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Naga HI, Kim J, Dunworth K, Oleck N, Emovon E, Graton M, Mithani SK. Upper Extremity Diaphyseal Osseous Gap Reconstruction with Free Vascularized Bone Flaps: A Scoping Review. J Reconstr Microsurg 2024. [PMID: 38782026 DOI: 10.1055/a-2332-0150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND Reconstruction of upper extremity osseous diaphyseal defects often requires complex reconstructions. In this study, we characterized and summarized the available literature on free vascularized bone flap (VBF) reconstruction for upper extremity diaphyseal defects. METHODS A scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews was conducted. A literature search of major electronic databases was conducted to identify journal articles relating to the management of VBF reconstruction of upper limb long bone defects. Articles with patient-level data were included. Descriptive statistics were performed using Python. RESULTS Overall, 364 patients were included in this study. The most common indications for VBFs included atrophic nonunion (125, 34.3%), postoncologic resection (125, 34.3%), septic nonunion (56, 15.4%), and trauma (36, 9.9%). Mean defect size was 8.53 ± 5.14 cm. A total of 67 (18.4%) cases had defects < 6 cm, and 166 cases (45.6%) had defects > 6 cm. The fibula was the most utilized VBF (272, 74.73%), followed by the medial femoral condyle flap (69, 18.96%). Overall, primary union rate was 87.1%. Subsequent flap fracture rate was 3.3%. There were only two (0.6%) VBF losses reported in the included cases, and donor-site complications were similarly rare (17, 4.7%). CONCLUSION VBF reconstruction is often utilized for postoncologic defects and recalcitrant nonunions. The fibula is the most utilized VBF, but the medial femoral condyle flap is used frequently for smaller defects. VBF reconstruction demonstrates high union rates and low flap fracture rate across indications.
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Affiliation(s)
- Hani I Naga
- Division of Hand Surgery, Department of Surgery, Duke University, Durham, North Carolina
- Division of Plastic Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Joshua Kim
- Division of Hand Surgery, Department of Surgery, Duke University, Durham, North Carolina
- Division of Plastic Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Kristina Dunworth
- Division of Hand Surgery, Department of Surgery, Duke University, Durham, North Carolina
- Division of Plastic Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Nicholas Oleck
- Division of Hand Surgery, Department of Surgery, Duke University, Durham, North Carolina
- Division of Plastic Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Emmanuel Emovon
- Division of Hand Surgery, Department of Surgery, Duke University, Durham, North Carolina
- Division of Plastic Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Margaret Graton
- Department of Medical Library, Duke University Hospital, Durham, North Carolina
| | - Suhail K Mithani
- Division of Hand Surgery, Department of Surgery, Duke University, Durham, North Carolina
- Division of Plastic Surgery, Department of Surgery, Duke University, Durham, North Carolina
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2
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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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Cha SM, Pai A, Lee HJ, Shin HD. Non-vascularised corticocancellous (tricortical) iliac bone graft longer than 3 cm for non-union after failed surgical treatment. J Plast Reconstr Aesthet Surg 2024; 88:37-44. [PMID: 37950990 DOI: 10.1016/j.bjps.2023.10.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/03/2023] [Accepted: 10/07/2023] [Indexed: 11/13/2023]
Abstract
PURPOSE We hypothesised that traditional iliac tricortical bone grafts (no vascularised) still have a reasonable role in promoting satisfactory bony healing in non-union defects of certain sizes. Here, we report the clinical/radiological outcomes through a retrospective case series. METHODS We screened 74 patients with definitive non-union in the long bones of the upper extremities who visited the outpatient department from 2008 to 2018. Among these patients, 25 who met our inclusion/exclusion criteria were investigated. RESULTS The mean age was 51.92 years, and there were 12, 9, 1, and 3 lesions of the radius, ulna, clavicle, and humerus, respectively. The tools for primary fixations were plate and intramedullary nails in 24 and 1 patients, respectively. Six patients presented with atrophic non-union. The mean period from a previous surgery was 6.84 months. The mean defective bone sizes were 1.81 and 3.50 cm pre-debridement and post-debridement, respectively. All devices had locking plates longer than the previous plate, and the graft was concurrently fixed by screws in three patients. At a mean of 15.92 weeks after the revision surgery, all patients experienced union. At the final follow-up, the clinical outcomes were satisfactory. No significant differences in clinical outcomes were found according to the lesion, type of non-union, period from the previous surgery, or harvest length of the iliac bone. CONCLUSIONS If the proper indications and some technical aspects are considered, a non-vascularised iliac bone graft longer than 3 cm could still be a reasonable option for treating diaphyseal non-union of the upper extremities. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Soo Min Cha
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Centre, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
| | - Ashwin Pai
- Department of Plastic Surgery, West Suffolk NHS Foundation Trust, United Kingdom
| | - Hyun Jong Lee
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Centre, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
| | - Hyun Dae Shin
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Centre, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea.
