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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 2024:10.1007/s00402-024-05351-0. [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] [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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Scampa M, Mégevand V, Martineau J, Schaefer DJ, Kalbermatten DF, Oranges CM. Medial Femoral Condyle Free Flap: A Systematic Review and Proportional Meta-analysis of Applications and Surgical Outcomes. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5708. [PMID: 38596574 PMCID: PMC11000773 DOI: 10.1097/gox.0000000000005708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/12/2024] [Indexed: 04/11/2024]
Abstract
Background Recalcitrant bone nonunion and osseous defect treatment is challenging and often requires vascularized bone transfer. The medial femoral condyle flap has become an increasingly popular option for reconstruction. The study aims at reviewing its different applications and synthesizing its surgical outcomes. Method A systematic review including all studies assessing surgical outcomes of free medial femoral condyle flap for bone reconstruction in adults was conducted on January 31, 2023. Flap failure and postoperative complications were synthesized with a proportional meta-analysis. Results Forty articles describing bony reconstruction in the head and neck, upper limb, and lower limb areas were selected. Indications ranged from bony nonunion and bone defects to avascular bone necrosis. Multiple flaps were raised as either pure periosteal, cortico-periosteal, cortico-cancellous-periosteal, or cortico-chondro-periosteal. A minority of composite flaps were reported. Overall failure rate was 1% [95% confidence interval (CI), 0.00-0.08] in head & neck applications, 4% in the lower limb (95% CI, 0.00-0.16), 2% in the upper limb (95% CI, 0.00-0.06), and 1% in articles analyzing various locations simultaneously (95% CI, 0.00-0.04). Overall donor site complication rate was 4% (95% CI, 0.01-0.06). Major reported complications were: femoral fractures (n = 3), superficial femoral artery injury (n = 1), medial collateral ligament injury (n = 1), and septic shock due to pace-maker colonization (n = 1). Conclusion The medial femoral condyle flap is a versatile option for bone reconstruction with high success rates and low donor site morbidity.
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Affiliation(s)
- Matteo Scampa
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, Geneva, Switzerland
| | - Vladimir Mégevand
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, Geneva, Switzerland
- Department of Plastic surgery, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, United Kingdom
| | - Jérôme Martineau
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, Geneva, Switzerland
| | - Dirk J. Schaefer
- Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery, Basel University Hospital, Basel, Switzerland
| | - Daniel F. Kalbermatten
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, Geneva, Switzerland
| | - Carlo M. Oranges
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, Geneva, Switzerland
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Rachunek-Medved K, Illg C, Einzmann A, Kolbenschlag J, Daigeler A, Medved F. Postoperative scaphoid alignment, smoking, and avascular necrosis mostly influence union rate after scaphoid reconstruction: Results from a retrospective single center study involving 370 patients. J Plast Reconstr Aesthet Surg 2023; 87:430-439. [PMID: 37944453 DOI: 10.1016/j.bjps.2023.10.098] [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: 04/03/2023] [Revised: 10/11/2023] [Accepted: 10/15/2023] [Indexed: 11/12/2023]
Abstract
Current literature does not definitely demonstrate the superiority of any particular scaphoid reconstruction method. The primary goal of this retrospective single center study was to evaluate the influence of reconstruction techniques and other factors on the union rate after reconstruction of scaphoid nonunions. In the study, 370 patients with nonunions classified as stable (Mayo 1) or unstable (Mayo 2) depending on carpal alignment were included. Minimal radiological follow-up was 3 months. Bone healing after scaphoid reconstruction was evaluated using computer tomography scans in 294 and radiograms in 76 patients. Univariate and multivariate logistic regressions were applied in the analysis. Eight statistically significant factors that influenced the union rate were fixation method, type of previous operations, number of all operations, number of reconstructions, smoking, postoperative pathological lateral intrascaphoid angle (LISA>45°), avascular necrosis (AVN), and stability of nonunion. Smoking and postoperative LISA>45° significantly reduced the probability of bone fusion by approximately 4.4 and 9.5 times, respectively. Patients with reduced vascularity in the nonunion site had a 5.2 times lower chance of bone fusion. Our multivariate logistic regression model can explain 32% of failures after scaphoid reconstruction, including postoperative LISA>45°, patients' present record of smoking, and reduced vascularity in the nonunion site. However, bone graft type does not impact the union rate in general; however, in case of AVN, the tendency toward higher union rates was observed for medial femoral condyle free flaps when compared to other types of graft (non-vascularized and pedicled bone grafts considered as one group, p = 0.09).
