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Roger de Oña I, Garcia Villanueva A, Garcia Lopez JI, Garcia de Lucas F. Versatility of the medial corticoperiosteal flap: from recalcitrant non-unions up to large bony defects. Arch Orthop Trauma Surg 2024; 144:2655-2663. [PMID: 38772929 DOI: 10.1007/s00402-024-05351-0] [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: 02/18/2024] [Accepted: 04/25/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Reconstructive microsurgery techniques using vascularized bone grafts have revolutionized the treatment of complex cases associated with recalcitrant non-unions or osteomyelitis. The medial femoral corticoperiosteal flap (MFCP flap) has emerged as a valuable option in bone reconstruction. Its clinical applications have been extended over the years considering this flap from non-unions with minimal bone lost, up to large intercalary defects of the upper and lower extremities. This article aims to present the clinical applications and outcomes of the MFCP flap in various reconstructive scenarios. METHODS Seventy-nine patients with persistent non-union and bone defects of the upper and lower limb were evaluated from June 2008 to October 2020. All of them were reconstructed with a corticoperiosteal flap from the medial femoral condyle in our hospital. Previous procedures, bone gap and type of flap used were recorded. Postoperative functional status was assessed with time of bone healing, complications and clinical final outcome. RESULTS Radiological evidence of bone union was observed at 4.09 months (range 2-9). Healing rate was 97% with periosteal corticocancellous flaps (PCC flaps) and 93% with corticoperiosteal flaps (CP flaps). Average follow-up was 14.5 months (range 5-28). There were no significant donor site complications. CONCLUSIONS The MFCP flap offers a versatile and reliable option for bone reconstruction. Its ability to provide vascularized bone tissue with low morbidity enhances the healing process and improves outcomes. The MFCP flap has been increasing its applications and it serves as a valuable option in the treatment of recalcitrant non-unions or bony defects irrespective of site and size up to 5 cm in the upper and lower extremities.
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Affiliation(s)
- Ignacio Roger de Oña
- Microsurgery Unit, Department of Orthopaedic Surgery, FREMAP Hospital Madrid, Carretera de Pozuelo 61, Majadahonda, 28222, Madrid, Spain
| | - Andrea Garcia Villanueva
- Microsurgery Unit, Department of Orthopaedic Surgery, FREMAP Hospital Madrid, Carretera de Pozuelo 61, Majadahonda, 28222, Madrid, Spain.
| | - Jose Ignacio Garcia Lopez
- Upper Limb Unit, Department of Orthopaedic Surgery, FREMAP Hospital Madrid, Carretera de Pozuelo 61, Majadahonda, 28222, Madrid, Spain
| | - Fernando Garcia de Lucas
- Upper Limb Unit, Department of Orthopaedic Surgery, FREMAP Hospital Madrid, Carretera de Pozuelo 61, Majadahonda, 28222, Madrid, Spain
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2
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Das De S. The Role of Microsurgery in Coverage of Defects of the Hand. Hand Clin 2024; 40:221-228. [PMID: 38553093 DOI: 10.1016/j.hcl.2023.10.003] [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] [Indexed: 04/02/2024]
Abstract
Soft tissue defects of the hand may result from trauma, infection, vascular disease, and after resection of tumors. Microsurgery has evolved to a stage where it is relatively commonplace today but procedures such as free flaps still incur significant time, manpower, cost, and material resources. The aim of this article is to articulate the specific situations in hand reconstruction when microsurgery is superior to nonmicrosurgical reconstructive options. The benefits of microsurgical reconstruction include a variety of important metrics, such as improved function, better tissue match, less donor site morbidity, and reduced downtime for the patient.
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Affiliation(s)
- Soumen Das De
- Department of Hand and Reconstructive Microsurgery, National University Health System, 1E Kent Ridge Road, Singapore 119228.
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3
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Boretto JG, Holc F, Gallucci GL, Donndorff A, Rellán I, De Carli P. Fibula flap in upper extremity segmental/critical size bone defects fixed with locking plates. Single-institution observational cohort. Injury 2023; 54 Suppl 6:110737. [PMID: 37072279 DOI: 10.1016/j.injury.2023.04.024] [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: 02/28/2023] [Revised: 04/10/2023] [Accepted: 04/12/2023] [Indexed: 04/20/2023]
Abstract
INTRODUCTION Management of bone defects in the upper extremity can vary depending on the size and location of the defect. Large defects may require complex reconstruction techniques. Vascularized bone grafts, mainly free vascularized fibula flap (FVFF), have many advantages in the treatment of bone or osteocutaneous defects. However, complications such as graft fracture are the most common, with a free fibula flap for bone defects in the upper extremity. This study aimed to describe the results and complications associated with the treatment of posttraumatic bone defects in the upper extremity using FVFF. We hypothesized that performing osteosynthesis using locking plates would prevent or reduce the fracture of the fibula flap MATERIALS AND METHODS: This was a retrospective single-centre cohort study. Patients with segmental bone defects caused by trauma who underwent reconstructive surgery with FVFF fixed with locking compression plates (LCP) between January 2014 and 2022 were included. Demographic variables and preoperative data, such as bone defect, location, and time until reconstruction, were collected. Bone defects were classified according to the Testworth classification. Intraoperative variables included the length of the FVFF, type of graft (osteocutaneous or not), type and technique of arterial and venous sutures, number of veins used as output flow, and the osteosynthesis technique used. RESULTS Ten patients were included (six humerus, three ulna, and one radius). All patients had critical-size bone defects, and nine patients had a history of infection. In 9 of 10 patients, bone fixation was performed with a bridge LCP and in one patient with two LCP plates. In eight cases, the FVFF was osteocutaneous. All the patients showed bone healing at the end of the follow-up period. There was one early complication, donor site wound dehiscence, and two long-term complications (proximal radioulnar synostosis and soft-tissue defect). CONCLUSION A high rate of bone union with a low rate of complications can be obtained with an FVFF in upper extremity segmental/critical-size bone defects. Rigid fixation with locking plates avoids stress fractures of the grafts, mainly in humeral reconstruction. However, in these cases, a bridge plate should be used.