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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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O'Neill R, Skochdopole A, Grush AE, Atassi OH, Maricevich M. Clavicular reconstruction utilizing free fibula flap with periosteal extension. Microsurgery 2023; 43:157-160. [PMID: 36541829 DOI: 10.1002/micr.30995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 11/02/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
Clavicular reconstruction is typically managed conservatively. Despite demonstrating improving outcomes, including range of motion and pain, there are currently no published reports of acute reconstruction with vascularized free fibula flaps (VFFF) or vascularized periosteal extensions in adult patients with clavicular defects. VFFFs have been utilized to correct critical bony defects of the clavicle and chronic nonunions; however, descriptions following acute trauma are rare. Bony union enhancement with periosteal extension has been described in both pediatric and adult populations, but never in the case of clavicular reconstruction. Herein, we seek to fill this gap in the literature by describing the acute reconstruction of a 6.5 cm bony gap in a 29-year-old male following a gunshot wound to the chest, utilizing a 6.5 cm VFFF with periosteal extension, and inset to the internal mammary vessels. The postoperative course was uncomplicated, with bony consolidation noted by 10 weeks, and full, pain-free range of motion at 8 months, showing this technique may be a viable option following acute trauma.
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Affiliation(s)
- Rebecca O'Neill
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Ben Taub Hospital, Houston, Texas, USA
| | - Anna Skochdopole
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Ben Taub Hospital, Houston, Texas, USA
| | - Andrew E Grush
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Omar H Atassi
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, USA.,Department of Orthopedic Surgery, Ben Taub Hospital, Houston, Texas, USA
| | - Marco Maricevich
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Plastic Surgery, Department of Surgery, Ben Taub Hospital, Houston, Texas, USA
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Monitor selection according to the defect location in the medial femoral condyle flap . Injury 2022; 53:4139-4145. [PMID: 36192200 DOI: 10.1016/j.injury.2022.09.030] [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: 07/15/2022] [Accepted: 09/19/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Medial femoral condyle(MFC) flap is frequently used in hand reconstruction, but like other buried flaps, MFC is not easy to monitor and follow.In this study, we present our adipofascial and periosteal tissue technical modifications and results for MFC free flap monitoring and compare different monitoring methods. METHODS Twenty one patients with wrist bone or metacarpal defect reconstructed with MFC flap were included in the study. Adipofascial tissue in wrist defect and periosteal tissue in metacarpal defect were selected as MFC flap's monitor. Patient characteristics, type of injury, flap size, early or late-period complications, flap elevation time,satisfaction scale, visual analogue scale (VAS) and postoperative X-ray view were noted. RESULTS There were 3 female and 18 male patients in the study. The mean age of the patients was 50.8 (38-68). The elevation times of flaps with adipofascial and periosteal monitors were 48 and 53.3 min, respectively. The satisfaction scale averages for the adipofascial and periosteal monitor groups were 3.5 and 3.54, respectively. The VAS scores of the adipofascial and periosteal monitor groups were 2.9 and 3.9, respectively. The flap sizes with periosteal and adipofascial monitors were 10.48 cm3 and 1.36 cm3, respectively. There was no statistically significant difference between flap elevation, VAS, and satisfaction scale (>0.05). There was a statistically significant difference in flap sizes. (<0.05) CONCLUSION: MFC free flap is frequently used in wrist and metacarpal reconstruction. Monitor selection according to the defect area positively affects the prognosis of the flap in the postoperative period.
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DeKeyser GJ, Bailey TL, Higgins TF, Tyser AR. Treatment of Recalcitrant Femoral Shaft Nonunion With Medial Femoral Condyle Pedicled Autograft: Technical Trick. J Orthop Trauma 2022; 36:e80. [PMID: 34050083 DOI: 10.1097/bot.0000000000002186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 02/02/2023]
Abstract
SUMMARY Nonunited fractures of the femoral shaft and distal femur are usually successfully addressed with stabilization with or without autogenous bone grafting. For the small subset of these problems that prove recalcitrant to front-line treatment, a pedicled medial femoral condyle (MFC) bone flap can provide a source of vascularized autograft with minimal donor site morbidity. The MFC has gained recent widespread adoption as a free vascularized bone transfer, and here, we present a surgical technique and retrospective analysis of patients treated with a pedicled MFC technique. This serves as a useful treatment option for these difficult problems and may be especially helpful in low resource environments or where microsurgical anastomosis is not feasible.
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Affiliation(s)
- Graham J DeKeyser
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
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Addressing common orthopaedic calamities with microsurgical solutions. Injury 2021; 52:3561-3572. [PMID: 34030865 DOI: 10.1016/j.injury.2021.05.003] [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: 04/13/2021] [Accepted: 05/04/2021] [Indexed: 02/02/2023]
Abstract
Reconstructive microsurgery has been an essential aspect of orthopaedic surgery and extremity reconstruction since the introduction of the operating microscope in the mid-20th century. The reconstructive ladder ranges from simple healing by secondary intention to complex procedures such as free tissue transfer and vascularized composite allotransplantation. As orthopaedic surgery has evolved over the past 60 years, so too have the reconstructive microsurgical skills that are often needed to address common orthopaedic surgery problems. In this article, we will discuss a variety of complex orthopaedic surgery scenarios ranging from trauma to infection to tumor resection as well as the spectrum of microsurgical solutions that can aid in their management.
