560 Journal of the College of Physicians and Surgeons Pakistan 2015, Vol. 25 (8): 560-563

INTRODUCTIONFibula is a long bone present on the lateral side of leg. Itreceives its own neuro-vascular bundle apart from themuscles attached to it. The nutrient artery to fibula arisesfrom the peroneal artery which winds around the neck offibula and descends down along the fibula deep to flexorhallucis longus. Near the middle of fibula, it gives offnutrient artery which enters the nutrient foramen, andramify within the fibula.1 The direction of the nutrientforamina is determined by the growing end of the bone,which is supposed to grow at least twice as fast as thenon-growing end. As a result, the nutrient vessels moveaway from the growing end of the bone.2 Informationand details about nutrient foramina is of clinicalimportance, especially in surgical procedures like bonegrafting and microsurgical vascularized bone trans-plantation.3

Fibula can be transplanted with least complications tobridge the gaps or defects in bones from various causes.Fibula can be transplanted with its nutrient vesselswhich are anastomosed with the concomitant vesselsnear the recipient bone. The transplant being a livingbone can unite with the recipient bone like an ordinary

fracture fragments without serious problem.4 In removingtumors of mandible, the advantages of the freevascularized fibular flap include its ability to be shapedwith relative ease and to be grafted at the same timewhen tumors are resected, with consequent reduction inoperation time.5-7

The topographical knowledge of the nutrient foramina offibula is important to proceed with the free implant of thevascularized bone.8 In bone transplant surgeries,statistical data on the nutrient foramina distribution inlong bones makes it possible for the surgeons to selectthe bone section levels in order to place the graftwithout damaging the nutrient arteries, preservingthe diaphyseal vascularization and the transplantconsolidation.9

Distribution of the nutrient foramina and exact position inbone diaphysis is important to avoid damage to thenutrient vessels during orthopedic surgical proceduresas fracture repair, bone grafting, vascularized bonemicrosurgery as well as in medico-legal cases.

The objective of present research was to study thediaphyseal nutrient foramina of dried fibula topo-graphically and morphometrically in Pakistani population.

METHODOLOGYThis descriptive cross-sectional study was conducted inthe Anatomy Department, Allama Iqbal Medical College,Lahore, from December 2013 to April 2014. For this

ORIGINAL ARTICLE

Morphological and Topographical Anatomy of Diaphyseal Nutrient Foramina of Dried Pakistani Fibulae

Aliya Zahid, Muhammad Afzal Shakir and Raana Shireen

ABSTRACTObjective: To study the diaphyseal Nutrient Foramina (NF) of dry Pakistani fibulae morphometrically and topographically.Study Design: Descriptive cross-sectional study.Place and Duration of Study: Anatomy Department, Allama Iqbal Medical College, Lahore, from December 2013 to April2014.Methodology: The materials comprised 168 dried fibulae, 80 of left side and 88 of right side. Length of bone and distanceof NF from the proximal end was calculated by placing bones on osteometric board. The Foramen Index (FI) wascalculated by applying the Hughes formula, dividing the distance of the foramen from the proximal end (DNF) by the totallength of the bone (TL) which was multiplied by hundred FI = (DNF/TL) x 100.Results: Eighty five bones (96.6%) of right side and 79 bones (98.8%) of left side had a single nutrient foramen. Meanlength of left fibula was 34.690 ± 2.353 cms and of right fibula 34.905 ± 2.198 cms. Mean foramen index was 47.651 ± 7.601on the left side and 50.283 ± 11.478 on the right side. In the right fibulae, type-1 foramen was present in one (1.13%) bone,type-2 was present in 77 (87.5%) bones and type-3 was found in 10 (11.36%) bones. In the left fibulae, type-1 foramenwas not found in any bone, type-2 in 79 bones (98.75%) and type 3 in only 1 bone (1.25%).Conclusion: This study provides important information on the topography of nutrient foramina of fibula in Pakistanipopulation. As microvascular bone transfer is becoming more popular, such data regarding nutrient foramina will be ofimportance to orthopaedic surgeons.

Key Words: Diaphyseal nutrient foramen. Dry fibula. Foramen index. Pakistan.

Department of Anatomy, Allama Iqbal Medical College, Lahore.

Correspondence: Dr. Aliya Zahid, 27-A1, Johar Town, Lahore.E-mail: draliyaimtiaz@gmail.com

Received: July 11, 2014; Accepted: June 30, 2015.

study, 168 fibulae were selected, out of which 88 were ofright side and 80 were of left side. The age and genderof the bones were not determined.