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Affiliation(s)
- K Rachunek-Medved
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076 Tuebingen, Germany.
| | - C Illg
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076 Tuebingen, Germany.
| | - A Einzmann
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076 Tuebingen, Germany.
| | - J Kolbenschlag
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076 Tuebingen, Germany.
| | - A Daigeler
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076 Tuebingen, Germany.
| | - F Medved
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Trauma Center, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076 Tuebingen, Germany.
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Hoftiezer YAJ, Posada Alvarez C, Werenski JO, Schreuder HWB, Eberlin KR, Lee SG, Lozano-Calderón SA. Salvage of a Fractured Proximal Ulnar Osteoarticular Allograft Using a Medial Femoral Condyle Free Flap: A Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00024. [PMID: 37531445 DOI: 10.2106/jbjs.cc.22.00796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
CASE We present the case of a 47-year-old paraplegic woman who underwent resection of an intermediate-grade chondrosarcoma in the proximal ulna, which was initially reconstructed with an osteoarticular allograft. However, after more than 25 years without complications, she sustained an intra-articular fracture of the allograft, which was then successfully treated using a vascularized medial femoral condyle (MFC) flap and anterolateral thigh flap. The patient has subsequently recovered her baseline elbow function, has no pain, and can use her wheelchair without restrictions. CONCLUSION Free MFC flaps are viable options to salvage osteoarticular allografts that are affected by intra-articular fractures.
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Affiliation(s)
- Yannick Albert J Hoftiezer
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Plastic, Reconstructive and Hand Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolina Posada Alvarez
- Department of Orthopaedics, University Medical Center Groningen/University of Groningen, Groningen, the Netherlands
| | - Joseph O Werenski
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - H W B Schreuder
- Department of Orthopaedic Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Sang-Gil Lee
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Santiago A Lozano-Calderón
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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5
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Sivakumar B, Lawson R, Graham DJ. The Medial Femoral Trochlea Osteochondral Flap for Scaphoid Reconstruction: A Systematic Review. Hand (N Y) 2023:15589447231151430. [PMID: 36779491 DOI: 10.1177/15589447231151430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
BACKGROUND The medial femoral trochlea flap has been used to resurface scaphoids with recalcitrant proximal pole fractures or avascular necrosis, providing vascularized osteochondral tissue with similar morphological characteristics. This article aims to review the contemporary literature on its use for scaphoid reconstruction. METHODS A systematic review of Embase, PubMed, Cochrane Central Register of Controlled Trials, and MEDLINE assessed the use of medial femoral trochlea flaps in scaphoids. RESULTS Eight studies were included, with 76 patients at a mean age of 26 years. Forty-three patients underwent clinical review, and 10 patients underwent radiographic evaluation, at a mean 23.3 months of follow-up. Flaps were generally performed for proximal pole fractures, avascular necrosis, nonunion, or failure of prior fixation; 94.4% of the flaps united. No marked change in sagittal plane motion was noted; reductions were seen in axial and coronal plane motion. The Disabilities of the Arm, Shoulder, and Hand scores improved from a mean of 25.2 to 11.5. Radiographic markers also improved. A total of 12.3% of patients had unplanned return to theater. Three patients required early revision for vascular thrombosis, and 1 patient suffered a volar carpal dislocation. Three patients underwent salvage procedures for ongoing pain. CONCLUSIONS Although technically demanding, promising early-term to medium-term results are noted with the use of medial femoral trochlea flaps in the scaphoid.