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Willemot L, Stewart D, Lawson R. Reconstruction of an infected midshaft radius and ulna nonunion using a free vascularized fibula and medial femoral condyle flap. Microsurgery 2021; 41:666-670. [PMID: 33932250 DOI: 10.1002/micr.30750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/16/2021] [Accepted: 04/23/2021] [Indexed: 11/07/2022]
Abstract
Conventional grafts do not perform well in the treatment of large diaphyseal bone defects. Forearm nonunions are especially challenging due to complex biomechanical and kinematic demands. Free bone flaps may yield more predictable bony restoration in these cases, while keeping morbidity acceptable to the patient. We aim to illustrate one combination of flaps which can be used in these conditions. This article reports on a 23 year old patient with an 8 cm diaphyseal nonunion of the radius and a similar 7 cm defect of the ulna after infection of fracture fixation hardware. The radius was treated with a free fibular flap (FFF) and the ulna with a medial femoral condyle (MFC) flap in a staged procedure after initial debridement. The patient was followed up for 6 months without significant complications. Both flaps healed within 3 months, yet the MFC demonstrated faster bony incorporation. We attributed this to the spongious nature of the MFC flap compared to the thick cortical FFF. This case report hopes to illustrate one type of flap combination for extensive forearm bone defects. The selection and approach minimizes donor site morbidity to a single limb and possibly hastens bony union of the forearm.
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Affiliation(s)
- Laurent Willemot
- Department of Orthopedic Surgery, Ghent University Hospital, Ghent, Belgium.,Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, Australia
| | - David Stewart
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, Australia
| | - Richard Lawson
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, Australia
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Flow Chart for Reconstructive Head and Neck Surgery in Composite Soft and Hard Tissue Defects. J Craniofac Surg 2020; 31:e588-e591. [PMID: 32649553 DOI: 10.1097/scs.0000000000006679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Virtual planning of reconstructive surgical procedures in patients with osseous and composite defects in the head and neck region is becoming increasingly a state of the art modality. However, computational algorithms lack the capability of planning the involved soft tissue and vascular pedicle position. The authors present a flow-chart to solve this problem in the reconstruction of defects of the upper and lower jaw. MATERIAL AND METHODS Clinical records from 2013 to 2018 from a tertiary care center were screened for patients undergoing osseous reconstruction in the head and neck region. A flow-chart considering soft tissue positioning and the anatomical course of the vascular pedicle was assessed in consideration of the defect and donor-site. RESULTS A total of 81 osseous and composite microvascular reconstructive procedures have been conducted. Defects of the lower jaw were the most common (n = 61). The free fibula flap was the most common reconstructive measure and showed a wide versatility of surgical options to reconstruct these defects. The flow charts were assessed accordingly in these procedures. CONCLUSION Soft tissue and vascular pedicle positioning can be planned pre-operatively by the use of virtual planning and should be considered as an enhancement tool to the already existing computational algorithms of planning hard tissue reconstruction.
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Quintero JI, Childs D, Moreno R. The medial femoral condyle free flap: An excellent option for difficult cases: case series. SAGE Open Med Case Rep 2020; 8:2050313X20933763. [PMID: 32647579 PMCID: PMC7325544 DOI: 10.1177/2050313x20933763] [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] [Received: 08/29/2019] [Accepted: 05/20/2020] [Indexed: 11/17/2022] Open
Abstract
The use of the medial femoral condyle free flap is a versatile option for the treatment of upper extremity non unions and reconstructive procedures associated with bone loss or osteonecrosis. The benefit of this type of flap is the viability of the bone which favors primary ossification and increases bone density. Vascularized free bone flaps are especially useful for the treatment of recalcitrant nonunions, or nonunions that have failed three or more treatments to obtain consolidation. We present a case series of three patients treated with medial femoral condyle free flap for reconstruction of the upper extremity of different etiologies at the level of the distal humerus, distal radius and distal phalanx of the thumb.