All the bones were macroscopically observed for thenumber, location and direction of the nutrient foraminaby means of a magnifying lens. The nutrient foraminawere identified by the presence of a well-marked grooveleading to them and a prominent slightly raised edge atthe commencement of the canal.

To determine the length of bones, each bone was placedon osteometric board and total length was recorded. Thedistance between the apex of the head of the fibula andthe tip of the lateral malleolus was recorded.

For measurement of distance of nutrient foramen offibula from the proximal end, nutrient foramen waslocated and bone was placed on osteometric board tonote the distance of nutrient foramen from the proximalend of bone. The Foramen Index (FI) was calculated byapplying the Hughes formula, dividing the distance of theforamen from the proximal end (D) by the total length ofthe bone (L) which was multiplied by hundred.10

FI = (DNF/TL) x 100

where DNF=the distance from the proximal end of thebone to the nutrient foramen; and TL=total bone length.

The position of the foramina was divided into three typesaccording to FI;11 type-1 had foramen index below33.33, the foramen was in the proximal third of the bone.

Type-2 had foramen index from 33.33 upto 66.66, theforamen was in the middle third of the bone. Type-3 hadforamen index above 66.66, the foramen was in thedistal third of the bone.

Data was entered and analyzed in SPSS version 18.0.Mean values and standard deviation was calculated forbone length and distance of nutrient foramen fromproximal end. Foramen index was also calculated.Frequency and percentages were calculated for numberand site of nutrient foramina.

RESULTSA total of 168 fibulae were studied (88 right and 80 leftfibulae) for topographical location of nutrient foraminaand morphometry. Mean length of left fibula was 34.690 ±2.353 cms and mean length of right fibula was 34.905 ±2.198 cms. The mean foramen index on left side was47.651 ± 7.601. The mean foramen index on the rightside was 50.283 ± 11.478 (Table I). Eighty five bones(96.6%) of right side and 79 bones (98.8%) of left sidehad single nutrient foramen. Three bones (3.4%) of rightside and only 1 bone (1.2%) of left side possesseddouble nutrient foramen. It was observed that 57 bones(62.6%) of right side and 48 bones (58.5%) of left sideshowed nutrient foramen on posterior surface (Table II).

Morphological and topographical anatomy of diaphyseal nutrient foramina of dried Pakistani fibulae

Table I: Morphometrical analysis of diaphyseal nutrient foramen in dryPakistani fibulae.

Fibula Total length Distance of NF from Foramen(cms) proximal end (cms) index

Left Fibula

N 80 80 80

Mean 34.690 16.436 47.6516

Std. Deviation 2.3539 2.1893 7.60126

Minimum 31.0 12.0 34.29

Maximum 43.0 24.0 75.00

Right Fibula

N 88 88 88

Mean 34.905 17.458 50.2832

Std. Deviation 2.1985 3.6953 11.47891

Minimum 30.6 10.0 31.25

Maximum 40.5 28.0 90.32

Total N 168 168 168

Mean 34.802 16.971 49.0300

Std. Deviation 2.2695 3.1053 9.88507

Minimum 30.6 10.0 31.25

Maximum 43.0 28.0 90.32

Table II: Topographical analysis of diaphyseal nutrient foramen in dried Pakistani fibulae.

No. of Nutrient Foramina (NF) Topographical location

(NF Right fibula n = 91), (NF Left fibula n = 82)

Total fibula (168) One Two NF on lateral surface NF on posterior surface NF on antero-medial surface

n (%) n (%) n (%)

Right side (88) 85 (96.6%) 3 (3.4%) 26 (28.6%) 57 (62.6%) 8 (8.8%)

Left side (80) 79 (98.8%) 1 (1.2%) 31 (37.8%) 48 (58.5%) 3 (3.7%)

Figure 1: Fibula placed on osteometric board for morphometry and topographyof nutrient foramen.

Journal of the College of Physicians and Surgeons Pakistan 2015, Vol. 25 (8): 560-563 561

On the right side, type-1 foramen was present in one(1.13%) bone, type-2 was present in 77 (87.5%) andtype-3 was found in 10 (11.36%) bones. On the left side,type-1 foramen was not found in any bone, type-2 wasfound in 79 bones (98.75%) and type-3 nutrient foramenwas found in only one bone (1.25%, Figure 2).

