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Abstract
Supplemental Digital Content is available in the text.
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Rhee PC, Jones DB, Shin AY, Bishop AT. Evaluation and Treatment of Scaphoid Nonunions: A Critical Analysis Review. JBJS Rev 2016; 2:01874474-201407000-00004. [PMID: 27490062 DOI: 10.2106/jbjs.rvw.m.00074] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Peter C Rhee
- Division of Hand Surgery, Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905
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Microvascular medial femoral condylar flaps in 107 consecutive reconstructions in the head and neck. Br J Oral Maxillofac Surg 2016; 54:614-8. [DOI: 10.1016/j.bjoms.2016.03.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 03/09/2016] [Indexed: 11/22/2022]
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Guzzini M, Calderaro C, Guidi M, Civitenga C, Ferri G, Ferretti A. Treatment of a Femur Nonunion with Microsurgical Corticoperiosteal Pedicled Flap from the Medial Femoral Condyle. Case Rep Orthop 2016; 2016:5125861. [PMID: 27064589 PMCID: PMC4811065 DOI: 10.1155/2016/5125861] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 02/24/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction. The vascularized corticoperiosteal flap is harvested from the medial femoral condyle and it is nourished by the articular branch of the descending genicular artery and the superomedial genicular artery. This flap is usually harvested as a free flap for the reconstruction of bone defects at forearm, distal radius, carpus, hand, and recently at lower limb too. Case Report. A 50-year-old Caucasian man referred to our department for hypertrophic nonunion of the distal femur, refractory to the conservative treatments. The first surgical choice was the revision of the nail and the bone reconstruction with a corticoperiosteal pedicled flap from the medial femoral condyle. We considered union to have occurred 3.5 months after surgery when radiographs showed bridging of at least three of the four bony cortices and clinically the patient was able to walk with full weight bearing without any pain. At the last follow-up (25 months), the patient was completely satisfied with the procedure. Discussion. The corticoperiosteal flap allows a faster healing of fractures with a minimal morbidity at the donor site. We suggest that the corticoperiosteal pedicled flap graft is a reliable and effective treatment for distal femur nonunion.
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Affiliation(s)
- Matteo Guzzini
- Department of Orthopaedic and Traumatology, Sant' Andrea Hospital, Faculty of Medicine and Psychology, “Sapienza” University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Cosma Calderaro
- Department of Orthopaedic and Traumatology, Sant' Andrea Hospital, Faculty of Medicine and Psychology, “Sapienza” University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Marco Guidi
- Department of Orthopaedic and Traumatology, Sant' Andrea Hospital, Faculty of Medicine and Psychology, “Sapienza” University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Carolina Civitenga
- Department of Orthopaedic and Traumatology, Sant' Andrea Hospital, Faculty of Medicine and Psychology, “Sapienza” University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Germano Ferri
- Department of Orthopaedic and Traumatology, Sant' Andrea Hospital, Faculty of Medicine and Psychology, “Sapienza” University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Andrea Ferretti
- Department of Orthopaedic and Traumatology, Sant' Andrea Hospital, Faculty of Medicine and Psychology, “Sapienza” University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
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Suh HS, Lee JS, Hong JPJ. Consideration in lower extremity reconstruction following oncologic surgery: Patient selection, surgical techniques, and outcomes. J Surg Oncol 2016; 113:955-61. [DOI: 10.1002/jso.24205] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 02/06/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Hyun Suk Suh
- Department of Plastic and Reconstructive Surgery; Asan Medical Center, University of Ulsan College of Medicine; Seoul Korea
| | - Jong Seok Lee
- Department of Orthopedic Surgery; Asan Medical Center, University of Ulsan College of Medicine; Seoul Korea
| | - Joon Pio Jp Hong
- Department of Plastic and Reconstructive Surgery; Asan Medical Center, University of Ulsan College of Medicine; Seoul Korea
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van der Woude JAD, van Heerwaarden RJ, Bleys RLAW. Periosteal vascularization of the distal femur in relation to distal femoral osteotomies: a cadaveric study. J Exp Orthop 2016; 3:6. [PMID: 26915006 PMCID: PMC4735087 DOI: 10.1186/s40634-016-0042-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/26/2016] [Indexed: 11/23/2022] Open
Abstract
Background The purpose of this study was to investigate periosteal vessels location as intra-operative landmarks in distal femoral osteotomies and focused on the branching pattern of the vascular supply of the medial and lateral femoral condyle, its constancy, and the relationship to the height of distal femoral osteotomies. Anastomoses of relevant vessels were studied to analyze the risk of vascular insufficiency after transection of landmark vessels. Methods A human cadaver dissection study on the vascular supply of the medial and lateral side of the distal femur was conducted. Surgical dissection was performed in eight knees in total. Distances between the vascular supply and bony landmarks were calculated. Relation of the vascular structures to the transverse bone cuts of distal femoral osteotomies was described, as well as anastomoses of relevant vessels. Results On the medial side of the distal femur the periosteum was primarily supplied by the descending genicular artery (DGA) in 87.5 % of the specimens. In the absence of the DGA, the superior medial genicular artery was the supplier. Vascularization took place through two constant branches, the upper transverse artery (UTA) and the central longitudinal artery. The UTA originated at a mean distance of 6.9 cm (range 5.9–7.9 cm) above the knee joint line. On the lateral side of the distal femur the superior lateral genicular artery was the main vessel. In all dissected knees it gave off the lateral transverse artery (LTA). The LTA originated at a mean distance of 6.9 cm (range 5.8–7.6 cm) above the knee joint line. Anastomoses between the UTA, LTA and the longitudinal arch of the femoral shaft were found that could prevent vascular insufficiencies after transection of the UTA and LTA. Conclusions The vascular supply of the medial and lateral aspects of the femoral condyle is highly constant. Both the UTA, on the medial side, and the LTA, on the lateral side, can serve as a landmark for orthopedic surgeons in determining the height of the osteotomy cuts in distal femoral osteotomies. Transection of these landmark vessels during the osteotomy will not result in vascular insufficiency because of a collateral supply.