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Affiliation(s)
- Jorge I Quintero
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA.,Division of Hand Surgery, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Dylan Childs
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA.,Division of Hand Surgery, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Rodrigo Moreno
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA.,Division of Hand Surgery, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
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Saad A, Jimenez ML, Rogero RG, Saad S, Nakashian MN, Winters BS. Medial Femoral Condyle Periosteal Free Flap for the Treatment of Talus Avascular Necrosis. Foot Ankle Int 2020; 41:728-734. [PMID: 32326752 DOI: 10.1177/1071100720917158] [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: 02/01/2023]
Abstract
BACKGROUND In patients with avascular necrosis (AVN) of the talus in the precollapse stage unresponsive to conservative measures, joint preservation should be considered. Good results have previously been reported for vascularized bone grafting. The medial femoral condyle (MFC) free flap has recently been introduced, which consists of corticoperiosteal bone. We present a novel surgical technique using a periosteal-only MFC (pMFC) free flap in the treatment of talus AVN. METHODS We retrospectively reviewed all pMFC free flaps performed from 2016 to 2018 in the precollapse stage of talus AVN. Surgical management included an ankle arthroscopy, talus core decompression, and ipsilateral pMFC free flap to the talus. Foot and Ankle Ability Measure (FAAM)-Activities of Daily Living (ADL) and visual analog scale (VAS) pain scores were evaluated, and pre- and postoperative imaging studies were assessed by a musculoskeletal-trained radiologist for all patients. Six pMFC free flaps in 5 patients were included in this case series. AVN etiology included idiopathic, posttraumatic, and sepsis-related treatment. All patients were female with an average age of 44.2 (range, 37-67) years. Average postoperative follow-up was 16.9 (range, 6-28) months. RESULTS Pre- to postoperative FAAM-ADL, ADL single assessment numeric evaluation, and VAS scores showed statistically significant improvement (P < .039). No reoperations or flap complications were observed. There was 1 minor complication, which included postoperative paresthesias at the pMFC harvest site. Postoperative x-rays showed no subsequent collapse, and magnetic resonance imaging (MRI) illustrated progressive improvement of bone marrow edema, decreased surrounding areas of AVN, and decreased joint effusion when compared to preoperative MRI. CONCLUSION The pMFC free flap is a novel modification of a previously described technique, which appears to have similar results compared to the traditional MFC free flap. It was safe and effective in the short term with excellent clinical and radiographic outcomes. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Adam Saad
- The Institute for Advanced Reconstruction, Egg Harbor Township, NJ, USA
| | - Megan L Jimenez
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Ryan G Rogero
- Rothman Orthopaedic Institute, Philadelphia, PA, USA.,Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Sherif Saad
- Atlantic Medical Imaging, Egg Harbor Township, NJ, USA
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Rollo G, Prkic A, Bisaccia M, Eygendaal D, Pichierri P, Marsilio A, Giaracuni M, Meccariello L. Grafting and fixation after aseptic non-union of the humeral shaft: A case series. J Clin Orthop Trauma 2020; 11:S51-S55. [PMID: 31992917 PMCID: PMC6977174 DOI: 10.1016/j.jcot.2019.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 07/12/2019] [Accepted: 08/30/2019] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Non-unions after humeral shaft fractures are seen frequently in clinical practice at about 2-10% after conservative management and 30% after surgical treatment. Non-union, displacement of structures and fixation failure can be hazardous complications. The purpose of our study was to evaluate the outcomes of an on-lay bone graft strut construction with bone chips as grafting augmentation in the management of aseptic non-unions of the humeral shaft. METHODS From 124 eligible patients with a humeral shaft non-union, we included 48 patients. In all cases an anterolateral humeral approach was used, with an on-lay bone graft using an allograft strut construction and with bone substitute augmentation in the non-union gap. To assess the bone healing on radiographs, we used the non-union scoring system according to Whelan. Patients were followed with objective and subjective scores. RESULTS In all 48 patients we achieved full bone healing without major complications. The average period of union was 124 days. In 40 cases after healing the alignment was neutral, valgus deformation occurred in 6 cases a varus deformation in 2 cases. At twelve months after surgery, all patients recovered with satisfactory range of motion of shoulder and elbow and a good quality of life, without any radial nerve palsies or other major complications. CONCLUSION Given the satisfactory results of full bone healing, recovery of the range of motion and the lack of major complications as seen in this study, we find that plating with supporting allograft as a good choice of treatment in the cases of aseptic non-union of the humeral shaft.
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Affiliation(s)
- Giuseppe Rollo
- Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy
| | | | - Michele Bisaccia
- Division of Orthopedics and Trauma Surgery, University of Perugia, “S. Maria della Misericordia” Hospital, Perugia, Italy
| | - Denise Eygendaal
- Amphia Hospital, Breda, the Netherlands,Department of Orthopedics AUMC, Amsterdam, the Netherlands
| | - Paolo Pichierri
- Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy
| | - Antonio Marsilio
- Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy
| | - Marco Giaracuni
- Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy
| | - Luigi Meccariello
- Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy,Corresponding author. Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Piazzetta Filippo Muratore, Block: A- Floor:V, Lecce, Italy.
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Ciclamini D, Tos P, Guzzini M, Soldati A, Crosio A, Battiston B. The medial femoral condyle free corticoperiosteal flap versus traditional bone graft for treatment of nonunions of long bones: a retrospective comparative cohort study. Injury 2019; 50 Suppl 5:S54-S58. [PMID: 31711649 DOI: 10.1016/j.injury.2019.10.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Fracture healing is a complex process and many factors change the local biology of the fracture and reduce the physiologic repair process. Since 1991 the free vascularised corticoperiosteal graft has been proposed to treat nonunions. In this study we compare the healing rate and the healing time of the free vascularised corticoperiosteal graft harvested from medial femoral condyle versus the traditional cancellous bone graft from the iliac crest combined with other biologic or pharmacologic factors. We performed a retrospective cohort study. The main measures of outcomes were the rate of bone union and the mean healing time from surgery. The authors performed 10 free vascularised corticoperiosteal grafts in the cohort A and 10 patients received traditional cancellous bone graft plus other biologic or pharmacologic treatment in the same period in the cohort B. The mean follow up in cohort A was 18.6 months with a healing rate of 100% (10/10). In cohort B the mean follow up was 22.5 month with a healing rate of 90%. The mean time to obtain union (healing time) in the group that was treated with the free flap procedure was significantly shorter, 3.2 months versus a mean time of 8.8 months in the other group. Some studies describe a high healing rate of recalcitrant nonunions with treatments different from vascularized bone flaps: it is difficult to compare the results of vascularized bone transfers with the results of other case series. Our groups are very homogeneous even if it is difficult to define correct inclusion criteria because there is still no agreement about what is defined a recalcitrant or difficult nonunion, and the number of trials of previous surgery before to perform a vascularized free flap. Even if our study cohort is small, we have demonstrated that the MFCCF generally seems to give a better healing chance with a shorter healing time compared to other treatments.