DISCUSSIONThe main blood supply to long bones occurs through thenutrient arteries, which enter through the nutrientforamina. The knowledge about these foramina is ofcrucial importance during surgical procedures topreserve the circulation especially to the plastic surgeonfor microvascular bone transfer surgeries.12 In freevascular bone grafting, the nutrient blood supply must bepreserved to promote fracture repair. It is necessary forosteoblast and osteocyte survival, as well as facilitatinggraft healing in recipient.13

In different populations, studies to determine thenumber, position, direction of nutrient foramen andforamen index of fibula have been done but no suchstudy about topography and morphometry of fibulae wascarried out previously in Pakistani population. Theresults of present study showed that 85 bones (96.6%)of right side and 79 bones (98.8%) of left side had singlenutrient foramen. It was found that 3 bones (3.4%) ofright side and only 1 bone (1.2%) of left side possesseddouble nutrient foramen. It was observed that 57 bones(62.6%) of right side and 48 bones (58.5%) of left sideshowed nutrient foramen on posterior surface.

In a study, Prashanth et al.14 found that 90.2% fibulaehad single foramen and foramen was absent in 9.8%.The mean foraminal index was 49.2 for fibulae. Sixtypercent of the fibulae had nutrient foramen at the 3/5thpart. In a research study on Caucasians, McKee et al.15

observed that 6% of the bones had no apparent foramenand 96% of the foramina were in the middle third of thefibula, a finding similar to the present study. This study

recommended that this segment of the shaft should beused for free vascularized fibular transfers to increasethe likelihood of including the endosteal blood supply.

In a study on South Brazilian adults by Pereira et al.16

the mean foraminal index for fibula was 46.1%. Thisstudy recorded data related to the population ofSouthern Brazil, providing ethnic data to be used forcomparison and that may help in surgical proceduresand in the interpretation of radiological images. In astudy in Indian population absence of nutrient foramenwas observed in 12 (6%) fibulae, 86.5% (173) of thefibulae possessed single nutrient foramen, while 6.5%(13) of the fibulae possessed double nutrient foraminaand 1% (2) fibula had triple foramen.17

In a study, Kumar et al.18 found that out of the 177bones, 30 specimens showed more than one foramenand direction of four foramina was going towards thegrowing end of the bone. In a study on Koreanpopulation, Choi et al.19 observed that the location of thenutrient foramen was just proximal to the midpoint. In astudy, Kocabiyik et al.20 found that in 90% of specimensstudied, there was single nutrient artery, 6.6% haddouble nutrient artery and in 3.3% no nutrient artery wasobserved.

Gumusburun et al.21 studied that out of 305 fibulae, 281had single nutrient foramen, 12 had two and theremaining 12 had no foramen. The foramina were seenprimarily on the posterior surface (48.36%) and in themiddle third (98.00%) of the bone, a finding similar topresent study. The mean foraminal index of the fibulawas found to be 48.14. Kizilkanat et al.22 noted thatforamina were located on the diaphysis in 26-83% of theoverall length of the fibula in the Turkish Caucasianpopulation. Zhu et al.23 studied thirty-four cadavericlower extremities and they found that all specimens hadsingle fibular nutrient artery. In a study on Indianpopulation, Bilodi et al.24 observed that nutrient foraminaof fibula were present more on posterior surface(29.62%), followed by 22.23% on the lateral surface and21.16% on the medial surface.

CONCLUSIONAs microvascular bone transfer is becoming morepopular, data regarding nutrient foramina of fibulae is ofimportance to orthopedic surgeons. Findings of presentstudy about the topography and morphometry of thenutrient foramina of fibula in Pakistani population mayprove helpful to proceed with the free implant of thevascularized fibula.

REFERENCES1. Sivakumar G, Mohan M. Position of nutrient foramen on fibula,

its variations and distance from styloid process and its clinicalapplication in fibular flap in a mandibular reconstruction.FASEB J 2010; 24 (Meeting Abstract Supplement 636).

Aliya Zahid, Afzal Shakir and Raana Shireen

562 Journal of the College of Physicians and Surgeons Pakistan 2015, Vol. 25 (8): 560-563

Figure 2: Types of nutrient foramen in dried Pakistani fibulae.

Morphological and topographical anatomy of diaphyseal nutrient foramina of dried Pakistani fibulae

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2. Malukar O, Joshi H. Diaphyseal nutrient foramina in longbones and miniature long bones. NJIRM 2011, 2:23-6.