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Affiliation(s)
- J A D van der Woude
- Department of Orthopedic Surgery, Limb Reconstruction Center, Maartenskliniek Woerden, Polanerbaan 2, 3447, GN, Woerden, The Netherlands
| | - R J van Heerwaarden
- Department of Orthopedic Surgery, Limb Reconstruction Center, Maartenskliniek Woerden, Polanerbaan 2, 3447, GN, Woerden, The Netherlands.
| | - R L A W Bleys
- Department of Anatomy, University Medical Center, Utrecht, The Netherlands
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Brandtner C, Bürger H, Hachleitner J, Gaggl A. The intraoral anastomosing technique in reconstructive surgery of the face – A consecutive case series of 70 patients. J Craniomaxillofac Surg 2015; 43:1763-8. [DOI: 10.1016/j.jcms.2015.07.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 07/17/2015] [Accepted: 07/20/2015] [Indexed: 11/16/2022] Open
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Song D, Deng X, Chen Y, Xie S, Zhou X. Thinned chimeric radial collateral artery perforator flap in complex distal thumb reconstruction. Arch Orthop Trauma Surg 2015; 135:1623-31. [PMID: 26377731 DOI: 10.1007/s00402-015-2324-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Tissue loss accompanied by bone defects in the thumb is a challenging reconstruction problem. Traditional repair methods are unsatisfactory. METHODS Microsurgical thumb reconstruction was performed using 13 thinned chimeric radial collateral artery (RCA) perforator flaps. The flap was created with a thinned skin paddle and humeral bone segments using independent perforators. Primary defatting was completed when the thickness of the perforator entry was approximately similar to that in the periphery. The posterior cutaneous nerve of the arm was carried to make a sensory flap. Defects were 8.5 × 4.5 cm(2) on average (ranging in size from 4.5 × 1.5 to 15.0 × 6.0 cm(2)), and flap size was 9.0 × 5.5 cm(2) on average (ranging in size from 5.0 × 2.0 to 16.0 × 7.0 cm(2)), whereas the humeral fragments were 2.0 × 1.0 cm(2) on average (ranging in size from 1.5 × 0.5 to 4.0 × 1.5 cm(2)). All data were expressed as mean ± SD. The cosmetic appearance of the donor and recipient sites, Kapandji opposition score and static two-point discrimination of the operated thumb were evaluated during a follow-up visit. RESULTS Follow-up time was 16.6 months (ranging from 14 to 28 months). Flap thickness before defatting, measured immediately after flap elevation was 14.5 mm (ranging from 10.0 to 25.0 mm). Average flap thickness after defatting was 3.5 mm (ranging from 3.0 to 6.0 mm). Venous congestion occurred in two cases. Successful microsurgical revision was achieved in both cases. All flaps survived. Bone components achieved union in all cases at an average period of 4.8 months (ranging from 3 to 6 months). Based on Kapandji opposition score, the mean thumb opposition score was 6. The mean sensation of flap was 7.5 mm (ranging from 6 to 11 mm). No further flap revision or defatting procedures were required in all cases. Cosmetically acceptable results were achieved for all patients. CONCLUSIONS Findings proved that thinned chimeric RCA perforator flap is a beneficial microsurgical alternative for reconstructing complex bone and soft tissue defects in thumb.
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Affiliation(s)
- Dajiang Song
- Department of Head and Neck Surgery, Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China.,Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Xiangwu Deng
- Hand Surgical Centre, Nanhua Hospital, Nanhua University, Henyang, China
| | - Yanmin Chen
- Hand Surgical Centre, Nanhua Hospital, Nanhua University, Henyang, China
| | - Songlin Xie
- Hand Surgical Centre, Nanhua Hospital, Nanhua University, Henyang, China. .,Department of Orthopaedics, Xiangya Hospital of Central South University, Changsha, China.
| | - Xiao Zhou
- Department of Head and Neck Surgery, Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China.