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Affiliation(s)
- Jorge G Boretto
- Hand and Upper Extremity Department, Instituto de Ortopedia y Traumatología "Prof. Dr. Carlos Ottolenghi". Hospital Italiano de Buenos Aires, Argentina.
| | - Fernando Holc
- Hand and Upper Extremity Department, Instituto de Ortopedia y Traumatología "Prof. Dr. Carlos Ottolenghi". Hospital Italiano de Buenos Aires, Argentina.
| | - Gerardo L Gallucci
- Hand and Upper Extremity Department, Instituto de Ortopedia y Traumatología "Prof. Dr. Carlos Ottolenghi". Hospital Italiano de Buenos Aires, Argentina.
| | - Agustín Donndorff
- Hand and Upper Extremity Department, Instituto de Ortopedia y Traumatología "Prof. Dr. Carlos Ottolenghi". Hospital Italiano de Buenos Aires, Argentina.
| | - Ignacio Rellán
- Hand and Upper Extremity Department, Instituto de Ortopedia y Traumatología "Prof. Dr. Carlos Ottolenghi". Hospital Italiano de Buenos Aires, Argentina.
| | - Pablo De Carli
- Hand and Upper Extremity Department, Instituto de Ortopedia y Traumatología "Prof. Dr. Carlos Ottolenghi". Hospital Italiano de Buenos Aires, Argentina.
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4
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Catena N, Baldrighi C, Jester A, Soldado F, Farr S. Microsurgery in pediatric upper limb reconstructions: An overview. J Child Orthop 2022; 16:241-255. [PMID: 35992521 PMCID: PMC9382710 DOI: 10.1177/18632521221106390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/13/2022] [Indexed: 02/03/2023] Open
Abstract
The use of microsurgery has spread during the last decades, making resolvable many complex defects considered hitherto inapproachable. Although the small vessel diameter in children was initially considered a technical limitation, the increase in microsurgical expertise over the past three decades allowed us to manage many pediatric conditions by means of free tissue transfers. Pediatric microsurgery has been shown to be feasible, gaining a prominent place in the treatment of children affected by limb malformations, tumors, nerve injuries, and post-traumatic defects. The aim of this current concepts review is to describe the more frequent pediatric upper limb conditions in which the use of microsurgical reconstructions should be considered in the range of treatment options.
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Affiliation(s)
- Nunzio Catena
- Reconstructive Surgery and Hand Surgery
Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy,Nunzio Catena, Reconstructive Surgery and
Hand Surgery Unit, IRCCS Istituto Giannina Gaslini, Largo G. Gaslini 5, 16121
Genova, Italy.
| | - Carla Baldrighi
- Children’s Hand and Upper Limb Service,
Department of Plastic Surgery, Birmingham Children’s Hospital NHS Foundation Trust,
Birmingham, UK
| | - Andrea Jester
- Children’s Hand and Upper Limb Service,
Department of Plastic Surgery, Birmingham Children’s Hospital NHS Foundation Trust,
Birmingham, UK
| | - Francisco Soldado
- Pediatric Hand, Nerve and Microsurgery
Institute, Vall d’Hebron Instituto de Oncologia, Barcelona, Spain
| | - Sebastian Farr
- Pediatric Orthopedics and Foot and
Ankle Surgery, Orthopedic Hospital Speising, Vienna, Austria
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5
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Guzzini M, Lupariello D, Argento G, Arioli L, Ferretti A. Vascular and Bone Regeneration of the Donor Site After Corticoperiosteal Flap From the Medial Femoral Condyle. Hand (N Y) 2022; 17:366-372. [PMID: 32686510 PMCID: PMC8984706 DOI: 10.1177/1558944720930299] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The aim of this study was to evaluate the morbidity and regeneration of descending genicular artery and bone on the donor site, the medial condyle of the femur, after harvesting the corticoperiosteal flap and to report the clinical, functional, and radiographic outcomes of the treatment of atrophic nonunions of upper limb with corticoperiosteal vascularized flap at 5-year follow-up. Methods: From January 2011 to January 2018, 36 patients (average age of 45.8 years) were enrolled and evaluated with clinical and radiographic follow-up (average time of 66 months). In 20 patients, magnetic resonance angiography was also performed preoperatively and postoperatively to investigate the fate of the descending genicular artery after harvesting the corticoperiosteal flap. Results: Radiographic evaluation demonstrated a success rate of 94.4% (average time of bone healing of 5.2 months). At the recipient site, clinical evaluation showed excellent results in 75% to 80% of cases, and at the donor site, no statistical differences were found between before and after surgery clinical condition. In all patients who underwent magnetic resonance imaging, images showed a complete recovery of the blood supply of the medial femoral condyle. Conclusions: Medial condyle corticoperiosteal flap represents a valid choice for the treatment of upper limb nonunions. This technique brings a very low morbidity on the donor site, with complete restoration of blood supply and bone tissue. The limit of this flap is its low mechanical support, which suggests performing this technique especially for the treatment of upper limb nonunions.
