Free vascularized tibial periosteal graft with monitoring skin island for limb reconstruction: Anatomical study and case report

Reconstruction of congenital pseudarthrosis of the radius with a vascularized tibial periosteal transplant: A case report

Congenital pseudarthrosis of the forearm poses a considerable challenge because of its rarity. The objective of this report is to introduce a novel surgical technique for its treatment. Here, we document a case of congenital pseudarthrosis of the radius in a 3-year-old boy diagnosed with type-1 neurofibromatosis. The surgical treatment involved the excision of approximately 9 cm of native radial periosteum and a bifocal radius osteotomy, which was supplemented with a vascularized tibial periosteal transplant to facilitate bone healing. Anastomosis between the anterior tibial vessels and radial vessels was performed. No immediate or late postoperative complications were observed. After 3 weeks, a robust callus formation was observed, and during a follow-up examination 3 years and 4 months later, a wide range of active forearm rotation was noted. This report suggests that vascularized periosteal flaps show promise as a viable treatment option for congenital pseudarthrosis of the forearm. They offer an alternative to vascularized fibular grafts or single-bone forearm constructs.

Vascularized Ulnar Periosteal Pedicled Flap for Upper Extremity Reconstruction in Adults: A Prospective Case Series of 11 Patients

PURPOSE

We hypothesized that a vascularized ulnar periosteal pedicled flap (VUPPF) is a versatile graft applicable in adult patients that yields good outcomes and is a reliable alternative to other vascularized bone grafts to reduce both the technical demands and donor site morbidity of other options.

METHODS

We reviewed 11 adult patients who underwent surgical treatment of forearm atrophic nonunion with a VUPPF. Patients' demographics, outcomes (measured by pain on the visual analog scale; Quick Disabilities of the Arm, Shoulder, and Hand score; range of motion; and grip strength), and associated complications were reported.

RESULTS

Of the 11 patients, 5 had previous surgery in an attempt to treat the nonunion with an autologous cancellous bone graft from the iliac crest or olecranon. The average time from nonunion until the VUPPF was 9 months (SD, ±3 months; range, 6-14 months). The mean visual analog scale score improved considerably after surgery (8.7 vs 0.6), and considerable improvement was also noted in the Quick Disabilities of the Arm, Shoulder, and Hand score (50 vs 6). A notable improvement was seen in grip strength after surgery. Pronation/supination also improved considerably between the preoperative assessment and the final postoperative follow-up.

CONCLUSIONS

A vascularized ulnar periosteal pedicled flap seems to be a useful and versatile option for a variety of bone union failures of the upper extremity in adults, either at initial presentation or as a salvage technique.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Free vascularized iliac periosteal graft for bilateral forearm nonunion reconstruction in a child with bilateral transfemoral amputation

Vascularized periosteal flaps have been reported as very effective for treating biologically complex bone nonunion in pediatric patients, owing to their high angiogenic and osteogenic potentials. The purpose of this article is to report a case of a 6-year-old patient with nonunion involving both forearms and a very limited bone flap donor site in the context of prior bilateral transfemoral amputation due to meningococcal sepsis. Two free vascularized iliac periosteal flaps (VIPF), supplied by the deep circumflex iliac vessels, were used in two stages to reconstruct the forearms. In the first stage, the left forearm, which had a diaphyseal bone defect of 5 cm diameter in the ulna and 4 cm in the radius, was combined with an iliac-crest bone allograft, fixed with two longitudinal 1.8 mm Kirschner wires and surrounded with a free VIPF of 24 cm² . Consolidation was achieved 3 months after left forearm surgery, while complete allograft revascularization and remodeling was observed at 12 months. In the second stage, the right forearm, which had a diaphyseal bone defect of 3 cm diameter in the ulna and 1 cm in the radius, was fixed the radius with a 2.7 mm plate and surrounded with a free VIPF of 24 cm² . The radius nonunion healed 6 weeks after surgery. There were no postoperative complications. Two years postoperatively, the patient had again resumed his arm gait painlessly and without a splint. VIPF may be considered a valuable and reliable surgical option for nonunion reconstruction in complex clinical scenarios in children.