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Henry M. Free Vascularized Medial Femoral Condyle Structural Flaps for Septic Terminal Digital Bone Loss. J Hand Microsurg 2015; 7:306-13. [PMID: 26578834 DOI: 10.1007/s12593-015-0207-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 10/20/2015] [Indexed: 10/22/2022] Open
Abstract
A unique clinical problem exists when the majority of distal bone stock in a digit is destroyed by osteomyelitis, leaving a residual soft tissue envelope with tenuous, random perfusion surrounding a nidus of scar tissue. Pulp pinch is lost in the absence of bony support, and limited options exist. Apart from toe transfer or revision amputation with shortening, non-vascularized bone grafting inside the residual soft tissue envelope risks graft resorption and reactivation of infection. The purpose of this investigation was to evaluate the clinical outcomes of free vascularized medial femoral condyle structural bone flaps to restore lost pulp pinch in such cases. Nine patients (8 males, 1 female) with a mean age of 43 years sustained extensive terminal bone loss near digital tips following osteomyelitis. The mean length of bone defect was 28 mm (± 8.4). The patients were reconstructed at a mean of 12 weeks from initial trauma/infection, having undergone a mean of two prior surgeries. A structural block of vascularized bone from the medial femoral condyle replaced the missing bone at the digital tip defect, temporarily fixed with K-wires. The bone flap was encased by the residual soft tissue envelope after removing scar tissue from the prior trauma and infection. All bone flaps incorporated fully, restoring pulp pinch function to the respective digits with a mean time to union of 8.6 (± 2.1) weeks; range 6-11 weeks. With few alternative solutions able to address this unique and difficult problem, the structural block of vascularized bone proved able to resist resorption, nonunion, and reactivation of infection; the problems normally encountered under this scenario.
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Affiliation(s)
- Mark Henry
- Hand and Wrist Center of Houston, 1200 Binz Street, 13th Floor, Houston, TX 77004 USA
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61
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Wong VW, Bürger HK, Iorio ML, Higgins JP. Lateral Femoral Condyle Flap: An Alternative Source of Vascularized Bone From the Distal Femur. J Hand Surg Am 2015; 40:1972-80. [PMID: 26277210 DOI: 10.1016/j.jhsa.2015.06.106] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 06/16/2015] [Accepted: 06/17/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To elucidate the vascular anatomy of the superolateral geniculate artery (SLGA) and its supply to the periosteum of the lateral femoral condyle (LFC) and to provide guidelines for flap design and describe an illustrative case. METHODS Thirty-one fresh cadaveric limbs were dissected. The vascular anatomy of the SLGA and its distal branches to skin, muscle, and periosteum were identified. Fluoroscopic images were taken during continuous perfusion of a radiopaque contrast dye into the SLGA. Intra-arterial injections of latex rubber were performed in 12 cadaver limbs. The vascular territory was traced from the SLGA to its distal branches, and surrounding soft tissues were dissected. RESULTS The SLGA originated from the popliteal artery 4.9 ± 1.2 cm (range, 2.8-7 cm) from the knee joint and its pedicle diameter was 1.8 ± 0.5 mm (range, 1-3 mm). SGLA pedicle-specific fluoroscopic angiography demonstrated a dense filigree of vessels over the lateral distal femur. Arterial latex injections confirmed that the SLGA supplied the periosteum of the LFC and distal femur shaft. The proximal-most extent of periosteal perfusion was 11.7 ± 2.1 cm (range, 9.3-14.1 cm) from the knee joint. The average pedicle length of LFC osteoperiosteal flaps was 4.8 ± 0.9 cm (range, 3.5-6.3 cm). CONCLUSIONS The LFC flap consistently demonstrated almost 12 cm of femur length perfusion based on the SLGA pedicle. The anatomy of this flap enables chimeric designs combining soft tissue, bone, and cartilage. CLINICAL RELEVANCE The vascularized LFC flap is an option for reconstruction of osseous defects of the upper extremity.
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Affiliation(s)
- Victor W Wong
- Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | | | - Matthew L Iorio
- Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - James P Higgins
- Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
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Elgammal A, Lukas B. Vascularized medial femoral condyle graft for management of scaphoid non-union. J Hand Surg Eur Vol 2015; 40:848-54. [PMID: 25487319 DOI: 10.1177/1753193414561900] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 10/08/2014] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to assess the results of the management of difficult scaphoid non-unions using a vascularized medial femoral condyle graft. We operated on 30 patients with necrosis of the proximal pole or with severe humpback deformity or who presented with persistent non-union despite previous surgery. Twenty-four cases in our series showed full consolidation and six cases showed persistent non-union. The free vascularized medial femoral condyle bone graft can provide not only structural support, but also a consistent and good blood supply that results in excellent rates of union. Level of evidence: IV.
