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Cha SM, Pai A, Lee HJ, Shin HD. Non-vascularised corticocancellous (tricortical) iliac bone graft longer than 3 cm for non-union after failed surgical treatment. J Plast Reconstr Aesthet Surg 2024; 88:37-44. [PMID: 37950990 DOI: 10.1016/j.bjps.2023.10.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/03/2023] [Accepted: 10/07/2023] [Indexed: 11/13/2023]
Abstract
PURPOSE We hypothesised that traditional iliac tricortical bone grafts (no vascularised) still have a reasonable role in promoting satisfactory bony healing in non-union defects of certain sizes. Here, we report the clinical/radiological outcomes through a retrospective case series. METHODS We screened 74 patients with definitive non-union in the long bones of the upper extremities who visited the outpatient department from 2008 to 2018. Among these patients, 25 who met our inclusion/exclusion criteria were investigated. RESULTS The mean age was 51.92 years, and there were 12, 9, 1, and 3 lesions of the radius, ulna, clavicle, and humerus, respectively. The tools for primary fixations were plate and intramedullary nails in 24 and 1 patients, respectively. Six patients presented with atrophic non-union. The mean period from a previous surgery was 6.84 months. The mean defective bone sizes were 1.81 and 3.50 cm pre-debridement and post-debridement, respectively. All devices had locking plates longer than the previous plate, and the graft was concurrently fixed by screws in three patients. At a mean of 15.92 weeks after the revision surgery, all patients experienced union. At the final follow-up, the clinical outcomes were satisfactory. No significant differences in clinical outcomes were found according to the lesion, type of non-union, period from the previous surgery, or harvest length of the iliac bone. CONCLUSIONS If the proper indications and some technical aspects are considered, a non-vascularised iliac bone graft longer than 3 cm could still be a reasonable option for treating diaphyseal non-union of the upper extremities. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Soo Min Cha
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Centre, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
| | - Ashwin Pai
- Department of Plastic Surgery, West Suffolk NHS Foundation Trust, United Kingdom
| | - Hyun Jong Lee
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Centre, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
| | - Hyun Dae Shin
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Centre, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea.
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Özdemir A, Odabaşı E, Eravsar E, Safalı S, Acar MA. Treatment of recalcitrant femur nonunion with pedicled corticoperiosteal medial femoral condyle flap. Sci Rep 2023; 13:20326. [PMID: 37990029 PMCID: PMC10663536 DOI: 10.1038/s41598-023-47432-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 11/14/2023] [Indexed: 11/23/2023] Open
Abstract
Periosteal or osteoperiosteal medial femoral condyle (MFC) flaps may be good options for atrophic nonunion. The aim of this study was to evaluate the effectiveness and safety of pedicled MFC flap in the treatment of recalcitrant femur nonunion without bone defect. Thirteen patients (11 male and 2 female), who suffered recalcitrant femur nonunion and were treated with pedicled osteoperiosteal MFC flap between January 2014 and April 2018, were included in this study. Patient files were reviewed retrospectively. Atrophic or recalcitrant 2/3 distal femoral nonunion were the indications for this clinical procedure. Demographics and operative data, flap size, visual analog scale (VAS) score, time to union, and complications were evaluated. A total of 13 patients underwent femur nonunion treatment with MFC flap after an average of 3.4 previous surgical procedures. The median age was 34 (Q1: 32.5, Q3:43) years old. The mean flap size was 4.3 × 6.4 cm, all nonunions healed in a median 5 months (Q1: 4.5, Q3: 6). There were an intraoperative knee medial collateral ligament injury in a patient, hematoma in a patient, and seroma in two patients. The median length of the follow-up was 40 months (Q1: 30, Q3: 47). There wasn't any additional complication in long-term follow-up. Functional outcomes were satisfactory. The median preoperative VAS score was 7 (Q1: 6, Q3: 9.5), decreasing to 1 (Q1: 0, Q3: 1) at the 6-month follow-up, and further reducing to 0 (Q1: 0, Q3: 1) at the 24-month follow-up. The nonunion period ranged from 6 to 18 months. The pedicled MFC flap is a good option for recalcitrant femur nonunion where larger vascularized flaps are not warranted. It is easy to harvest, does not require microvascular anastomosis, is effective, and offers minimal donor site morbidity.