Free vascularised medial femoral condyle periosteal flaps in recalcitrant long bone non-union: a systematic review

INTRODUCTION

In adults, treatment of recalcitrant long bone non-union is extremely challenging, with poorly vascularised and atrophic defects unresponsive to standard non-vascularised bone graft treatment. Recent studies have documented the use of free vascularised periosteal flaps to achieve union in refractory long bone fracture non-union, yet its use is not well established. This systematic review aims to assess the evidence for free vascularised periosteal flaps in recalcitrant long bone non-union.

MATERIALS AND METHODS

The MEDLINE®/PubMed^® and Embase databases were searched for the Medical Subject Heading (MeSH) terms periosteal flap/vascularised flap/long bone/non-union/non united fracture in accordance with the PRISMA guidelines. Bibliographies were scrutinised for additional articles.

RESULTS

Pooled data from 14 studies met the inclusions criteria, comprising 137 cases of non-union, with 117 relating to long bone non-union. Pooled data indicated an overall 99% (116/117) successful union rate. All studies were of mid- to low-level evidence (Level III, IV and V). Only one study directly compared vascularised periosteal flaps to non-vascularised bone grafts, showing union rates of 100% versus 80% and faster time to union (2 versus 5.5 months).

CONCLUSIONS

Free vascularised periosteal flaps are promising with pooled data showing a 99% success rate in achieving union in refractory long bone non-union. This compares favourably with standard orthopaedic care consisting of revision fixation and non-vascularised bone graft union rates of approximately 80%. However, study design flaws should be addressed by validated outcome measures plus adequate blinding, and further comparative studies with greater patient numbers are required.

Are Vascularized Periosteal Flaps Useful for the Treatment of Difficult Scaphoid Nonunion in Adults? A Prospective Cohort Study of 32 Patients

PURPOSE

To evaluate clinical and radiological outcomes after surgical treatment of difficult scaphoid nonunion in adults with a vascularized thumb metacarpal periosteal pedicled flap (VTMPF).

MATERIALS AND METHODS

Thirty-two patients at least 18 years old, with scaphoid nonunion and characteristics associated with a poor prognosis, who underwent a VTMPF procedure, were included in this retrospective cohort study with a mean follow-up of 17 months. Factors associated with a poor prognosis were a delay in presentation of over 5 years, the presence of avascular necrosis, and previous nonunion surgery. All patients had at least 1 poor prognostic factor and 25% had 2 or more.

RESULTS

In 30 men and 2 women, the mean age was 36 years (range, 19-56 years). There were 11 type D3 nonunions (Herbert classification) and 15 type D4. Five patients had delayed presentation of over 5 years. Fourteen patients had previously undergone an unsuccessful surgical attempt to treat their nonunion. The patients experienced no postoperative complications. Overall union rate was 97% (31 of 32 patients), with 72% cross-sectional trabecular percentage bridging at 12 weeks. Pain subsided after surgery and patients experienced improvements in both their Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Modified Mayo Wrist Score (MMWS). Overall 41% and 42% gains in strength and wrist motion, relative to the contralateral normal side, were observed. At final follow-up, there were no differences between the treated and the untreated (healthy) hands, in terms of wrist range of motion, grip, or pinch strength.

CONCLUSIONS

In this study, the use of VTMPF for difficult scaphoid nonunion in adults was associated with good general outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Vascularized Thumb Metacarpal Periosteal Flap for Scaphoid Nonunion in Adolescents: A Prospective Cohort Study of 12 Patients

PURPOSE

To evaluate clinical and radiological outcomes after surgical treatment of scaphoid nonunion in adolescents with a vascularized thumb metacarpal periosteal pedicled flap (VTMPF).