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Affiliation(s)
- A Elgammal
- Ain Shams University Hospitals Egypt, Landshut Achdorf Klinik, Munich, Germany
| | - B Lukas
- Hand, Elbow and Plastic Surgery Department, Schön Klinik München Harlaching, Munich, Germany
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63
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Higgins JP. 2013-2014 sterling bunnell traveling fellowship report. J Hand Surg Am 2015; 40:347-51. [PMID: 25617958 DOI: 10.1016/j.jhsa.2014.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 11/03/2014] [Accepted: 11/04/2014] [Indexed: 02/02/2023]
Abstract
Since 1982, the American Society for Surgery of the Hand has sponsored a young member each year as its Bunnell Traveling Fellow. The Sterling Bunnell Traveling Fellowship enables young hand surgeons to foster national and international relationships that contribute to their pursuit of higher learning and advance the principles of scholarship by improving treatment of hand and upper extremity disorders. As the Sterling Bunnell Traveling Fellow for 2013 to 2014, I studied microvascular osteochondral reconstruction of the upper extremity. The year allowed me to pursue research abroad and participate in novel operations. These experiences have challenged how I approach common osteoarticular problems in hand surgery. Leaders in wrist surgery around the globe helped me reconsider the treatment of osteonecrotic, degenerative, and posttraumatic cartilage loss in radical new ways.
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Affiliation(s)
- James P Higgins
- Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
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64
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Wong VW, Higgins JP, Katz RD. Functional reconstruction of subtotal thumb metacarpal defect with a vascularized medial femoral condyle flap: case report. J Hand Surg Am 2014; 39:2005-8. [PMID: 25064623 DOI: 10.1016/j.jhsa.2014.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 06/05/2014] [Accepted: 06/05/2014] [Indexed: 02/02/2023]
Abstract
Devastating hand injuries require customized reconstructive strategies to maximize functional outcomes. We report a case of thumb metacarpal reconstruction using a vascularized medial femoral condyle osteocutaneous flap in the setting of nearly complete metacarpal loss. In addition to achieving the traditional goals of reconstructing thumb length and providing stability, the medial femoral condyle flap allowed motion at the carpometacarpal joint. The patient's hand function was further optimized by a component transfer of a proximally injured but distally preserved index finger to the amputated middle finger position. The patient regained satisfactory grip and thumb function with minimal donor site morbidity. This case highlights the role of both creative and established approaches to reconstruct composite tissues following devastating hand injury.
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Affiliation(s)
- Victor W Wong
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - James P Higgins
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Ryan D Katz
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
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Vascularized Treatment Options for Reconstruction of the Ascending Mandible With Introduction of the Femoral Medial Epicondyle Free Flap. J Craniofac Surg 2014; 25:1690-7. [DOI: 10.1097/scs.0000000000001192] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Levinson H, Miller KJ, Adams SB, Parekh SG. Treatment of Spontaneous Osteonecrosis of the Tarsal Navicular With a Free Medial Femoral Condyle Vascularized Bone Graft: A New Approach to Managing a Difficult Problem. Foot Ankle Spec 2014; 7:332-337. [PMID: 24368773 DOI: 10.1177/1938640013514270] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
UNLABELLED Adult-onset spontaneous osteonecrosis of the tarsal navicular joint, or Mueller-Weiss syndrome (MWS), is an uncommon debilitating disease characterized by a painful clinical course with progressive midfoot deformity. Treatment options include nonoperative management and/or operative intervention, including percutaneous decompression of the navicular bone, stabilization of existing structures, and cancellous bone grafting from the tibia or iliac crest. To our knowledge, there have been no reported cases of treatment of MWS with a vascularized bone graft. We report an unusual case of unilateral MWS in a 25-year-old male who failed nonoperative therapy and was successfully treated with a novel operative approach using debridement followed by a free medial femoral condyle vascularized bone graft. At 18-month follow-up, the patient demonstrated an excellent outcome with return to previous level of function, including work-related and recreational activities. LEVEL OF EVIDENCE Therapeutic, Level IV: Case study.