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Affiliation(s)
- Brahman Sivakumar
- Royal North Shore Hospital, St Leonards, NSW, Australia
- Australian Research Collaboration on Hands (ARCH), Mudgeeraba, QLD, Australia
- The University of Sydney, Camperdown, NSW, Australia
- Hornsby Ku-ring-gai Hospital, Hornsy, NSW, Australia
- Nepean Hospital, Kingswood, NSW, Australiaa
| | | | - David J Graham
- Australian Research Collaboration on Hands (ARCH), Mudgeeraba, QLD, Australia
- Gold Coast University Hospital, Southport, QLD, Australia
- Griffith University School of Medicine and Dentistry, Southport, QLD, Australia
- Queensland Children's Hospital, South Brisbane, Australia
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Rodriguez JR, Chan JKK, Huang RW, Chen SH, Lin CH, Lin YT, Lin CH, Hsu CC. Free Medial Femoral Condyle Flap for Phalangeal and Metacarpal Bone Reconstruction. J Plast Reconstr Aesthet Surg 2022. [DOI: 10.1016/j.bjps.2022.08.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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7
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Golin AP, Zhang Z, Ratanshi I, McInnes CW. Acute Thumb Reconstruction With Medial Femoral Condyle and Radial Forearm Free Flaps: A Case Report. Hand (N Y) 2022; 18:NP1-NP6. [PMID: 35668636 PMCID: PMC10152520 DOI: 10.1177/15589447221096705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Traumatic thumb injuries often result in significant functional disability. With segmental bone loss, reconstructive options include antibiotic cement with delayed bone graft, revision amputation with webspace deepening, metacarpal distraction osteogenesis, index pollicization, bone flap, and free toe transfer. We present a case of a subtotal thumb amputation just distal to the metacarpal phalangeal joint resulting in loss of both soft tissue and a segmental bone defect of the proximal and distal phalanx. Reconstruction was initially performed with a chimeric bone free flap from the medial femoral condyle with a vastus medialis muscle cuff to provide soft tissue coverage. A revision soft tissue coverage procedure was required and a radial forearm free flap was utilized. His reconstruction restored his missing bone and soft tissue, and provided stability with sufficient grip strength and metacarpophalangeal function resulting in a satisfactory functional outcome.
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Affiliation(s)
- Andrew P Golin
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Zach Zhang
- Division of Plastic Surgery, University of British Columbia, Vancouver, Canada
| | - Imran Ratanshi
- Division of Plastic Surgery, University of British Columbia, Vancouver, Canada.,Royal Columbian Hospital, Fraser Health Authority, British Columbia, Canada
| | - Colin W McInnes
- Division of Plastic Surgery, University of British Columbia, Vancouver, Canada.,Royal Columbian Hospital, Fraser Health Authority, British Columbia, Canada
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8
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"Use of pedicled corticoperiosteal flap in resistant cases of distal femur non-union: Our learning experience". J Plast Reconstr Aesthet Surg 2021; 75:621-628. [PMID: 34732336 DOI: 10.1016/j.bjps.2021.09.004] [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: 06/13/2020] [Revised: 06/04/2021] [Accepted: 09/19/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Nonunion of distal femur is a complex problem with the added burden of poor bone stock, osteopenia, and joint contracture. Various procedures are described ranging from osteosynthesis using auto/allograft, to use of mega prosthesis. Use of vascularized corticoperiosteal flap based on descending genicular artery and superomedial genicular artery is a new technique to provide living vascular graft for the nonunion site. Although few free corticoperiosteal flap reconstructions have been reported in the past for these distal femur nonunions, this flap has seldom been used as a pedicled variety. Through this article, we aimed at highlighting the main obstacles faced while using pedicled corticoperiosteal flap for these patients given its dearth in literature. MATERIALS AND METHODS Five patients of at least two previously failed osteosynthesis for distal femur fracture non-union were selected for performing corticoperiosteal flaps. The intraoperative findings that were both favourable and unfavourable were documented along with the outcome of procedure in the form of callus formation or fracture healing. RESULTS Dissection of the flap was more tedious in these cases than when performed for a different indication in a virgin territory. However, despite the previous trauma resulting in decreased pliability of their vessels, all flaps were viable at the end of procedure with favourable cosmetic and functional outcomes. CONCLUSION Despite the complexities in flap harvest, use of the less morbid and technically easier "Pedicled corticoperiosteal flap" and osteosynthesis along with the auto technique is a worthwhile option for retaining the native joint with favourable outcome in non-unions of distal femur.