METHODS

Twelve patients younger than 18 years with scaphoid nonunion, who underwent a VTMPF procedure without bone grafting, were included for this prospective cohort study, at a mean follow-up of 10.2 months. Patients were operated on by 3 different hand surgeons at 3 hand surgery institutions. All patients received a VTMPF, but with different scaphoid internal fixation modalities, in 10 cases using 1 or 2 retrograde 2-mm headless compression screws and in 2 cases without internal fixation.

RESULTS

In 11 boys and 1 girl, the mean age was 15.6 years. There were 1 type D1 nonunions (Herbert classification), 6 type D2, 2 type D3, and 2 type D4. Six patients had previously undergone an unsuccessful surgical attempt to treat their nonunion. The mean anterior bone defect was 3.5 mm in length. The patients experienced no postoperative complications. Successful consolidation was achieved in all cases, with 79% cross-sectional trabecular bridging at 12 weeks. Pain subsided after surgery and patients experienced improvements in both their Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Modified Mayo Wrist Score (MMWS) results. Overall, 34% and 40% gains in strength and wrist motion, relative to the contralateral normal side, were observed.

CONCLUSIONS

In this study, the use of VTMPF for scaphoid nonunion in children and adolescents is associated with generally good outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Repair of a critical-size segmental rabbit femur defect using bioglass-β-TCP monoblock, a vascularized periosteal flap and BMP-2

Various synthetic bone substitutes are not suitable for reconstructing critical-size bone defects. This study tested whether a bioglass-β-tricalcium phosphate (β-TCP) monoblock is effective for repairing critical-size segmental bone defects if combined with a vascularized periosteal flap and bone morphogenetic protein (BMP)-2. A femoral osteotomy with a gap size of 20 mm was created and stabilized using a plate in 40 rabbits.The defect was left untreated (group A) or repaired using a monoblock (group B), a monoblock with a vascularized periosteal flap (group C), or a monoblock with a vascularized periosteal flap and BMP-2 (group D). Bone regeneration, vascularization and monoblock degradation were analyzed after four and eight weeks using x-ray, hematoxylin-eosin, CD34 immunohistochemical and Masson's trichrome staining observation and histometric evaluation. The radiographic grading score showed a time-dependent increase from weeks 4 to 8. At 8-week postoperative, the total new regenerated bone in groups C and D was 20.0 ± 0.3 and 55.5 ± 8.0 mm² , respectively, which was significantly greater than in group B. Conversely, group D showed less residual monoblock than did group C. An increase in microvessel density was also observed in groups C and D compared with group B at 4 and 8 weeks postoperative, respectively. This study suggests that bioglass-β-TCP monoblock alone exhibits poor potential to repair a 20-mm femoral defect. However, supplementation with a vascularized periosteal flap and BMP-2 led to effective vascularization and reliable bone regeneration throughout the monoblock, with concordant material degradation in a timely manner. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 2148-2156, 2018.

The medial femoral trochlea flap with a monitor skin island-Report of two cases

In this report, we present two cases of the bony reconstruction with the medial trochlea (MFT) flap including a skin island that was used to monitor the perfusion of flap in the postoperative period. Between March 2013 and April 2015, we performed surgery on two patients who suffered from scaphoid and talus non-union after trauma and initial treatment by osteosynthesis. A skin island (1 cm × 1 cm and 3 cm × 1 cm, respectively) was included with the osseous flap (1.6 cm × 1 cm × 1 cm and 2 cm × 3 cm × 2 cm, respectively) to assess the perfusion of the flap. The design of the skin island was based on either the saphenous artery perforator or a cutaneous perforator of the descending genicular artery. Both flaps remained viable throughout the postoperative period, and there were no donor site complications. After a follow-up of 36 and 11 months, bony union was observed in both patients with a high degree of satisfaction. Thus, a MFT flap with a skin island could be a tool to assess the perfusion of the flap in the early postoperative period. © 2016 Wiley Periodicals, Inc. Microsurgery 37:431-435, 2017.