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Affiliation(s)
- Ali Özdemir
- Department of Orthopaedics and Traumatology and Hand Surgery Konya, Selcuk University, Konya, Turkey.
| | - Egemen Odabaşı
- Department of Orthopaedics and Traumatology, Konya Beyhekim Training and Research Hospital, Konya, Turkey
| | - Ebubekir Eravsar
- Department of Orthopaedics and Traumatology, Konya City Hospital, Konya, Turkey
| | - Selim Safalı
- Department of Orthopaedics and Traumatology and Hand Surgery Konya, Selcuk University, Konya, Turkey
| | - Mehmet Ali Acar
- Department of Orthopaedics and Traumatology and Hand Surgery Konya, Selcuk University, Konya, Turkey
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Cheema AN, Conyer RT, Triplet JJ, O’Driscoll SW, Morrey ME, Sanchez-Sotelo J. Outcomes of Humeral Allograft-Prosthetic Composites with Plate Fixation in Revision Total Elbow Arthroplasty. JB JS Open Access 2023; 8:e22.00136. [PMID: 37790198 PMCID: PMC10545412 DOI: 10.2106/jbjs.oa.22.00136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Background Traditionally, the reconstruction of severe distal humeral bone loss at the time of revision total elbow arthroplasty (TEA) has used allograft-prosthetic composites (APCs) stabilized with cerclage wires or cables. We have migrated to plate fixation when revision TEA using a humeral APC is performed. This study shows the outcomes of patients treated with a humeral APC with plate fixation during revision TEA. Methods Between 2009 and 2019, 41 humeral APCs with plate fixation of distal humeral allograft to the native humerus were performed in the setting of revision TEA. There were 12 male patients (29%) and 29 female patients (71%), with a mean age of 63 years (range, 41 to 87 years). The mean allograft length was 12 cm. All elbows had a minimum follow-up of 2 years (mean follow-up, 3.3 years). Patients were evaluated for visual analog scale pain scores, range of motion, the ability to perform select activities of daily living, and the Mayo Elbow Performance Score (MEPS). Outcomes including reoperations, complications, and revisions were noted. The most recent radiographs were evaluated for union at the allograft-host interface, failure of the plate-and-screw construct, or component loosening. Results The mean postoperative flexion was 124° (range, 60° to 150°) and the mean postoperative extension was 26° (range, 0° to 90°); the mean arc of motion was 99° (range, 30° to 150°). The mean MEPS was 58 points (range, 10 to 100 points). Two surgical procedures were complicated by neurologic deficits. The overall reoperation rate was 14 (34%) of 41. Of the 33 patients with complete radiographic follow-up, 12 (36%) had evidence of nonunion at the allograft-host interface with humeral component loosening, 1 (3%) had evidence of partial union, and 1 (3%) had ulnar stem loosening. Conclusions Revision TEA with a humeral APC using compression plating was successful in approximately two-thirds of the elbows. Further refinement of surgical techniques is needed to improve union rates in these complex cases. Level of Evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Adnan N. Cheema
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Ryan T. Conyer
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jacob J. Triplet
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Shawn W. O’Driscoll
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mark E. Morrey
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joaquín Sanchez-Sotelo
- Division of Shoulder and Elbow Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Lo S, Yonjan I, Rose A, Roditi G, Drury C, MacLean A. In search of the ideal periosteal flap for bone non-union: The chimeric fibula-periosteal flap. J Plast Reconstr Aesthet Surg 2023; 83:221-232. [PMID: 37285775 DOI: 10.1016/j.bjps.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/13/2023] [Accepted: 04/07/2023] [Indexed: 06/09/2023]
Abstract
Vascularised periosteal flaps may increase the union rates in recalcitrant long bone non-union. The fibula-periosteal chimeric flap utilises the periosteum raised on an independent periosteal vessel. This allows the periosteum to be inset freely around the osteotomy site, thereby facilitating bone consolidation. PATIENTS AND METHODS Ten patients underwent fibula-periosteal chimeric flaps (2016-2022) at the Canniesburn Plastic Surgery Unit, UK. Preceding non-union 18.6 months, with mean bone gap of 7.5 cm. Patients underwent preoperative CT angiography to identify the periosteal branches. A case-control approach was used. Patients acted as their own controls, with one osteotomy covered by the chimeric periosteal flap and one without, although in two patients both the osteotomies were covered using a long periosteal flap. RESULTS A chimeric periosteal flap was used in 12 of the 20 osteotomy sites. Periosteal flap osteotomies had a primary union rate of 100% (11/11) versus those without flaps at 28.6% (2/7) (p = 0.0025). Union occurred in the chimeric periosteal flaps at 8.5 months versus 16.75 months in the control group (p = 0.023). One case was excluded from primary analysis due to recurrent mycetoma. The number needed to treat = 2, indicating that 2 patients would require a chimeric periosteal flap to avoid one non-union. Survival curves with a hazard ratio of 4.1 were observed, equating to a 4 times higher chance of union with periosteal flaps (log-rank p = 0.0016). CONCLUSIONS The chimeric fibula-periosteal flap may increase the consolidation rates in difficult cases of recalcitrant non-union. This elegant modification of the fibula flap uses periosteum that is normally discarded, and this adds to the accumulating data supporting the use of vascularised periosteal flaps in non-union.