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9
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Castillo-Vázquez FG, Palafox-Carral I, Romo-Rodríguez R, Limón-Muñoz M, Farías-Cisneros E. Surgical Solution for Total Carpectomy due to Destructive Wrist Pan-Osteomyelitis Using a Free Femoral Condyle Osteocutaneous Flap for Wrist Arthrodesis. J Hand Microsurg 2021; 14:100-106. [DOI: 10.1055/s-0041-1736083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractOsteomyelitis of the hand is rare, even more so in the carpal bones. Patients with rheumatoid arthritis (RA) have a higher infection rate overall, and up to a 14-fold increase in the incidence of septic arthritis of the hand. The destruction of immunologic barriers, such as cartilage and joint capsules, as well as the use of immunosuppressive medications will have an impact on the higher incidence of articular infections and osteomyelitis in these patients. Infection in these cases is often overlooked because of the similarity of presentation to an acute event of RA. When osteomyelitis is present, rapid and aggressive treatment should be given. Surgical debridement, lavage, and excision of necrotic bone is the best choice, followed by cemented antibiotic impregnated spacer to resolve the acute scenario. Vascularized bone grafts (VBG) can then be used for a definitive solution, as these have great biologic properties that increase the possibility of a good outcome. We hereby present a report of a wrist arthrodesis, using a free medial femoral condyle VBG for the treatment of destructive osteomyelitis of the carpal bones in a female patient with RA.
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Affiliation(s)
| | - Ignacio Palafox-Carral
- Orthopedic Surgery Resident, Department of Orthopedic Surgery, Hospital Español de México, Mexico City, Mexico
| | | | - Marisol Limón-Muñoz
- Anesthesiology Division, Department of Regional Anesthesiology, Instituto Nacional de Rehabilitación “Luis Guillermo Ibarra Ibarra,” CDMX, Mexico
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Suganuma S, Tada K, Yamauchi D, Takagawa S, Yasutake H, Shimanuki K, Tsuchiya H. Reconstruction using a free vascularised medial femoral condyle corticoperiosteal flap for osteomyelitis of the juxta-articular distal radius: A case report and literature review. Trauma Case Rep 2021; 32:100408. [PMID: 33665305 PMCID: PMC7905069 DOI: 10.1016/j.tcr.2021.100408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2021] [Indexed: 11/17/2022] Open
Abstract
Osteomyelitis of the epiphysis after a distal radius fracture is uncommon. If not adequately and promptly treated, the detrimental effects on wrist function can be devastating. However, management of septic bone defects of the epiphysis is significantly challenging. We report the case of a patient with juxta-articular distal radius osteomyelitis successfully treated with a free vascularised corticoperiosteal flap from the medial femoral condyle (MFC corticoperiosteal flap). A 46-year-old right-handed man fell on the grass from a height of 2 m during a demolition. He was diagnosed with a right distal radius and ulnar styloid process fracture. He underwent open reduction and internal fixation. However, he developed a deep infection, resulting in postoperative osteomyelitis. Therefore, thorough debridement was performed and an external fixator was applied. Antibiotics were administered according to the culture results. He underwent reconstruction for bone defect using an MFC corticoperiosteal flap 28 days after re-operation. The patient could resume work without limitations 4 months after the reconstruction. The infection subsided completely, and radiographs confirmed bone union at 5 months after the reconstruction. His wrist range of motion was 40° in dorsal flexion (uninjured side 70°), 50° in palmar flexion (75°), 80° in supination (90°), and 90° in pronation (90°). There was no donor site complication. The patient has reported no pain for 1 year since the injury. The use of the MFC corticoperiosteal flap for reconstruction of the juxta-articular distal radius osteomyelitis decreased the time required for bone union, enabled local antibiotic delivery to control infection, and helped preserve wrist function.