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Affiliation(s)
- Howard Levinson
- Division of Plastic and Reconstructive Surgery, Departments of Surgery and Pathology (HL, KJM), Duke University Medical Center, Durham, North CarolinaDepartment of Orthopaedic Surgery (SBA), Duke University Medical Center, Durham, North CarolinaNorth Carolina Orthopaedic Clinic, Department of Orthopaedic Surgery (SGP), Duke University Medical Center, Durham, North CarolinaFuqua School of Business, Duke University, Durham, North Carolina (SGP)
| | - Kyle J Miller
- Division of Plastic and Reconstructive Surgery, Departments of Surgery and Pathology (HL, KJM), Duke University Medical Center, Durham, North CarolinaDepartment of Orthopaedic Surgery (SBA), Duke University Medical Center, Durham, North CarolinaNorth Carolina Orthopaedic Clinic, Department of Orthopaedic Surgery (SGP), Duke University Medical Center, Durham, North CarolinaFuqua School of Business, Duke University, Durham, North Carolina (SGP)
| | - Samuel B Adams
- Division of Plastic and Reconstructive Surgery, Departments of Surgery and Pathology (HL, KJM), Duke University Medical Center, Durham, North CarolinaDepartment of Orthopaedic Surgery (SBA), Duke University Medical Center, Durham, North CarolinaNorth Carolina Orthopaedic Clinic, Department of Orthopaedic Surgery (SGP), Duke University Medical Center, Durham, North CarolinaFuqua School of Business, Duke University, Durham, North Carolina (SGP)
| | - Selene G Parekh
- Division of Plastic and Reconstructive Surgery, Departments of Surgery and Pathology (HL, KJM), Duke University Medical Center, Durham, North CarolinaDepartment of Orthopaedic Surgery (SBA), Duke University Medical Center, Durham, North CarolinaNorth Carolina Orthopaedic Clinic, Department of Orthopaedic Surgery (SGP), Duke University Medical Center, Durham, North CarolinaFuqua School of Business, Duke University, Durham, North Carolina (SGP)
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Bürger HK, Windhofer C, Gaggl AJ, Higgins JP. Vascularized medial femoral trochlea osteochondral flap reconstruction of advanced Kienböck disease. J Hand Surg Am 2014; 39:1313-22. [PMID: 24855965 DOI: 10.1016/j.jhsa.2014.03.040] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 03/27/2014] [Accepted: 03/27/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To describe the operative technique and report the results of 16 consecutive cases of arthroplasty for advanced Kienböck disease using a vascularized osteochondral graft from the medial femoral trochlea (MFT) with a minimum 12-month follow-up. METHODS Chart reviews of 16 cases of osteochondral MFT flap transfers for lunate reconstruction were performed in 2 institutions. Mean patient age was 35 years (range, 19-51 y). Preoperative Lichtman staging was 2 in 7 patients, 3a in 8 patients, and 3b in 1. Five of 16 patients had undergone a previous procedure for Kienböck disease (3 radial shortening osteotomies, 1 wrist denervation, and 1 distal radius vascularized bone grafting). Ulnar variance recorded at the time of the MFT reconstruction was negative in 8 patients, positive in 6 patients, and neutral in 2 patients. Follow-up data were recorded at a minimum of 12 months (average, 19 mo). Radiographic parameters recorded included preoperative ulnar variance, preoperative and final follow-up radioscaphoid angle, lunate height, lunate diameter, and the Stahl index and Lichtman stage. RESULTS Healing was confirmed in 15 of 16 reconstructed lunates. Lichtman staging remained unchanged in 10 patients, improved in 4 patients from grade 3a and 3b to 2, and worsened in 2 patients from grade 3a to 3b. All but 1 patient experienced improvement in wrist pain (12/16 complete relief; 3/16 incomplete relief). Wrist motion at follow-up averaged 50° extension and 38° flexion, similar to preoperative measurements. Grip strength at follow-up was 85% of the contralateral side. CONCLUSIONS Osteochondral vascularized MFT flaps provided a reliable means of lunate reconstruction in advanced Kienböck disease. This flap allowed resection of the proximal portion of the collapsed lunate and reconstruction with an anatomically analogous convex segment of vascularized cartilage-bearing bone. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Heinz K Bürger
- Privat Hospital Maria Hilf, Klagenfurt, Austria; Trauma Department, Unfallkrankenhaus, Austria; Department of Oral and Maxillofacial Surgery, University Hospital Salzburg, Austria; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Christian Windhofer
- Privat Hospital Maria Hilf, Klagenfurt, Austria; Trauma Department, Unfallkrankenhaus, Austria; Department of Oral and Maxillofacial Surgery, University Hospital Salzburg, Austria; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Alexander J Gaggl
- Privat Hospital Maria Hilf, Klagenfurt, Austria; Trauma Department, Unfallkrankenhaus, Austria; Department of Oral and Maxillofacial Surgery, University Hospital Salzburg, Austria; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - James P Higgins
- Privat Hospital Maria Hilf, Klagenfurt, Austria; Trauma Department, Unfallkrankenhaus, Austria; Department of Oral and Maxillofacial Surgery, University Hospital Salzburg, Austria; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
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68
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Kang Y, Ren L, Yang Y. Engineering vascularized bone grafts by integrating a biomimetic periosteum and β-TCP scaffold. ACS APPLIED MATERIALS & INTERFACES 2014; 6:9622-9633. [PMID: 24858072 PMCID: PMC4075998 DOI: 10.1021/am502056q] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 05/23/2014] [Indexed: 05/29/2023]
Abstract