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Affiliation(s)
- Matteo Guzzini
- S. Andrea Hospital, University of Rome
“La Sapienza”, Rome, Italy
| | | | - Giuseppe Argento
- S. Andrea Hospital, University of Rome
“La Sapienza”, Rome, Italy
| | - Leopoldo Arioli
- S. Andrea Hospital, University of Rome
“La Sapienza”, Rome, Italy,Leopoldo Arioli, Unit of Orthopedics and
Traumatology, S. Andrea Hospital, University of Rome “La Sapienza”, Via di
Grottarossa, 1035-1039, 00189 Rome, Italy.
| | - Andrea Ferretti
- S. Andrea Hospital, University of Rome
“La Sapienza”, Rome, Italy
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Karunaratne YG, Davies J, Carty CP, Graham D. Chronic Recurrent Multifocal Osteomyelitis of the Hand: A Rare Pediatric Condition. Hand (N Y) 2021; 16:213-222. [PMID: 31137982 PMCID: PMC8041419 DOI: 10.1177/1558944719846599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Chronic recurrent multifocal osteomyelitis (CRMO) is a rare autoinflammatory condition characterized by bone pain and swelling, secondary to sterile bone osteolytic lesions. Estimated incidence is 1:1 000 000, with ~2% involving the hand. We present a case series of CRMO of the hand and review the available literature, with the aim of educating and raising awareness of this condition. Methods: A retrospective chart review was conducted for all patients presenting to the institution diagnosed with CRMO involving the hands. Subsequently, a literature review was performed. Results/Case Series: Three cases of CRMO of the hand were identified. Age ranged from 20 months to 6 years, with 1 female. Time from presentation to diagnosis ranged from 3 to 15 months. Two had a single lesion, with the remaining patient having a second lesion on full-body magnetic resonance imaging (MRI). Three lesions involved phalanges, and one involved a metacarpal. Two received antibiotics without improvement prior to diagnosis. After diagnosis of CRMO, two received intravenous pamidronate. They both later showed improvement on MRI. Conclusion: CRMO is a rare disease with scarce literature to guide management. We present a series of CRMO specifically of the hand. The cases educate key stakeholders, raise awareness of the diagnosis, and illustrate challenging aspects of managing these patients. This includes the special functional and anatomical consideration essential in managing cases involving the hand.
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Affiliation(s)
| | | | | | - David Graham
- Queensland Children’s Hospital, Brisbane, Australia
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7
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Deng AD, Innocenti M, Arora R, Gabl M, Tang JB. Vascularized Small-Bone Transfers for Fracture Nonunion and Bony Defects. Clin Plast Surg 2020; 47:501-520. [PMID: 32892797 DOI: 10.1016/j.cps.2020.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Vascularized small-bone grafting is an efficient and often necessary surgical approach for nonunion or necrosis of several bones in particular sites of the body, including scaphoid, lunate, distal ulna, and clavicle. The medial femoral condyle is an excellent graft source that can be used in treating scaphoid, ulna, clavicle, or lower-extremity bone defects, including nonunion. Vascularized bone grafting to the small bones, particularly involving reconstruction of damaged cartilage surfaces, should enhance subchondral vascular supply and help prevent cartilage regeneration. Vascularized osteoperiosteal and corticoperiosteal flaps are useful for treating nonunion of long bones.
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Affiliation(s)
- Ai Dong Deng
- Department of Hand Surgery, Affiliated Hospital of Nantong University, 20 West Temple Road, Nantong 226001, Jiangsu, China
| | - Marco Innocenti
- Plastic Surgery, University of Florence Careggi University Hospital, CTO, Largo Palagi 150139, Florence, Italy
| | - Rohit Arora
- Department of Trauma Surgery and Sports Medicine, Medical University Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Markus Gabl
- Department of Trauma Surgery and Sports Medicine, Medical University Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Jin Bo Tang
- Department of Hand Surgery, Affiliated Hospital of Nantong University, 20 West Temple Road, Nantong 226001, Jiangsu, China.