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Affiliation(s)
- Steven Lo
- Canniesburn Regional Plastic Surgery and Burns Unit, Glasgow Royal Infirmary, Glasgow G4 0SF, United Kingdom; School of Medicine, Dentistry and Nursing, University of Glasgow, G12 8QQ, United Kingdom.
| | - Indira Yonjan
- Canniesburn Regional Plastic Surgery and Burns Unit, Glasgow Royal Infirmary, Glasgow G4 0SF, United Kingdom
| | - Anna Rose
- Canniesburn Regional Plastic Surgery and Burns Unit, Glasgow Royal Infirmary, Glasgow G4 0SF, United Kingdom
| | - Giles Roditi
- Department of Radiology, Glasgow Royal Infirmary, Glasgow G4 0SF, United Kingdom
| | - Colin Drury
- Department of Orthopaedics, Glasgow Royal Infirmary, Glasgow G4 0SF, United Kingdom
| | - Angus MacLean
- Department of Orthopaedics, Glasgow Royal Infirmary, Glasgow G4 0SF, United Kingdom
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Guidi M, Guzzini M, Civitenga C, Lanzetti RM, Kim BS, Besmens IS, Riegger M, Lucchina S, Calcagni M, Perugia D. Multifactorial Analysis of Treatment of Long-Bone Nonunion with Vascularized and Nonvascularized Bone Grafts. J Hand Microsurg 2023; 15:106-115. [PMID: 37020609 PMCID: PMC10070005 DOI: 10.1055/s-0042-1748783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Introduction The purpose of the study was to evaluate the results of treatment of the nonunion of long bones using nonvascularized iliac crest grafts (ICGs) or vascularized bone grafts (VBGs), such as medial femoral condyle corticoperiosteal flaps (MFCFs) and fibula flaps (FFs). Although some studies have examined the results of these techniques, there are no reports that compare these treatments and perform a multifactorial analysis. Methods The study retrospectively examined 28 patients comprising 9 women and 19 men with an average age of 49.8 years (range: 16-72 years) who were treated for nonunion of long bones between April 2007 and November 2018. The patients were divided into two cohorts: group A had 17 patients treated with VBGs (9 patients treated with MFCF and 8 with FF), while group B had 11 patients treated with ICG. The following parameters were analyzed: radiographic patterns of nonunion, trauma energy, fracture exposure, associated fractures, previous surgeries, diabetes, smoking, age, and donor-site morbidity. Results VBGs improved the healing rate (HR) by 9.42 times more than the nonvascularized grafts. Treatment with VBGs showed a 25% decrease in healing time. Diabetes increased the infection rate by 4.25 times. Upper limbs showed 70% lower infection rate. Smoking among VBG patients was associated with a 75% decrease in the HR, and diabetes was associated with an 80% decrease. Conclusion This study reports the highest success rates in VBGs. The MFCFs seem to allow better clinical and radiological outcomes with less donor-site morbidity than FFs.