Treatment of large bone defects using synthetic scaffolds remain a challenge mainly due to insufficient vascularization. This study is to engineer a vascularized bone graft by integrating a vascularized biomimetic cell-sheet-engineered periosteum (CSEP) and a biodegradable macroporous beta-tricalcium phosphate (β-TCP) scaffold. We first cultured human mesenchymal stem cells (hMSCs) to form cell sheet and human umbilical vascular endothelial cells (HUVECs) were then seeded on the undifferentiated hMSCs sheet to form vascularized cell sheet for mimicking the fibrous layer of native periosteum. A mineralized hMSCs sheet was cultured to mimic the cambium layer of native periosteum. This mineralized hMSCs sheet was first wrapped onto a cylindrical β-TCP scaffold followed by wrapping the vascularized HUVEC/hMSC sheet, thus generating a biomimetic CSEP on the β-TCP scaffold. A nonperiosteum structural cell sheets-covered β-TCP and plain β-TCP were used as controls. In vitro studies indicate that the undifferentiated hMSCs sheet facilitated HUVECs to form rich capillary-like networks. In vivo studies indicate that the biomimetic CSEP enhanced angiogenesis and functional anastomosis between the in vitro preformed human capillary networks and the mouse host vasculature. MicroCT analysis and osteocalcin staining show that the biomimetic CSEP/β-TCP graft formed more bone matrix compared to the other groups. These results suggest that the CSEP that mimics the cellular components and spatial configuration of periosteum plays a critical role in vascularization and osteogenesis. Our studies suggest that a biomimetic periosteum-covered β-TCP graft is a promising approach for bone regeneration.
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Affiliation(s)
- Yunqing Kang
- Department
of Orthopedic Surgery, Stanford University 300 Pasteur Drive, Stanford, California 94305, United States
| | - Liling Ren
- Department
of Orthopedic Surgery, Stanford University 300 Pasteur Drive, Stanford, California 94305, United States
- School
of Stomatology, Lanzhou University 199 Donggang West Road, Lanzhou, Gansu 730000, China
| | - Yunzhi Yang
- Department
of Orthopedic Surgery, Stanford University 300 Pasteur Drive, Stanford, California 94305, United States
- Department
of Materials Science and Engineering, Stanford
University, 300 Pasteur
Drive, Stanford, California 94305, United States
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69
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Abstract
Free vascularized bone graft from the medial femoral condyle has been described as a superior method for treatment of recalcitrant scaphoid nonunion with proximal pole avascularity and humpback deformity. Few complications and high union rates have been reported. In a series of three patients we describe an undesired volar ossification as a potential complication of the method. The risk of developing the ectopic bone formation can be minimized if the surgeon is aware of the strong osteogenic capacity of the periosteum. Meticulous dissection of the vascular bundle to the graft is mandatory to avoid the complication. Caution is warranted so as not to leave a periosteal sleeve under the vessels at the margin of the graft.
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Affiliation(s)
- Torbjörn Vedung
- Department of Hand Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Bertil Vinnars
- Department of Hand Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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70
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Scaphoid overstuffing: the effects of the dimensions of scaphoid reconstruction on scapholunate alignment. J Hand Surg Am 2013; 38:2419-25. [PMID: 24275051 DOI: 10.1016/j.jhsa.2013.09.035] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 09/23/2013] [Accepted: 09/24/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE Osteochondral replacement of the proximal scaphoid has been reported using a vascularized flap from the medial femoral trochlea. A concern with this technique is the loss of stability of the scapholunate relationship with resection of the scaphoid proximal pole. Overexpansion of the scaphoid dimensions (overstuffing) during scaphoid reconstruction with the osteochondral flap may play a role in maintaining scapholunate alignment. Our purpose was to determine if overstuffing the scaphoid can correct rotatory carpal instability in a cadaveric model studied radiographically. METHODS The radiolunate angle and scapholunate interval were measured for 5 fresh cadaver wrists. We completely incised the scapholunate interosseous ligament and performed an osteotomy to excise the proximal third of the scaphoid to simulate a proximal pole deficiency nonunion and create a dorsal intercalated segmental instability deformity. Radiographic measurements were repeated. The proximal pole of the scaphoid was replaced with its original piece of bone; radiographic measurements were repeated without scapholunate ligament repair. The osteotomy site was overstuffed with a 4-mm sawbone spacer without scapholunate ligament repair, and radiographs were obtained. RESULTS Sectioning of scapholunate ligaments and proximal pole excision successfully created carpal instability demonstrated by abnormal radiolunate angles. Without ligament repair, proximal pole replacement did not restore normal radiolunate angles. Expansion of the scaphoid dimensions corrected radiolunate angles on lateral unloaded radiographs and improved scapholunate intervals on clenched fist radiographs. These findings were statistically significant compared with the unexpanded (replaced) scaphoid. CONCLUSIONS These findings suggest that scaphoid reconstruction that results in expansion of the scaphoid's normal dimensions will restore carpal alignment without scapholunate ligament reconstruction. CLINICAL RELEVANCE Osteochondral reconstruction of difficult proximal pole nonunions may not require any preservation or reconstruction of scapholunate integrity if the reconstruction expands the normal dimensions of the native scaphoid. Scapholunate interval and carpal alignment may be restored by scaphoid over stuffing. The effects on increased contact pressure and range of motion require further investigation.
