mechanical failure because of deficiencies of cortical load-bearing capacity in these flaps.

Hypothesis: Cortico-cancellous bone from the anterolateral femoral shaft based on the descending branch of the lateral circumflex femoral artery (LCFA) and the accompanying vastus intermedius muscle which envelopes the bone at that level may provide a better single-stage mechanical option for large tibial defect reconstructions.

Methods: 10 Fresh human cadavers, 4 male and 6 female, ages ranging between 65 and 85, had dissections of 18 limbs. 8 limbs were dissected for photographic documentation, 2 dissected for mercox acrylic resin injections, 2 dissected for angiographic evaluation. 8 limbs were dissected for measurements of length and diameters of vessels in relation to skeletal landmarks.

Results: Our dissections demonstrated a consistent relationship between the LCFA and the vastus intermedius and the anterolateral segment of the femoral shaft. Our preferred approach to the femur is through an anterior medial approach. In eighteen limb dissections the blood supply to the femur was noted to be from the descending branch of the LCFA, which was noted to be a branch off of the profunda or the femoral artery. The pedicle length for the flap was noted to be 6 to 8 cm and was often solitary, but in 3 cases there were two pedicles. A 15 cm segment of femur was harvested, which incorporates the LCFA descending branch perforators and a broad vascularized muscle belly of the vastus intermedius. Osteotomies along the medial and lateral borders of the femur can be done to release the bone and the vastus intermedius. While there was some variability in the origin of the descending branch of the LCFA, these branches were noted to ramify throughout the muscle parenchyma and branch off multiple perforators to the periosteum of the femoral shaft.

Conclusion: Femur flaps have a reliable pedicle, which is of sufficient length and caliber for myo-osteo free flaps of durable cortico-cancellous bone. Reconstruction of large segmental tibial defects is a reconstructive challenge and may benefit from the utilization of such a robust vascularized flap.