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Affiliation(s)
- Seigo Suganuma
- Department of Orthopaedic Surgery, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Kaoru Tada
- Department of Orthopaedic Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Daisuke Yamauchi
- Department of Orthopaedic Surgery, Fukui-ken Saiseikai Hospital, Fukui, Japan
| | - Shingo Takagawa
- Department of Orthopaedic Surgery, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Hidetoshi Yasutake
- Department of Orthopaedic Surgery, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Keito Shimanuki
- Department of Orthopaedic Surgery, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Kanazawa University Hospital, Kanazawa, Japan
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11
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Vascularized bone grafts for post-traumatic defects in the upper extremity. Arch Plast Surg 2021; 48:84-90. [PMID: 33503750 PMCID: PMC7861969 DOI: 10.5999/aps.2020.00969] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/29/2020] [Indexed: 11/26/2022] Open
Abstract
Vascularized bone grafts (VBGs) are widely employed to reconstruct upper extremity bone defects. Conventional bone grafting is generally used to treat defects smaller than 5–6 cm, when tissue vascularization is adequate and there is no infection risk. Vascularized fibular grafts (VFGs) are mainly used in the humerus, radius or ulna in cases of persistent non-union where traditional bone grafting has failed or for bone defects larger than 6 cm. Furthermore, VFGs are considered to be the standard treatment for large bone defects located in the radius, ulna and humerus and enable the reconstruction of soft-tissue loss, as VFGs can be harvested as osteocutaneous flaps. VBGs enable one-stage surgical reconstruction and are highly infection-resistant because of their autonomous vascularization. A vascularized medial femoral condyle (VFMC) free flap can be used to treat small defects and non-unions in the upper extremity. Relative contraindications to these procedures are diabetes, immunosuppression, chronic infections, alcohol, tobacco, drug abuse and obesity. The aim of our study was to illustrate the use of VFGs to treat large post-traumatic bone defects and osteomyelitis located in the upper extremity. Moreover, the use of VFMC autografts is presented.
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12
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Free vascularised medial femoral condyle periosteal flaps in recalcitrant long bone non-union: a systematic review. Arch Orthop Trauma Surg 2020; 140:1619-1631. [PMID: 31974694 DOI: 10.1007/s00402-020-03354-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Indexed: 12/14/2022]
Abstract
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.
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13
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Nicholls AJ, Hargreaves I, Wheen D. Vascularized medial femoral condyle flap harvest adjacent to total knee arthroplasty: a case report. J Hand Surg Eur Vol 2020; 45:202-204. [PMID: 31795811 DOI: 10.1177/1753193419889299] [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: 02/03/2023]
Affiliation(s)
- Alexander J Nicholls
- St Luke's Hand Unit, St Luke's Private Hospital, NSW, Australia.,Department of Orthopaedics, Hampshire Hospitals NHS Foundation Trust, Hampshire, UK
| | - Ian Hargreaves
- St Luke's Hand Unit, St Luke's Private Hospital, NSW, Australia
| | - Douglass Wheen
- St Luke's Hand Unit, St Luke's Private Hospital, NSW, Australia
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14
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Keller M, Kastenberger T, Anoar AF, Kaiser P, Schmidle G, Gabl M, Arora R. Clinical and radiological results of the vascularized medial femoral condyle graft for scaphoid non-union. Arch Orthop Trauma Surg 2020; 140:835-842. [PMID: 32124031 PMCID: PMC7244456 DOI: 10.1007/s00402-020-03386-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION This study evaluated the use of a free vascularized bone graft with and without cartilage from the medial femoral condyle (MFC) in patients with recalcitrant scaphoid non-union, with a special focus on union rates and the osteochondral graft for proximal pole destruction. MATERIALS AND METHODS Thirty-eight avascular scaphoid non-unions in 37 patients who were treated with a free osteoperiosteal or osteochondral MFC graft were retrospectively evaluated (mean follow-up 16 months). Bone union, the scapholunate and the radiolunate angles were evaluated on X-ray images. The range of motion, grip strength, VAS, DASH and PRWE scores were evaluated clinically. RESULTS The overall union rate was 95%. Bone union was achieved in 27 out of 29 (93%) scaphoids treated with a free osteoperiosteal MFC grafts and in 9 out of 9 (100%) scaphoids treated with a free osteochondral MFC graft. The range of motion remained almost unchanged, while grip strength increased significantly (34 kg vs. 44 kg) and the VAS (22-5), DASH (59-19) and PRWE (62-30) score decreased significantly. The scapholunate (71°-65°) and radiolunate (28°-18°) angle decreased. No major donor site morbidity was observed. Postoperative complications were observed in eight cases (21%). CONCLUSIONS The vascularized medial femoral bone graft leads to a good functional outcome in the treatment of scaphoid non-unions. The graft provides adequate blood supply and structural stability to the scaphoid. A proximal pole destruction can be replaced using an osteochondral graft with promising short-term results preventing carpal osteoarthritis and collapse.