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71
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Matzon JL, Patel TJ, Katz RD, Higgins JP. Chronic thrombosis in the descending genicular artery during harvest of a medial femoral condyle corticocancellous flap: a case report. Hand (N Y) 2013; 8:330-3. [PMID: 24426943 PMCID: PMC3745231 DOI: 10.1007/s11552-013-9501-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Jonas L. Matzon
- Rothman Institute, Thomas Jefferson University, 925 Chestnut St., 5th floor, Philadelphia, PA 19107 USA
| | - Tejas J. Patel
- School of Osteopathic Medicine, Department of Orthopaedic Surgery, University of Medicine and Dentistry of New Jersey, Stratford, NJ USA
| | - Ryan D. Katz
- The Curtis National Hand Center, MedStar Union Memorial Hospital, 3333 North Calvert Street, Mezzanine, Baltimore, MD 21218 USA
| | - James P. Higgins
- The Curtis National Hand Center, MedStar Union Memorial Hospital, 3333 North Calvert Street, Mezzanine, Baltimore, MD 21218 USA
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72
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Abstract
Background The medial trochlea of the femur (medial femoral trochlea, MFT) provides a source of convex osteocartilaginous vascularized bone that has been demonstrated to have a similar contour to the proximal scaphoid. This provides a potential solution for difficult recalcitrant proximal pole scaphoid nonunions. Materials and Methods Sixteen consecutive patients who underwent MFT proximal scaphoid arthroplasty were reviewed. Follow-up data were recorded at a minimum of 6 months, with an average of 14 months. The results of this cohort were previously reported in detail but are summarized herein. Description of Technique The ability to reconstruct both bone and cartilage of the nonunion enables the surgeon to resect the nonunited proximal pole to prepare for scaphoid reconstruction. A segment of osteocartilaginous MFT is harvested in dimensions required by the scaphoid defect. The MFT segment is harvested on the transverse branch of the descending geniculate vessels. Fixation may be achieved with ease due to the size of the reconstructed segment. Results Computed tomography imaging demonstrated 15 of 16 reconstructed scaphoids achieving osseous union. Follow-up range of motion (ROM) of the wrist averaged 46.0° extension (range 28-80°) and 43.8° flexion (range 10-80°), which was similar to preoperative (average 45.7° extension and 43.0° flexion). Scapholunate angles remained unaffected (51.6° preoperatively and 48.6° postoperatively), indicating preservation of carpal relationships. Conclusions Vascularized MFT flaps provide a useful tool in the treatment of difficult proximal pole scaphoid nonunions. Early follow-up demonstrates high rate of achieving union with acceptable ROM and good pain relief.
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Affiliation(s)
- James P. Higgins
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, Maryland
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73
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Ehanire T, Blanton M, Levin L, Levinson H. Osteocutaneous defects of the clavicle: Two case reports, analysis of the literature, and a novel management algorithm. J Plast Reconstr Aesthet Surg 2013; 66:593-600. [DOI: 10.1016/j.bjps.2013.02.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 02/10/2013] [Accepted: 02/21/2013] [Indexed: 11/16/2022]
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74
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Abstract
BACKGROUND The medial femoral condyle has become a reliable source of vascularized bone with many advantages to the reconstructive microsurgeon. The authors examined the donor-site morbidity of medial femoral condyle flap harvest. METHODS A retrospective review of all patients who underwent medial femoral condyle free flap procedures between April of 2009 and December of 2010 was conducted. Study participants underwent computed tomographic scans of their bilateral distal femurs and knee joints to evaluate the donor site and examine differences between the operated and nonoperated sides. RESULTS Fifteen patients underwent medial femoral condyle free flap procedures. Ten of them agreed to participate in the study. The average time between surgery and computed tomographic scans was 18.0 months (range, 12.2 to 30.4 months). Average bone harvested per procedure was 16.1 cm3 (range, 2 to 34 cm3), representing an average condylar volume of 9 percent (range, 1 to 18 percent). Reparative bone formation was minimal, with an average thickness of 4.5 mm (range, 4 to 6 mm). There were no findings of new degenerative joint disease on computed tomographic scans resulting from medial femoral condyle harvest. The flap success rate was 100 percent (10 of 10) for patency and achieving osseous union. There were no major or flap-related complications. Two patients reported numbness of the donor site at long-term follow-up (average, 17.5 months; range, 12.2 to 30.4 months). CONCLUSIONS Medial femoral condyle harvest creates minimal donor-site morbidity according to radiographic measures at more than 1-year follow-up. Surgeons can anticipate minimal unassisted bone regeneration at the donor site at this time interval.