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Affiliation(s)
- Marco Guidi
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Matteo Guzzini
- Department of Orthopedics and Traumatology, S. Andrea Hospital, University of Rome “La Sapienza,” Rome, Italy
| | - Carolina Civitenga
- Department of Orthopedics and Traumatology, S. Andrea Hospital, University of Rome “La Sapienza,” Rome, Italy
| | | | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Inga Swantje Besmens
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Martin Riegger
- Department of Orthopedics and Traumatology, Lugano's Regional Hospital, Viganello, Switzerland
| | - Stefano Lucchina
- Hand Surgery Unit, Locarno Hand Center, Locarno's Regional Hospital, Locarno, Switzerland
| | - Maurizio Calcagni
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Dario Perugia
- Department of Orthopedics and Traumatology, S. Andrea Hospital, University of Rome “La Sapienza,” Rome, Italy
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DeKeyser GJ, Bailey TL, Higgins TF, Tyser AR. Treatment of Recalcitrant Femoral Shaft Nonunion With Medial Femoral Condyle Pedicled Autograft: Technical Trick. J Orthop Trauma 2022; 36:e80. [PMID: 34050083 DOI: 10.1097/bot.0000000000002186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 02/02/2023]
Abstract
SUMMARY Nonunited fractures of the femoral shaft and distal femur are usually successfully addressed with stabilization with or without autogenous bone grafting. For the small subset of these problems that prove recalcitrant to front-line treatment, a pedicled medial femoral condyle (MFC) bone flap can provide a source of vascularized autograft with minimal donor site morbidity. The MFC has gained recent widespread adoption as a free vascularized bone transfer, and here, we present a surgical technique and retrospective analysis of patients treated with a pedicled MFC technique. This serves as a useful treatment option for these difficult problems and may be especially helpful in low resource environments or where microsurgical anastomosis is not feasible.
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Affiliation(s)
- Graham J DeKeyser
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
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Mazzotta A, Stagni C, Rocchi M, Rani N, Del Piccolo N, Filardo G, Dallari D. Bone marrow aspirate concentrate/platelet-rich fibrin augmentation accelerates healing of aseptic upper limb nonunions. J Orthop Traumatol 2021; 22:21. [PMID: 34089398 PMCID: PMC8179859 DOI: 10.1186/s10195-021-00582-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 05/04/2021] [Indexed: 12/30/2022] Open
Abstract
Introduction Nonunions remain a significant burden in orthopedics, often afflicting young males of working age. Positive findings have been published using bone marrow aspirate concentrate (BMAC) and platelet-rich fibrin (PRF) for the treatment augmentation of lower limb nonunions. The aim of this study was to investigate if the treatment augmentation with BMAC and PRF can also accelerate the healing of nonunions of the upper limb. Materials and methods Sixty-eight patients (45 men, 23 women) affected by 75 nonunions of long bones of the upper limb were treated and divided into two groups. The first series was treated with standard surgery alone (group A); afterwards, the second series benefited from standard surgery with the addition of BMAC and PRF applied on lyophilized bone chips. Nonunions were classified radiographically according to the Weber–Cech method and prognostically using the Calori and Moghaddam scores. All patients were radiographically assessed at 1.5, 3, 6, 12, and 24 months of follow-up. Results Baseline demographic characteristics did not present differences between groups. No differences were documented in terms of complications (two in group A and three in group B). Significant differences were instead documented in terms of healing time. The first healing signs were observed 1.5 months after surgery in 90.7% of patients in group B and 34.4% of group A (p < 0.0005). At 1.5, 3, 6, and 12 months, a higher radiographic score was found for group B (all p < 0.0005), while no difference was found at final follow-up of 24 months (90.6% of group A and 97.7% of group B achieved radiological healing). Faster healing with BMAC/PRF augmentation was confirmed for all bones, as well as for the subgroup of patients affected by atrophic nonunions (p = 0.001). Conclusion This study showed the benefits of restoring both mechanical and biological aspects when addressing nonunions of the long bones of the upper limb. In particular, the association of BMAC and PRF to lyophilized bone chips was safe and able to accelerate healing time. These good results were confirmed for humerus, radius, and ulna sites, as well as for challenging atrophic nonunions of the upper limb.
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Affiliation(s)
- Alessandro Mazzotta
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Cesare Stagni
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Martina Rocchi
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy. .,, Via di Casaglia 28, 40135, Bologna, Italy.
| | - Nicola Rani
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Nicolandrea Del Piccolo
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy
| | - Giuseppe Filardo
- Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, via di Barbiano, 1/10, 40136, Bologna, Italy
| | - Dante Dallari
- Reconstructive Orthopaedic Surgery Innovative Techniques, Musculoskeletal Tissue Bank, IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli, 1, 40136, Bologna, Italy
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