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8
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Xu C, Orec R, Mathy JA. Both Bone Forearm Infected Nonunion: Report of a One-Bone Free Fibula Flap Salvage and Literature Review. Hand (N Y) 2020; 15:NP51-NP56. [PMID: 31215792 PMCID: PMC7370380 DOI: 10.1177/1558944719857168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Both bone forearm infective nonunions represent a rare but functionally limb threatening condition. Method: We report a successful salvage of a severe near total both bone diaphysial osteomyelitis by conversion to a one-bone forearm with free fibula flap. A literature review on forearm salvage addressing both bone defects was performed. Results: Bony union was achieved at 4 months with a highly functional extremity salvage in our case. Conclusion: While very little prior experience has been reported for long segmental both bone forearm infected nonunions, we report of this highly satisfactory salvage using one-bone free tissue transfer strategy. We also provided our literature review with history, indication and evolution of individualized treatment options for this difficult surgical condition.
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Affiliation(s)
- Chris Xu
- Middlemore Hospital, Auckland, New Zealand
| | - Rob Orec
- Middlemore Hospital, Auckland, New Zealand
| | - Jon A Mathy
- Middlemore Hospital, Auckland, New Zealand,School of Medicine, The University of Auckland, Auckland, New Zealand,Jon A Mathy, Auckland Regional Plastic, Reconstructive & Hand Surgery Unit, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland 1640, New Zealand.
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9
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Lim Z, Strike SA, Puhaindran ME. Sarcoma of the Lower Limb: Reconstructive Surgeon's Perspective. Indian J Plast Surg 2019; 52:55-61. [PMID: 31456613 PMCID: PMC6664852 DOI: 10.1055/s-0039-1688101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Management of sarcomas in the lower extremities have evolved from amputations to limb-preserving surgeries with evidence to support that they have equal overall survival, albeit with better functional outcome. The challenge of reconstruction lies in providing a durable, functional, and aesthetically pleasing limb. However, limb-preserving intention should not delay interventions that provide a survival benefit such as chemotherapy and radiotherapy. The advent of radiotherapy and chemotherapy also has implications on wound healing and should be considered during the reconstructive process. This article reviews the methodical approach, reconstructive strategies, and considerations for the reconstructive surgeon with respect to the lower extremity after sarcoma excision.
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Affiliation(s)
- Zhixue Lim
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore, Singapore
| | - Sophia A Strike
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore, Singapore
| | - Mark E Puhaindran
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore, Singapore
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10
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Pedicled Vascularized Bone Graft of the Distal Radius for Recalcitrant Nonunion of the Distal Humerus. J Orthop Trauma 2018; 32:e394-e399. [PMID: 30247283 DOI: 10.1097/bot.0000000000001255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To analyze the clinical and radiological outcomes of a series of patients treated with a pedicled vascularized bone graft (VBG) of the distal radius for the treatment of recalcitrant atrophic nonunions of the distal humerus. DESIGN Retrospective clinical study. SETTING University-affiliated teaching hospital. PATIENTS Fifteen patients with supracondylar humeral atrophic nonunions with at least 3 previous failed surgical interventions were included. INTERVENTION Debridement of the distal humerus nonunion through a posterior elbow approach with provisional fixation was performed. Then, a pedicled VBG was harvested from the distal radius and tunneled back into the humeral bone defect. Iliac crest was used as needed, both for the nonunion and to stabilize the radius. Finally, definitive fixation with 2 locked plates was performed. MAIN OUTCOME MEASUREMENTS Radiological results, complications, elbow range of motion, Mayo elbow performance score, and subjective pain were evaluated. RESULTS There were 4 male and 11 female patients, with a mean age of 51 (range, 28-73) years. The mean follow-up period was 46 (range, 37-72) months with a minimum of 3 years. Radiological consolidation was achieved in all patients. Elbow range of motion was >100 degrees in 11 patients and between 50 and 100 degrees in 4 patients. Preoperative Mayo scores were poor in all patients. At final follow-up, Mayo scores were excellent in 3, good in 9, and fair in 3 patients. The mean postoperative visual analog scale score was 1.2 (range 0-3). CONCLUSIONS Pedicled VBG of the distal radius was shown to be a reliable and effective alternative for the treatment of recalcitrant atrophic nonunions of the distal humerus, when other methods have failed. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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11
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Zaidenberg EE, Martinez E, Zaidenberg CR. Vascularized Distal Radius Bone Graft for Treatment of Ulnar Nonunion. J Hand Surg Am 2018; 43:685.e1-685.e5. [PMID: 29650375 DOI: 10.1016/j.jhsa.2018.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 03/06/2018] [Indexed: 02/02/2023]
Abstract
Various methods have been reported to treat forearm nonunions with good results. However, in the presence of infection, inadequate vascularity of surrounding tissues, or failed prior grafts, vascularized bone grafts are a valid alternative. We describe the surgical technique to obtain distal radius vascularized bone graft pedicled on the radial artery (RA) and its clinical application in 1 case of an ulnar nonunion. We studied the surgical technique in 12 freshly injected cadavers. In the distal forearm, the RA provides several periosteal branches to supply the distal radius metaphysis. These vessels are located between the distal insertion of the brachioradialis and the deep surface of the radial half of the pronator quadratus. A 6-cm vascularized bone graft can be harvested from the radius, and dissection of the RA enables a long pedicle with a wide arc of rotation readily able to reach the proximal part of the ulna. The present technique is a reproducible alternative that allows the treatment of bone defects up to 6 cm, without the potential technical difficulties of a free bone flap.