3. Wei FC, El-Gammal TA, Lin CH, Ueng WN. Free fibulaosteoseptocutaneous graft for reconstruction of segmentalfemoral shaft defects. J Trauma 1997; 43:784-92.

4. Guo F. Fibular blood supply. Chin Med J 1981; 94:396-400.

5. Kim MG, Lee ST, Park JY, Choi SW. Reconstruction with fibularosteocutaneous free flap in patients with mandibularosteoradionecrosis. Maxillofac Plast Reconstr Surg 2015; 37:7.

6. Fan S, Wang YY, Lin ZY, Zhang DM, Yu X, Chen WX, et al.Synchronous reconstruction of bilateral osteoradionecrosis ofthe mandible using a single fibular osteocutaneous flap innasopharyngeal carcinoma patients. Head Neck 2015; 17.

7. Hayden RE, Mullin DP, Patel AK. Reconstruction of thesegmental mandibular defect: current state of the art. CurrOpin Otolaryngol Head Neck Surg 2012; 20:231-6.

8. Collipal E, Vargas R, Parra X, Silva H, Del Sol M. Diaphysealnutrient foramina in the femur, tibia and fibula bones. Int JMorphol 2007; 25:305-8.

9. Wavreille G, Remedios, Dos C, Chantelot C. Anatomic basesof vascularized elbow joint harvesting to achieve vascularizedallograft. Surg Radiol Anat 2006, 28:498-510.

10. Hughes H. The factors determining the direction of the canalfor the nutrient artery in the long bones of mammals and birds.Acta Anat 1952; 15:261-80.

11. Ukoha UU, Umeasalugo KE, Nzeako HC, Ezejindu DN,Ejimofor OC, Obazie IF. Study of nutrient foramina in longbones of Nigerians. Natl J Med Res 2013; 3:304-8.

12. Premchandran D, Murlimanju BV, Prabhu LV, Saralaya VV,Kumari A, Rao KA, et al. Topography and morphologicalanatomy of nutrient foramina in human metacarpal bones andtheir clinical implications. Clin Ter 2013; 164:295-300.

13. Shamsunder RV, Jyothinath K. The diaphyseal nutrient foramina

architecture: a study on the human upper and lower limb longbones. J Pharm Biol Sci 2014; 1:36-41.

14. Prashanth KU, Murlimanju BV, Prabhu LV, Kumar CG, Pai MM,Dhananjaya KVN. Morphological and topographical anatomyof nutrient foramina in the lower limb long bones and its clinicalimportance. AMJ 2011; 4:10:530-7.

15. McKee NH, Haw P, Vettese T. Anatomic study of the nutrientforamen in the shaft of the fibula. Clin Orthop Relat Res 1984;184:141-4.

16. Pereira G, Lopes P, Santos PV, Silveira HS. Nutrient foraminain the upper and lower limb long bones: morphometric study inbones of Southern Brazilian adults. Int J Morphol 2011; 29:514-20.

17. Morphometric study of nutrient foramina of fibula. Rajiv GandhiUniversity of Health Sciences, 2013.

18. Kumar S, Kathiresan K, Gowda MST. Study of diaphysealnutrient foramen in human long bones. Anatomica Karnataka2012; 6:66-70.

19. Choi SW, Kim HJ, Koh KS, Chung IH, Cha IH. Topographicalanatomy of the fibula and peroneal artery in Koreans. Int J OralMaxillofac Surg 2001; 30:329-32.

20. Kocabiyik N, Yalçin B, Ozan H. Variations of the nutrient arteryof the fibula. Clin Anat 2007; 20:440-3.

21. Gumusburun E, Adiguzel E, Erdil H, Ozkan Y, Gulec E. A studyof the nutrient foramina in the shaft of the fibula. OkajimasFolia Anat Jpn 1996; 73:125-7.

22. Kizilkanat E, Boyan N, Ozsahin ET, Soames R, Oguz O.Location, number and clinical significance of nutrient foraminain human long bones. Ann Anat 2007; 189:87-95.

23. Zhu YL, Xu YQ, Yang J, Li J, Lan XF. An anatomic study ofvascularized fibular grafts. Chin J Traumatol 2008;11:279-82.

24. Bilodi AKS, Reddy BS. A study on nutrient foramina of fibula,its medicolegal aspect and clinical importance in dentistry.World J Pharm Sci 2014; 3:2133-44.