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75
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Bürger HK, Windhofer C, Gaggl AJ, Higgins JP. Vascularized medial femoral trochlea osteocartilaginous flap reconstruction of proximal pole scaphoid nonunions. J Hand Surg Am 2013; 38:690-700. [PMID: 23474156 DOI: 10.1016/j.jhsa.2013.01.036] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 01/16/2013] [Accepted: 01/17/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE The descending geniculate artery's branching pattern includes periosteal vessels supplying the cartilage-bearing trochlea of the medial patellofemoral joint. Previous cadaveric studies described anatomic similarities between the greater curvature of the proximal scaphoid and the convex surface of the medial femoral trochlea (MFT). We describe the technique and report our first 16 consecutive cases of vascularized osteocartilaginous arthroplasty for chronic scaphoid proximal pole nonunions using the MFT, with a minimum of 6 months of follow-up. METHODS Chart reviews of 16 consecutive cases of osteocartilaginous MFT flap transfers for scaphoid reconstruction were performed at 2 institutions. Follow-up data were recorded at a minimum of 6 months, with an average of 14 months (range, 6-72 mo). Patient age and sex, duration of nonunion, number of previous surgical procedures, surgical technique, achievement of osseous union, preoperative and postoperative scapholunate angles, preoperative and postoperative range of motion, and pain relief were recorded. RESULTS Computed tomography imaging confirmed healing in 15 of 16 reconstructed scaphoids. Mean patient age was 30 years (range, 18-47 y). The average number of previous surgical procedures was 1 (range, 0-3). All patients experienced some wrist pain improvement (12/16 complete relief, 4/16 incomplete relief). Wrist range of motion at follow-up averaged 46° extension (range, 28° to 80°) and 44° flexion (range, 10° to 80°), which was similar to preoperative measurements (average 46° extension and 43° flexion). Scapholunate relationship remained unchanged with average scapholunate angles of 52° before surgery and 49° after surgery. CONCLUSIONS Osteochondral vascularized MFT flaps provide a reliable means of achieving resolution of difficult proximal pole scaphoid nonunions. These flaps allow resection of the proximal portion of the unhealed scaphoid and reconstruction with an anatomically analogous convex segment of cartilage-bearing bone. This technique provides the advantages of vascularized bone and ease of fixation. Early follow-up demonstrates a high rate of union with acceptable motion and pain relief. CLINICAL RELEVANCE Early follow-up suggests that the vascularized MFT osteocartilaginous flap is a valuable tool for treating challenging proximal pole scaphoid nonunions.
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76
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Jones DB, Rhee PC, Bishop AT, Shin AY, Shin AY. Free vascularized medial femoral condyle autograft for challenging upper extremity nonunions. Hand Clin 2012; 28:493-501. [PMID: 23101599 DOI: 10.1016/j.hcl.2012.08.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Free vascularized bone grafts from the medial femoral condyle have increasingly demonstrated utility in the successful treatment of challenging nonunions and bony defects. The consistent, robust vascular anatomy and the versatility to function as either a thin, flexible periosteal or corticoperiosteal graft or as a structural corticocancellous graft have made this graft a valuable option for addressing recalcitrant nonunions. The rationale, indications, vascular anatomy, and surgical technique of harvesting these grafts from the medial femoral condyle are presented.
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Affiliation(s)
- David B Jones
- Division of Hand Surgery, Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
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77
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Rapp SJ, Jones DC, Gerety P, Taylor JA. Repairing critical-sized rat calvarial defects with progenitor cell-seeded acellular periosteum: A novel biomimetic scaffold. Surgery 2012; 152:595-604, 605.e1; discussion 604-5. [DOI: 10.1016/j.surg.2012.07.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 07/12/2012] [Indexed: 01/22/2023]
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79
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Jones DB, Rhee PC, Shin AY. Vascularized bone grafts for scaphoid nonunions. J Hand Surg Am 2012; 37:1090-4. [PMID: 22483177 DOI: 10.1016/j.jhsa.2012.03.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 03/01/2012] [Indexed: 02/02/2023]
Abstract
Scaphoid fractures that fail to unite are at risk of developing avascular necrosis and progressive structural collapse, thereby complicating attempts at revision surgical treatment. Vascularized bone grafts have demonstrated utility in promoting consolidation in the treatment of scaphoid nonunions complicated by avascular necrosis. Numerous pedicled and free vascularized grafts have been described with variable, but generally favorable, outcomes. Understanding the indications for different grafts is critical to the successful application of these techniques and grafts in the treatment of challenging scaphoid nonunions.
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Affiliation(s)
- D B Jones
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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