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Affiliation(s)
- Davide Ciclamini
- Orthopaedics and Traumatology II, Surgery of the Hand and Upper Limb, AOU Città della Salute e della Scienza, CTO Hospital, Turin, Italy
| | - Pierluigi Tos
- Microsurgery and Surgery of the Hand, Gaetano Pini Hospital, Milan, Italy
| | - Matteo Guzzini
- Orthopaedics and Traumatology Department, University of Rome "La Sapienza" - AO Sant'Andrea, Rome, Italy
| | - Alessandra Soldati
- Orthopaedics and Traumatology Department, Ospedale del Mare, Naples, Italy
| | - Alessandro Crosio
- Orthopaedics and Traumatology II, Surgery of the Hand and Upper Limb, AOU Città della Salute e della Scienza, CTO Hospital, Turin, Italy
| | - Bruno Battiston
- Orthopaedics and Traumatology II, Surgery of the Hand and Upper Limb, AOU Città della Salute e della Scienza, CTO Hospital, Turin, Italy.
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15
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Abstract
With the advent of the Industrial Revolution, traumatic injuries of the upper extremity increased exponentially. As a result, surgeons began to reevaluate amputation as the standard of care. Following the Second World War, local and regional pedicled flaps became common forms of traumatic upper extremity reconstruction. Today, microsurgery offers an alternative when options lower on the reconstructive ladder have been exhausted or will not produce a desirable result. In this article, the authors review the use of free tissue transfer for upper extremity reconstruction. Flaps are categorized as fasciocutaneous, muscle, and functional tissue transfers. The thin pliable nature of fasciocutaneous flaps makes them ideal for aesthetically sensitive areas, such as the hand. The radial forearm, lateral arm, scapula, parascapular, anterolateral thigh, and temporoparietal fascia flaps are highlighted in this article. Muscle flaps are utilized for their bulk and size; the latissimus dorsi flap serves as a "workhorse" free muscle flap for upper extremity reconstruction. Other muscle flaps include the rectus abdominis and serratus anterior. Lastly, functional tissue transfers are used to restore active range of motion or bony integrity to the upper extremity. The innervated gracilis can be utilized in the forearm to restore finger flexion or extension. Transfer of vascularized bone such as the fibula may be used to correct large defects of the radius or ulna. Finally, replacement of "like with like" is embodied in toe-to-thumb transfers for reconstruction of digital amputations.
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Affiliation(s)
- Rami Dibbs
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | - Luke Grome
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
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16
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Oh WT, Kang HJ, Chun YM, Koh IH, Lee YJ, Choi YR. Retrospective Comparative Outcomes Analysis of Arthroscopic Versus Open Bone Graft and Fixation for Unstable Scaphoid Nonunions. Arthroscopy 2018; 34:2810-2818. [PMID: 30173911 DOI: 10.1016/j.arthro.2018.04.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 04/23/2018] [Accepted: 04/25/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare union rates and clinical and radiologic outcomes after arthroscopic and open bone grafting and internal fixation for unstable scaphoid nonunions. METHODS Between March 2009 and November 2014, patients with unstable scaphoid nonunion underwent arthroscopic (group A) or open (group O) bone grafting and internal fixation. One senior surgeon alternatively performed either arthroscopic or open osteosynthesis for the same surgical indications. Visual analog scale score, grip strength, active range of motion, Mayo wrist score (MWS), and Disabilities of Arm, Shoulder, and Hand score were assessed preoperatively and postoperatively. Union was determined by computed tomography 8 to 10 weeks postoperatively with bridging trabecula at the nonunion site. Scapholunate angle (SLA), radiolunate angle (RLA), and lateral intrascaphoid angle (LISA), plus height/length ratio (HLR) served to gauge carpal bone alignment in preoperative and postoperative radiographs. Those outcomes of patients with carpal collapse deformities, who met following conditions; (1) LISA of >45° or HLR of >0.65 on computed tomography images or (2) SLA of >60° or RLA of >10° on plain radiographs, were also compared. RESULTS Overall, 62 patients qualified for study (group A, 28; group O, 34). Union rates did not differ by patient subset (group A, 96.4%; group O, 97.1%; P ≒ 1); and visual analog scale score, grip strength, range of motion, Mayo Wrist Score, and Disabilities of Arm, Shoulder, and Hand scores were similar at last follow-up. In radiographic assessments, SLA, RLA, and LISA were similar, whereas scaphoid HLR excelled through open technique (group A, 0.59 ± 0.07; group O, 0.55 ± 0.05; P = .002). Subgroup analysis of patients with carpal collapse deformities (group A, 9; group O, 14) showed that all radiographic measures in group A (vs group O) reflected lesser correction (SLA, 56.7° ± 7.3° vs 49.2°±9.1° [P = .049]; RLA, 9.2° ± 2.0° vs 5.7° ± 3.0° [P = .005]; LISA, 34.8° ± 4.8° vs 25.6° ± 13.0° [P = .028]; HLR, 0.66 ± 0.04 vs 0.54 ± 0.07 [P < .001]). CONCLUSIONS Arthroscopic and open bone grafting and internal fixation in treating unstable scaphoid nonunions, did not show any significant differences in clinical and radiologic outcomes at the minimum of 2 years after operation. In scaphoid nonunions with carpal collapse deformities, open bone grafting restored better carpal alignment than arthroscopic bone grafting, although there were no differences in clinical outcomes between the 2 techniques. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Won-Taek Oh
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Ho-Jung Kang
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Min Chun
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Il-Hyun Koh
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Jun Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yun-Rak Choi
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea.