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Affiliation(s)
- Marco Keller
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria ,grid.440128.b0000 0004 0457 2129Department of Orthopaedics and Traumatology, Kantonsspital Baselland, Rheinstrasse 26, 4410 Liestal, Switzerland
| | - Tobias Kastenberger
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Anizar Faizi Anoar
- grid.412516.50000 0004 0621 7139Department of Orthopaedics and Traumatology, Kuala Lumpur Hospital, Jalan Pahang, 50586 Kuala Lumpur, Malaysia
| | - Peter Kaiser
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Gernot Schmidle
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Markus Gabl
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Rohit Arora
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
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Grohmann M, Benedikt S, Vasilyeva A, Bürger H, Forbes A, Schintler MV. An Innovative Application of the Free Vascularized Medial Femoral Condyle Flap in the Prevention of Recurring Neuropathic Ulcer in the Diabetic Foot: A Case Report. J Foot Ankle Surg 2019; 57:1020-1023. [PMID: 29804922 DOI: 10.1053/j.jfas.2018.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Indexed: 02/03/2023]
Abstract
Despite various therapy options, the prophylactic and symptomatic treatment of recurrent ulcerations in the diabetic foot are still challenging. We report the application of a free vascularized medial femoral condyle flap to prevent the recurrence of pressure ulcer in a patient with diabetic foot syndrome. Our patient had type 2 diabetes and presented with pressure ulcers and osteomyelitis of metatarsal heads 2 and 3 after a great toe amputation. We chose to use a medial femoral condyle flap as a damper in the area of the metatarsal heads because of the relatively young age and good vascularity of our patient. We shaped the graft like a ski to distribute the pressure and prevent perforation of the plantar skin. Good results were achieved for wound healing, pain reduction, and improvement of gait. No pressure ulceration had recurred after a 3-year follow-up period. The versatility of the osteomyocutaneous graft from the medial femoral condyle is an important reconstructive tool for addressing major surgical problems. We present the first use of a medial femoral condyle flap in the treatment of a pressure ulcer in a diabetic foot. In selected patients, our method could prevent premature and extended amputations, thereby providing good improvement in patients' quality of life.
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Affiliation(s)
- Martin Grohmann
- Medical Doctor, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Stefan Benedikt
- Medical Doctor, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.
| | - Anna Vasilyeva
- Medical Doctor, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Heinz Bürger
- Medical Doctor, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Abigail Forbes
- Medical Doctor, Plastic Surgery, University of Texas Medical Branch, Galveston, TX
| | - Michael Valentin Schintler
- Professor, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
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Donor-Site Morbidity of Vascularized Bone Flaps from the Distal Femur: A Systematic Review. Plast Reconstr Surg 2019; 142:363e-372e. [PMID: 30148786 DOI: 10.1097/prs.0000000000004691] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Vascularized grafts from the femur, including the medial femoral condyle and medial femoral trochlea, are increasingly being used. It is critical to understand the lower extremity complications from flap harvest. METHODS The authors searched available literature reporting on femoral flaps using PubMed, Embase, Cochrane Database, and Web of Science. After article selection, data were collected regarding demographics, procedure details, outcomes, and complications. The authors classified outcomes as good, fair, or poor based on pain, range-of-motion, sensory changes, subjective reporting, patient-reported outcomes, and other donor-site complications, including the need for additional procedures. RESULTS Two hundred twenty articles were identified. Forty-five met criteria for review, with data available for 283 patients. No patients had range-of-motion deficits beyond 1 year. Two percent of patients (six of 283) required additional donor-site procedures, with one report of a femur fracture after medial femoral condyle harvest. Only one study on 45 medial femoral trochlea patients presented patient-reported outcomes regarding the knee. Few objective data were presented. Twenty-eight articles presented adequate complication data for 252 patients to be rated as good, fair, or poor. Overall, 89 percent had good outcomes without donor-site complications. Of the 176 medial femoral condyle patients with outcomes reported, 92 percent had good outcomes; and 71 percent of the 48 medial femoral trochlea patients had good outcomes reported. CONCLUSIONS Overall, the reported donor-site morbidity from medial femoral condyle and medial femoral trochlea harvest is low. Chronic knee pain and sensory changes are most frequently reported, especially in medial femoral trochlea patients.