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Affiliation(s)
- Ezequiel Ernesto Zaidenberg
- Anatomy Department, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina; Department of Orthopaedics, Italian Hospital of Buenos Aires, Buenos Aires, Argentina.
| | - Ezequiel Martinez
- Anatomy Department, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
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12
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Guzzini M, Lanzetti RM, Perugia D, Lupariello D, Vadalà A, Guidi M, Civitenga C, Ferretti A. The treatment of long bones nonunions of upper limb with microsurgical cortico-periosteal free flap. Injury 2017; 48 Suppl 3:S66-S70. [PMID: 29025613 DOI: 10.1016/s0020-1383(17)30661-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE Medial condyle corticoperiosteal flap is an emerging option for the treatment of upper limb non-infected nonunions. The hypothesis of our study is that corticoperiosteal flap could be an effective and safe procedure for the treatment of upper limb non-infected nonunions, evaluating radiographic and clinical outcome. METHODS We enrolled 14 patients who underwent vascularized medial femoral condyle corticoperiosteal free flaps from January 2011 to December 2014. All patients were clinically evaluated (VAS, DASH) before surgery and at 6 and 12 months post surgery. The radiographic evaluation was performed every 30 days until the complete healing and at 12-month follow-up. We also recorded the range of motion pre and post surgery at the donor site. RESULTS All nonunion sites healed primarily at an average time period of 5.2 months ±1. Preoperative DASH score was 70 ± 15.6; at 6 month follow-up was 21.51 ± 10.63; at 12 month follow-up 18.0 ± 9.9. Preoperative VAS was 7.05 ± 2; at 6-month follow-up was 2.1 ± 2; at 12-month follow-up was 1.8 ± 1.16. Statistical analysis showed a significant difference (p <0.001) about the preoperative and the postoperative VAS and DASH evaluation both at 6 and 12-month follow-up, but we did not record any statistical difference between the 6-month and 12-month follow-up. At the donor site, the mean VAS score was 2 ± 2.1 at seven days post operatively. All patients restore the full ROM at 7 days post surgery. CONCLUSIONS Vascularized medial condyle corticoperiosteal free flap represents an effective and safe procedure for the treatment of upper limb nonunions.
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Affiliation(s)
- Matteo Guzzini
- Unit of Orthopedics and Traumatology, S. Andrea Hospital, "La Sapienza" University, Rome, Italy; Corresponding author at: Unit of Orthopedics and Traumatology, S. Andrea Hospital, Via grottarossa 1053, 00100, Rome, Italy
| | - Riccardo Maria Lanzetti
- Unit of Orthopedics and Traumatology, S. Andrea Hospital, "La Sapienza" University, Rome, Italy; Corresponding author at: Unit of Orthopedics and Traumatology, S. Andrea Hospital, Via grottarossa 1053, 00100, Rome, Italy
| | - Dario Perugia
- Unit of Orthopedics and Traumatology, S. Andrea Hospital, "La Sapienza" University, Rome, Italy; Corresponding author at: Unit of Orthopedics and Traumatology, S. Andrea Hospital, Via grottarossa 1053, 00100, Rome, Italy
| | - Domenico Lupariello
- Unit of Orthopedics and Traumatology, S. Andrea Hospital, "La Sapienza" University, Rome, Italy; Corresponding author at: Unit of Orthopedics and Traumatology, S. Andrea Hospital, Via grottarossa 1053, 00100, Rome, Italy..