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17
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Feasibility of a bone and soft tissue chimeric anterolateral thigh free flap? Anatomic study and report of two cases for oral cavity reconstruction. J Plast Reconstr Aesthet Surg 2018; 71:729-735. [DOI: 10.1016/j.bjps.2017.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 10/24/2017] [Accepted: 12/05/2017] [Indexed: 11/20/2022]
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18
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Reexploring the Anatomy of the Distal Humerus for its Role in Providing Vascularized Bone. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1636. [PMID: 29464165 PMCID: PMC5811295 DOI: 10.1097/gox.0000000000001636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 11/17/2017] [Indexed: 12/02/2022]
Abstract
Background: The lateral arm flap is used for composite defects in need of vascularized soft tissue, skin, and bone. From its original description, the distal humeral metaphysis can be included with the flap, supplied by the periosteal extensions of the posterior branch of the radial collateral artery. We sought to reexplore the anatomy of the lateral arm to determine its utility as a donor site for vascularized bone. Methods: Twelve fresh, silicone-injected cadaver dissections were performed. Arteriovenous anatomy, pedicle length and diameter, and anatomic variability as well as photo documentation was recorded. Results: The distal extent of the deltoid, lateral intermuscular septum and lateral humeral epicondyle were identified before the dissection. A septocutaneous perforator was consistently located 10 cm proximal to the lateral humeral epicondyle, which could be used for a skin paddle to monitor. Harvest of a 1.5 cm × 2 cm corticocancellous bone graft was performed. Average pedicle length was 9.1 ± 1.1 cm, and average pedicle diameter was 1.74 ± 0.52 mm. The inferior lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm were consistently identified and preserved. Conclusion: The predictable anatomy of the lateral distal humerus make it an ideal donor site for small segments of vascularized bone.
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Dumont CE, Keel MJ, Djonov V, Haefeli PC, Schmid T, Olariu R, Cullmann JL, Bastian JD. The Pararectus approach provides secure access to the deep circumflex iliac vessel for harvest of a large sized and vascularized segment of the iliac crest. Injury 2017; 48:2169-2173. [PMID: 28823386 DOI: 10.1016/j.injury.2017.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 08/05/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The feasibility of harvesting a vascularized iliac crest utilizing the Pararectus approach was assessed in cadavers and then this new technique was implemented in a clinical case. METHODS Bilaterally in five cadavers the branches of both external iliac arteries were injected with colored silicone to assess their position to each other and to harvest a bone graft vascularized by the deep circumflex iliac artery (DCIA) through the Pararectus approach. This technique was implemented in a 68-years-old female patient, initially admitted to a level-I-trauma center after sustaining multiple injuries by falling from great height. For definitive treatment of a severely contaminated medially open (Gustilo-Anderson Type 3A) calcaneal luxation fracture (Sanders type IIIBC) in this patient a vascularized iliac crest autograft harvest by the Pararectus approach was used for reconstructive surgery. RESULTS The DCIA and the deep inferior epigastric vessels (DIEV: vascularizing the rectus abdominis muscle and main pedicle of the inferiorly based rectus abdominis myocutaneous flap) are very close on the lateral and medial border of the external iliac artery, respectively. As a consequence, the retrograde dissection of the DIEV towards the DCIA through the Pararectus approach made the dissection of the vascularized iliac crest more amenable, preserving both the lateral femoral cutaneous and the genitofemoral nerves. Four months after the surgery the patient was able to fully weight-bear in orthopedic shoes. Radiographs and CT scans showed correct hind foot alignment and bony integration of the vascularized iliac crest graft into the residual calcaneal body. CONCLUSION The Pararectus approach allowed for secure collection of large vascularized iliac grafts. The presented technique was successful as a salvage procedure in a clinical case with substantial bone loss after an open calcaneal fracture.