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Donor-Site Morbidity and Functional Status following Medial Femoral Condyle Flap Harvest. Plast Reconstr Surg 2018; 142:734e-741e. [DOI: 10.1097/prs.0000000000004886] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Saad NH, Pontell ME, Winters BS, Daniel J, Saad A. The Periosteal Medial Femoral Condyle Free Flap: A New Option for Soft Tissue Reconstruction of the Distal Lower Extremity. Ann Plast Surg 2018; 79:372-376. [PMID: 28604551 DOI: 10.1097/sap.0000000000001104] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Small (<30 cm) soft tissue defects of the distal leg, foot, and ankle pose a complicated issue with regard to wound healing. Multiple flaps have been proposed for reconstruction of these wounds with varying levels of success. The medial femoral condyle flap is a free bone flap supplied by the descending geniculate artery. It is currently used in the treatment of fracture nonunion, infected bone defects, avascular necrosis, and osteoradionecrosis. This study proposes the use of the periosteal portion of the medial femoral condyle (PMFC) flap for soft tissue reconstruction of the distal leg, foot, and ankle. METHODS We performed a single-center, retrospective series of 6 patients with distal leg, foot, and ankle wounds. All patients underwent reconstruction using the PMFC flap. RESULTS Of the 6 patients, 5 had chronic wounds. There were no incidences of flap loss. Five patients healed without complication, four of which had undergone immediate skin grafting, whereas one had concomitant skin paddle reconstruction. The remaining patient required a second surgery with a rotation flap for recurrent osteomyelitis and wound infection 2 months after the initial surgery. Mean operative time decreased after a 2-case learning curve. CONCLUSIONS Small wounds of the distal extremity can be difficult to treat, with many requiring free or rotational flap coverage. We propose novel use of the PMFC flap for reconstruction of small soft tissue defects of the distal leg, foot, and ankle. In our series, we demonstrated no donor site morbidity, with excellent cosmetic and functional outcomes.
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Affiliation(s)
- Noah H Saad
- From the *University of Maryland Medical System, Baltimore, MD; †Department of Surgery, Drexel University College of Medicine, Philadelphia, PA; and ‡Rothman Institute of Orthopedics; and §The Plastic Surgery Center, The Institute for Advanced Reconstruction, Egg Harbor, NJ
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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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Kazmers NH, Thibaudeau S, Steinberger Z, Scott Levin L. Upper and lower extremity reconstructive applications utilizing free flaps from the medial genicular arterial system: A systematic review. Microsurgery 2016; 38:328-343. [DOI: 10.1002/micr.30138] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 11/10/2016] [Accepted: 12/02/2016] [Indexed: 11/07/2022]
Affiliation(s)
| | - Stephanie Thibaudeau
- Division of Plastic and Reconstructive Surgery; McGill University; Montreal Quebec H3A 14A Canada
| | - Zvi Steinberger
- Department of Orthopaedic Surgery; Penn Medicine University City; Philadelphia Pennsylvania
| | - L. Scott Levin
- Department of Orthopaedic Surgery; Penn Medicine University City; Philadelphia Pennsylvania
- Division of Plastic Surgery; Perelman Center for Advanced Medicine; Philadelphia Pennsylvania
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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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Roger I, Worden A, Panattoni J, Garcia I, Aranda F, Delgado PA. Subtalar fusion with iliac bone free flap after a recalcitrant nonunion: Report of two cases. Microsurgery 2015; 36:501-6. [PMID: 26456638 DOI: 10.1002/micr.22513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 07/07/2015] [Accepted: 09/25/2015] [Indexed: 11/09/2022]
Abstract
Fractures of the calcaneus are associated with secondary osteoarthritis of the subtalar joint. In a persistent nonunion, vascularized bone flaps offer superior biologic and mechanical properties as well as accelerates joint fusion and decreases morbidity. In this report, we present results of the use of vascularized iliac bone free flap for treating subtalar failed fusions in two patients. Two patients sustained calcaneal fractures due to foot trauma, which were initially or subsequently treated with subtalar arthrodesis. Case one developed septic subtalar nonunion during treatment and case two failed three attempts at subtalar arthrodeses. The iliac crest bone flap harvested measured 4 × 4 cm (case one) and 3 × 3 cm (case two). The flap was pedicled by the deep circumflex iliac artery, which was anastomosed to the anterior tibial artery at the recipient site. No flap donor or recipient site complications occurred. Fusion was confirmed on CT scan and weight bearing was initiated at 5-6 months. At latest follow up (1-2 years), no complications occurred. Our results show that subtalar nonunion treatment with a vascularized iliac bone flap may be feasible and such a reconstruction could be clinically successful. © 2015 Wiley Periodicals, Inc. Microsurgery 36:501-506, 2016.