| | - Antonio Vadalà
- Unit of Orthopedics and Traumatology, S. Andrea Hospital, "La Sapienza" University, Rome, Italy; Corresponding author at: Unit of Orthopedics and Traumatology, S. Andrea Hospital, Via grottarossa 1053, 00100, Rome, Italy
| | - Marco Guidi
- Unit of Orthopedics and Traumatology, S. Andrea Hospital, "La Sapienza" University, Rome, Italy; Corresponding author at: Unit of Orthopedics and Traumatology, S. Andrea Hospital, Via grottarossa 1053, 00100, Rome, Italy
| | - Carolina Civitenga
- Unit of Orthopedics and Traumatology, S. Andrea Hospital, "La Sapienza" University, Rome, Italy; Corresponding author at: Unit of Orthopedics and Traumatology, S. Andrea Hospital, Via grottarossa 1053, 00100, Rome, Italy
| | - Andrea Ferretti
- Unit of Orthopedics and Traumatology, S. Andrea Hospital, "La Sapienza" University, Rome, Italy; Corresponding author at: Unit of Orthopedics and Traumatology, S. Andrea Hospital, Via grottarossa 1053, 00100, Rome, Italy
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13
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Boretto JG, Fernandez-Fernandez D, Gallucci G, De Carli P. The Fourth Extensor Compartment Artery Vascularized Bone Graft of the Distal Radius for CMC Fusion in the Treatment of Carpal Boss: A Case Report. Hand (N Y) 2017; 12:NP88-NP91. [PMID: 28832203 PMCID: PMC5684924 DOI: 10.1177/1558944716672203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Carpometacarpal joints can be affected by traumatic or degenerative pathology. Although different techniques have been described to treat these conditions, most authors agree that arthrodesis is an effective treatment modality. Vascularized bone grafts of the distal radius have been used to treat carpal conditions, such as scaphoid nonunion or Kiënbock disease, and they have been shown to have several advantages over nonvascularized bone grafts. METHODS We report a case of a carpal boss in a female patient treated with an arthrodesis of the second and third carpometacarpal joints by using the fourth extensor compartment artery vascularized bone graft. RESULTS At 6 weeks postoperative bone union was achieved. At 2 years follow-up the patient was able to perform daily life activities without pain. CONCLUSIONS The fourth ECA VBG with reverse blood flow from the dorsal intercarpal arch allowed the graft to reach the CMC. A solid fusion was obtained at 6 weeks due to the biological advantage of the VBG.
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Affiliation(s)
- Jorge G. Boretto
- Hospital Italiano de Buenos Aires, Argentina,Jorge G. Boretto, Hand and Upper Extremity Surgery Department, Prof. Dr. Carlos Ottolenghi Institute, Orthopaedic and Traumatology Service, Hospital Italiano de Buenos Aires, Potosí 4247, Ciudad Autónoma de Buenos Aires C1199ACK, Argentina.
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Henn D, Abouarab MH, Hirche C, Hernekamp JF, Schmidt VJ, Kneser U, Kremer T. Sequential chimeric medial femoral condyle and anterolateral thigh flow-through flaps for one-stage reconstructions of composite bone and soft tissue defects: Report of three cases. Microsurgery 2017; 37:824-830. [DOI: 10.1002/micr.30209] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 07/15/2017] [Accepted: 07/21/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Dominic Henn
- Department of Hand; Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg; Heidelberg Germany
| | - Mohamed H. Abouarab
- Department of Hand; Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg; Heidelberg Germany
- Department of Plastic and Reconstructive Surgery and Burns; Faculty of Medicine, University of Alexandria; Alexandria Egypt
| | - Christoph Hirche
- Department of Hand; Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg; Heidelberg Germany
| | - Jochen F. Hernekamp
- Department of Hand; Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg; Heidelberg Germany
| | - Volker J. Schmidt
- Department of Hand; Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg; Heidelberg Germany
| | - Ulrich Kneser
- Department of Hand; Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg; Heidelberg Germany
| | - Thomas Kremer
- Department of Hand; Plastic, and Reconstructive Surgery, BG Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg; Heidelberg Germany
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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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Hamada Y, Hibino N, Kobayashi A. Expanding the utility of modified vascularized femoral periosteal bone-flaps: An analysis of its form and a comparison with a conventional-bone-graft. J Clin Orthop Trauma 2014; 5:6-17. [PMID: 25983463 PMCID: PMC4009458 DOI: 10.1016/j.jcot.2014.01.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 01/12/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Vascularized medial femoral condyle (MFC) corticoperiosteal bone-flap is a well-accepted technique when dealing with tissue defects or infection. Its role in refractory conditions and in the possible use for options concerning modifications of this bone-flap compared to a conventional iliac bone graft (conventional-graft) are rarely discussed. METHODS We reviewed 21 consecutive cases concerning alternatives with some modifications of original MFC bone-flap surgery used to treat refractory conditions with bone defects, necrosis, or infection in the extremities. We present our devised approaches for this boneflap, and especially modifications of the grafted bone (including strut bone, perforator to the vastus medialis muscle, and the use of one vascular pedicle for some bone flaps) as well as the combined use of artificial bone as hybrid bone transplantation. We also compared the clinical results of 21 cases that received a conventional-graft. RESULTS AND CONCLUSIONS Following flap placement, 100% of the nonunion sites healed in an average of 2 months, which was significantly shorter than 5.5 months for the conventional-graft. The results showed the expanding possibility for options with regard to the form and options of this bone-flap as well as the shortening the duration of treatment, especially at the site of an infected distal tibia, insertion of the Achilles tendon on the posterior aspect of calcaneal osteomyelitis, distal end of the clavicle, clavicle or forearm with a bone defect, small bones with refractory conditions, and a femur without implant failure. However, it was not efficient for treating a forearm without bone defect.