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Affiliation(s)
- C E Dumont
- Department of Orthopaedic and Trauma Surgery, University of Bern, Inselspital, Bern, Switzerland
| | - M J Keel
- Department of Orthopaedic and Trauma Surgery, University of Bern, Inselspital, Bern, Switzerland
| | - V Djonov
- Institute of Anatomy, University of Bern, Switzerland
| | - P C Haefeli
- Department of Orthopaedic and Trauma Surgery, University of Bern, Inselspital, Bern, Switzerland
| | - T Schmid
- Department of Orthopaedic and Trauma Surgery, University of Bern, Inselspital, Bern, Switzerland
| | - R Olariu
- Department of Plastic and Hand Surgery, University of Bern, Inselspital, Switzerland
| | - J L Cullmann
- Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Switzerland
| | - J D Bastian
- Department of Orthopaedic and Trauma Surgery, University of Bern, Inselspital, Bern, Switzerland.
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20
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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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21
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Kang HJ, Chun YM, Koh IH, Park JH, Choi YR. Is Arthroscopic Bone Graft and Fixation for Scaphoid Nonunions Effective? Clin Orthop Relat Res 2016; 474:204-12. [PMID: 26250139 PMCID: PMC4686522 DOI: 10.1007/s11999-015-4495-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 07/31/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Arthroscopic management of scaphoid nonunions has been advanced as a less invasive technique that allows evaluation of associated intrinsic and extrinsic ligamentous injuries; however, few studies have documented the effectiveness of arthroscopic treatment of scaphoid nonunions and which intraarticular pathologies coexist with scaphoid nonunions. QUESTIONS/PURPOSES (1) What are the outcomes of arthroscopic management of scaphoid nonunions as assessed by the proportion of patients achieving osseous union, visual analog scale (VAS) pain score, grip strength, range of motion, Mayo Wrist Score (MWS), and Disabilities of the Arm, Shoulder and Hand (DASH) score? (2) What complications are associated with arthroscopic scaphoid nonunion management? (3) What forms of intraarticular pathology are associated with scaphoid nonunions? METHODS Between 2008 and 2012, we treated 80 patients surgically for scaphoid nonunions. Of those, 45 (56%) had arthroscopic management. During that time, our general indications for using an arthroscopic approach over an open approach were symptomatic scaphoid nonunions without necrosis of the proximal fragment, severe deformities, or arthritis. Of the patients treated arthroscopically, 33 (73%) were available for followup at least 2 years later. There were five distal third, 19 middle third, and nine proximal third fractures. The mean followup was 33 months (range, 24-60 months). Union was determined by CT taken at 8 to 10 weeks after operation with bridging trabecula at nonunion site. VAS pain scores, grip strength, active flexion-extension angle, MWS, and DASH scores were obtained preoperatively and at each followup visit. The coexisting intraarticular pathologies and complications were also recorded. RESULTS Thirty-two (97%) scaphoid nonunions healed successfully. At the last followup, the mean VAS pain score decreased (preoperative: mean 4.5 [SD 1.8], postoperative: mean 0.6 [SD 0.8], mean difference: 3.9 [95% confidence interval {CI}, 3.2-4.6], p < 0.001) and the mean active flexion-extension angle increased (preoperative: mean 100° [SD 26], postoperative: mean 109° [SD 16], mean difference: 9° [95% CI, 2-16], p = 0.017). The mean grip strength increased (preoperative: mean 35 kg of force [SD 8], postoperative: mean 50 kg of force [SD 10], mean difference: 15 kg of force [95% CI, 11-19], p < 0.001). The mean MWS increased (preoperative: mean 56 [SD 23], postoperative: mean 89 [SD 8], mean difference: 33 [95% CI, 26-41], p < 0.001) and the mean DASH score decreased (preoperative: mean 25 [SD 18], postoperative: mean 4 [SD 3], mean difference: 21 [95% CI, 15-28], p < 0.001). There were no operation-related complications and no progression of arthritis at the last followup. Seventeen patients had coexisting intraarticular pathology, including nine triangular fibrocartilage complex tears (seven traumatic and two degenerative), 17 intrinsic ligament tears (nine scapholunate interosseous ligament tears and eight lunotriquetral interosseous ligament tears), and five mild radioscaphoid degenerative changes. CONCLUSIONS Arthroscopic management of scaphoid nonunions without severe deformities or arthritis was effective in this small series. Although intraarticular pathologies such as triangular fibrocartilage complex tears and intrinsic ligament injuries commonly coexisted with scaphoid nonunions, patients generally achieved good results. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Ho Jung Kang
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 50 Yonseiro, Seodaemun-gu, Seoul, 120-752 South Korea
| | - Yong-Min Chun
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 50 Yonseiro, Seodaemun-gu, Seoul, 120-752 South Korea
| | - Il Hyun Koh
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 50 Yonseiro, Seodaemun-gu, Seoul, 120-752 South Korea
| | - Jae Han Park
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 50 Yonseiro, Seodaemun-gu, Seoul, 120-752 South Korea
| | - Yun Rak Choi
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 50 Yonseiro, Seodaemun-gu, Seoul, 120-752 South Korea
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22