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Affiliation(s)
- Ignacio Roger
- Departments of Microsurgery Unit at Hospital Fremap Majadahonda, Madrid, Spain
| | - Alicia Worden
- Department of Orthopaedic Surgery at Saint Louis University School of Medicine, Saint Louis, MO.
| | - Joao Panattoni
- Department of Orthopaedic Surgery at Saint Louis University School of Medicine, Saint Louis, MO
| | - Ignacio Garcia
- Departments of Microsurgery Unit at Hospital Fremap Majadahonda, Madrid, Spain
| | - Fernando Aranda
- Departments of Orthopaedic Surgery at Hospital Ramon Y Cajal Madrid, Spain
| | - Paula A Delgado
- Departments of Plastic Surgery at Hospital Ramon Y Cajal Madrid, Spain
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Effect of preservation of corticoperiosteal attachment on bone healing at osteotomy sites after ulna-shortening osteotomy. Hand (N Y) 2015; 10:105-10. [PMID: 25767428 PMCID: PMC4349831 DOI: 10.1007/s11552-014-9662-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Although precise ulna-shortening osteotomy is popular, the procedure sometimes results in delayed union or nonunion. The periosteum including the inner cambium layer plays an important role in fracture healing. We tested the hypothesis that preservation of the corticoperiosteal attachment may accelerate healing at osteotomy sites after ulna-shortening osteotomy. METHODS We performed a chart review of 32 patients who underwent ulna-shortening osteotomy for ulnar impaction syndrome or triangular fibrocartilage complex tears in a retrospective single-surgeon series. Of the 32 cases, the periosteum was preserved in 21 osteotomies performed from April 2009 onwards (periosteum-preserved group) and not preserved in 11 osteotomies performed before April 2009 (control group). Following sugar tong immobilization, patients in both groups used a short wrist supporter during the first two postoperative weeks (POW) and up to at least four POW. Union of the osteotomy site was assessed at 2-week intervals using radiographs taken at three different projections until 12 POW and at 4-week intervals thereafter until 24 POW. Ulna shortening was performed using a transverse osteotomy cut with the aid of a commercially available compression device. RESULTS All osteotomies achieved complete union except in one case in the control group. The mean interval to complete cortical union was 7.7 weeks in the periosteum-preserved group and 9.5 weeks in the control group. The corresponding mean times for endosteal union were 15.6 and 21.8 weeks. The periosteum-preserved group had reduced times for both types of union but only the endosteal union time was significantly different from the control group. CONCLUSIONS Preservation of the corticoperiosteal attachment significantly shortened the endosteal union time. Our results indicate that preservation of the periosteum may accelerate bone healing after ulna-shortening osteotomy.
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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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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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Pantelides NM, Sharma P, Grant I. Free vascularized cortico-periosteal grafting for a traumatic defect of the DIP joint. J Hand Surg Eur Vol 2013; 38:442-4. [PMID: 22918880 DOI: 10.1177/1753193412458627] [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] [Indexed: 02/03/2023]
Affiliation(s)
- N. M. Pantelides
- Department of Plastic and Reconstructive Surgery, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - P. Sharma
- Department of Plastic and Reconstructive Surgery, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - I. Grant
- Department of Plastic and Reconstructive Surgery, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Pagnotta A, Taglieri E, Molayem I, Sadun R. Posterior interosseous artery distal radius graft for ulnar nonunion treatment. J Hand Surg Am 2012; 37:2605-10. [PMID: 23174076 DOI: 10.1016/j.jhsa.2012.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 08/09/2012] [Accepted: 09/16/2012] [Indexed: 02/02/2023]
Abstract
The aim of our study was to describe a dorsal distal radius vascularized bone graft pedicled on the posterior interosseous artery (PIA), and its clinical application in 2 cases of ulnar nonunion. We studied the surgical technique in 5 freshly injected cadavers. The 4th extensor compartment artery originates from the anastomotic arch between the posterior division of the anterior interosseous artery and the PIA and provides periosteal branches to supply the dorsal distal radius metaphysis. A 2-cm vascularized bone graft can be harvested from the radius, and dissection of the PIA enables a long pedicle with a wide arc of rotation able to reach the ulnar diaphysis. The approach is limited to the forearm and distal radius and has minimal donor morbidity.
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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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