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Affiliation(s)
- Yoshitaka Hamada
- Department of Orthopedics, Tokushima Prefectural Central Hospital, 1-10-3, Kuramoto-cho, Tokushima 770-8539, Japan,Corresponding author. Tel.: +81 88 631 7151; fax: +81 88 631 8354. http://www.tph.gr.jp/kenchu/
| | - Naohito Hibino
- Department of Orthopedics, Tokushima Naruto Hospital, Tokushima, Japan
| | - Anna Kobayashi
- Center for Clinical Education, Tokushima Prefectural Central Hospital, Tokushima, Japan
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Hasan SA, Alla S, Yuen JC. Traumatic extrusion of 13-cm segment of humerus and complete transection of ulnar nerve treated with vascularized fibular graft and acute nerve repair: case report. J Shoulder Elbow Surg 2013; 22:e17-22. [PMID: 24138822 DOI: 10.1016/j.jse.2013.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 07/26/2013] [Accepted: 08/05/2013] [Indexed: 02/01/2023]
Affiliation(s)
- S Ashfaq Hasan
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA.
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Reconstruction of a tibial defect with a previously fractured fibula including the fractured segment as a free osteoseptocutaneous flap. Ann Plast Surg 2013; 73:402-4. [PMID: 23851368 DOI: 10.1097/sap.0b013e31827fb387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Reconstruction of major bone defects using free fibular transfer provides a good biological option in unsound situations. Most authors recommend selection of the recipient blood vessels outside the zone of injury to achieve successful free fibular transfer. Occasionally, in polytraumatized patients, the surgeon has to use a previously fractured fibula as a graft, with increased risk of inclusion of the injury zone that may lead to failure. METHODS We report a rare case of successful reconstruction of a large tibial defect using a previously fractured fibula as a free osteoseptocutaneous flap. The innovative point in our case is the inclusion of the fracture site within the utilized segment, which to our knowledge has never been reported. CONCLUSIONS As long as the microsurgical principles are adhered to, the effect of the zone of injury on the graft viability should not be overwhelming.
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Abstract
Large bone defects in the upper limb pose many challenges in reconstructive surgery. Conventional and innovative methods have been described, employing the use of microsurgical and non-microsurgical techniques to overcome both bony and soft tissue defects. This article reviews the success and pitfalls of different techniques of reconstruction of large bone defects in the upper limb, including microsurgical transfer of the free vascularised fibula graft as a diaphyseal bone replacement and as a hemivascularised joint transplant, and non-microsurgical options using conventional bone grafting, the induced membrane technique and the role of callotatic distraction-lengthening procedures.
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Affiliation(s)
- Aaron W T Gan
- Department of Hand & Reconstructive Microsurgery, National University Hospital, NUHS Tower Block, Level 11, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Mark E Puhaindran
- Department of Hand & Reconstructive Microsurgery, National University Hospital, NUHS Tower Block, Level 11, 1E Kent Ridge Road, Singapore 119228, Singapore.
| | - Robert W H Pho
- Department of Hand & Reconstructive Microsurgery, National University Hospital, NUHS Tower Block, Level 11, 1E Kent Ridge Road, Singapore 119228, Singapore
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Del Piñal F, Studer A, Thams C, Moraleda E. Sigmoid notch reconstruction and limited carpal arthrodesis for a severely comminuted distal radius malunion: case report. J Hand Surg Am 2012; 37:481-5. [PMID: 22305723 DOI: 10.1016/j.jhsa.2011.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 12/04/2011] [Accepted: 12/07/2011] [Indexed: 02/02/2023]
Abstract
We present the case of a young patient with a severely comminuted, malunited, intra-articular distal radius fracture and complete disruption of the sigmoid notch. We reconstructed the malunited distal radioulnar joint by osteotomy and repositioning the displaced sigmoid notch fragments through a combined dorsal and volar approach. At the same time, we carried out a radioscapholunate arthrodesis with distal scaphoid excision. We used a free vascularized corticoperiosteal flap from the medial femoral condyle to span the massive bone defect in the radius to obtain union. At the 2.5-year follow-up, the patient had essentially normal function of the distal radioulnar joint (painless, with 85° of active pronation and 75° of supination). He resumed work as a bricklayer without limitations. We conclude that sigmoid notch reconstruction by osteotomy is worthwhile in the setting of malunited distal radius whether or not the radiocarpal joint is reconstructable.
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Affiliation(s)
- Francisco Del Piñal
- Department of Hand and Plastic Surgery, Hospital Mutua Montañesa, Instituto de Cirugía Plástica y de la Mano, Santander, Spain.
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Rodríguez-Vegas J, Delgado-Serrano P. Corticoperiosteal flap in the treatment of nonunions and small bone gaps: Technical details and expanding possibilities. J Plast Reconstr Aesthet Surg 2011; 64:515-27. [DOI: 10.1016/j.bjps.2010.06.035] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 05/21/2010] [Accepted: 06/18/2010] [Indexed: 10/19/2022]
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Hollenbeck ST, Komatsu I, Woo S, Schoeman M, Yang J, Erdmann D, Levin LS. The current role of the vascularized-fibular osteocutaneous graft in the treatment of segmental defects of the upper extremity. Microsurgery 2011; 31:183-9. [DOI: 10.1002/micr.20703] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Larsen M, Friedrich PF, Bishop AT. A modified vascularized whole knee joint allotransplantation model in the rat. Microsurgery 2011; 30:557-64. [PMID: 20842706 DOI: 10.1002/micr.20800] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Previous papers have shown surgical neoangiogenesis to allow long-term bone allotransplant survival without immunosuppression. Whole joint composite tissue allotransplants (CTA) might be treated similarly. A novel rat knee CTA model is described for further study of the roles of neoangiogensis in joint allotransplant survival and adjustment of immunosuppression. Microvascular knee CTA was performed in nine rats across a major histocompatibility barrier with both pedicle repair and implantation of host-derived arteriovenous ("a/v") bundles. In the control group (N = 3), the pedicle was ligated. Immunosuppression was given daily. Joint mobility, weight-bearing, pedicle patency, bone blood flow, and sprouting from a/v bundles were assessed at 3 weeks. All but the nonrevascularized control knees had full passive motion and full weight bearing. One nutrient pedicle thrombosed prematurely. Blood flow was measurable in transplants with patent nutrient pedicles. Implanted a/v bundles produced new vascular networks on angiography. This new rat microsurgical model permits further study of joint allotransplantation. Patency of both pedicles and implanted a/v bundles was maintained, laying a foundation for future studies.
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Affiliation(s)
- Mikko Larsen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Vascularized genicular osseous-periosteal flap for pseudarthrosis of the proximal phalanx of the little finger: a case report. Hand (N Y) 2011; 6:98-101. [PMID: 22379448 PMCID: PMC3041880 DOI: 10.1007/s11552-010-9299-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This study describes pseudoarthrosis of the proximal phalanx of the little finger and its successful treatment using a free vascularized genicular osseous-periosteal flap. Since this thin and pliable flap can be harvested as a small vascularized unit, it is ideal for the treatment of phalangeal pseudoarthrosis.
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[Fractures of the extremities with severe open soft tissue damage. Initial management and reconstructive treatment strategies]. Unfallchirurg 2011; 113:647-70; quiz 671-2. [PMID: 20680241 DOI: 10.1007/s00113-010-1801-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The successful management of open extremity injuries continues to represent a surgical challenge requiring a structured and multidisciplinary treatment concept. The treatment strategy depends on specific parameters, including the overall injury severity, life threatening trauma components, the degree oft soft tissue injury, the ischemia time, the contamination of the wound as well as the age and accompanying diseases of the patient. The treatment of fractures with a high-grade open soft tissue injury is guided by the severity of soft tissue damage including neurovascular damages, type of the fracture, overall state of the patient and is based on a clearly defined reconstructive algorithm sequentially employing initial wound treatment (debridement), stabilisation of the fracture and soft tissue coverage. The initial wound management includes radical and serial debridements and vessel reconstruction, followed by the gradual reconstruction of bone, tendons and nerves and a subsequent plastic soft tissue coverage.The sequential and priority-orientated implementation of these treatment steps is decisive for the long term outcome, which ideally results in an regular healing of bone and soft tissue without the presence of infection and good regain of extremity function.
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Guzzetti T, Thione A. Delayed successful free fibula flap for treatment of complex arm gunshot wound--a case report. HAND SURGERY : AN INTERNATIONAL JOURNAL DEVOTED TO HAND AND UPPER LIMB SURGERY AND RELATED RESEARCH : JOURNAL OF THE ASIA-PACIFIC FEDERATION OF SOCIETIES FOR SURGERY OF THE HAND 2010; 15:35-39. [PMID: 20422725 DOI: 10.1142/s0218810410004448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Revised: 11/27/2009] [Accepted: 01/15/2010] [Indexed: 05/29/2023]
Abstract
More than 25% of unintentional gunshot injuries and more than 15% of intentional gunshot injuries involve extremities. In these patients, early acute multidisciplinary treatment is essential and critical to achieve a satisfactory mobility and composite wounds repair. We hereby report a logistic delayed successful treatment of a complex arm gunshot wound with a free fibula flap. The significance of this case report is related to the necessity of emphasising the organised and multidisciplinary approach required to cure these patients in the proper way from a surgical and medical point of view.
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Jupiter JB, Fernandez DL, Levin LS, Wysocki RW. Reconstruction of posttraumatic disorders of the forearm. J Bone Joint Surg Am 2009; 91:2730-9. [PMID: 19884450 DOI: 10.2106/00004623-200911000-00027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jesse B Jupiter
- Hand and Upper Limb Service, Massachusetts General Hospital, Yawkey Building, Suite 2100, 55 Parkman Street, Boston, MA 02114, USA.
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