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McInnes CW, Giuffre JL. Fixation and Grafting After Limited Debridement of Scaphoid Nonunions. J Hand Surg Am 2015; 40:1791-6. [PMID: 26162231 DOI: 10.1016/j.jhsa.2015.05.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 05/22/2015] [Accepted: 05/22/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate a surgical technique of treating nondisplaced waist and proximal pole scaphoid nonunions without avascular necrosis (AVN). METHODS We performed a retrospective review of all patients with nondisplaced, scaphoid waist or proximal pole nonunions without AVN treated with the following technique. Two K-wires are positioned along the scaphoid axis to stabilize the proximal and distal poles. Debridement with a curette or burr is performed parallel to the nonunion site until the K-wires are visualized and punctate bleeding of the proximal and distal fragments is encountered. The volar, radial fibrous union is left intact. Distal radius cancellous bone graft is packed into the nonunion site. A headless screw is placed perpendicular to the fracture and the K-wires are removed. RESULTS Between 2012 and 2014, 12 patients (ages 13-29 y) with clinical and radiographic evidence (10 had computed tomography or magnetic resonance imaging; 2 had radiographs only) of scaphoid nonunion were identified (10 transverse waist and 2 proximal pole fractures). Median interval from injury to surgery was 38 weeks (range, 3 mo to 9 y). Four patients were active smokers and 2 had failed previous iliac crest bone grafting. All patients healed as confirmed by computed tomography. Average time to union was 14 weeks (range, 6-31 wk). Four patients had delayed union requiring a bone stimulator. All patients had resolution of pain and there were no complications. CONCLUSIONS The technique described is an effective and efficient method of treating nondisplaced scaphoid nonunions without AVN. We suggest that complete debridement of the nonunion is not essential to achieve union. In addition, pinning the proximal and distal scaphoid poles initially and maintaining the volar fibrous union of the scaphoid nonunion stabilizes the fracture fragments, increasing the technical ease of grafting and fixation. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Colin W McInnes
- Section of Plastic Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jennifer L Giuffre
- Section of Plastic Surgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada.
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23
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Ben-Amotz O, Ho C, Sammer DM. Reconstruction of scaphoid non-union and total scaphoid avascular necrosis in a pediatric patient: a case report. Hand (N Y) 2015; 10:477-81. [PMID: 26330781 PMCID: PMC4551645 DOI: 10.1007/s11552-014-9711-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The medial femoral condyle vascularized bone graft has grown in popularity for treating recalcitrant fracture non-unions and has become particularly useful in treating scaphoid non-union with avascular necrosis of the proximal pole. The medial femoral condyle is an excellent source of dense, well-vascularized bone and results in minimal donor site morbidity. METHODS We describe an unusual case of chronic scaphoid non-union and total scaphoid avascular necrosis in a skeletally immature patient. Scaphoid reconstruction was performed with a vascularized medial femoral condyle graft, with successful graft incorporation, and restoration of pain-free wrist motion. CONCLUSIONS Technical considerations for harvest of the medial femoral condyle bone graft in the skeletally immature patient are discussed.
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Affiliation(s)
- Oded Ben-Amotz
- Department of Plastic Surgery, University of Texas Southwestern Medical Center at Dallas, 1801 Inwood Rd., Dallas, TX 75390 USA
| | - Christine Ho
- Department of Orthopedic Surgery, Texas Scottish Rite Hospital for Children-Children’s Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Douglas M. Sammer
- Department of Plastic Surgery, University of Texas Southwestern Medical Center at Dallas, 1801 Inwood Rd., Dallas, TX 75390 USA
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Houdek MT, Wagner ER, Wyles CC, Nanos GP, Moran SL. New options for vascularized bone reconstruction in the upper extremity. Semin Plast Surg 2015; 29:20-9. [PMID: 25685100 DOI: 10.1055/s-0035-1544167] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Originally described in the 1970s, vascularized bone grafting has become a critical component in the treatment of bony defects and non-unions. Although well established in the lower extremity, recent years have seen many novel techniques described to treat a variety of challenging upper extremity pathologies. Here the authors review the use of different techniques of vascularized bone grafts for the upper extremity bone pathologies. The vascularized fibula remains the gold standard for the treatment of large bone defects of the humerus and forearm, while also playing a role in carpal reconstruction; however, two other important options for larger defects include the vascularized scapula graft and the Capanna technique. Smaller upper extremity bone defects and non-unions can be treated with the medial femoral condyle (MFC) free flap or a vascularized rib transfer. In carpal non-unions, both pedicled distal radius flaps and free MFC flaps are viable options. Finally, in skeletally immature patients, vascularized fibular head epiphyseal transfer can provide growth potential in addition to skeletal reconstruction.
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Affiliation(s)
- Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Eric R Wagner
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Cody C Wyles
- School of Medicine, Mayo Clinic, Rochester, Minnesota
| | - George P Nanos
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Steven L Moran
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota ; Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
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25
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Abstract
Since the advent of the operating microscope by Julius Jacobson in 1960, reconstructive microsurgery has become an integral part of extremity reconstruction and orthopaedics. During World War I, with the influx of severe extremity trauma Harold Gillies introduced the concept of the reconstructive ladder for wound closure. The concept of the reconstructive ladder goes from simple to complex means of attaining wound closure. Over the last half century microsurgery has continued to evolve and progress. We now have a microsurgical reconstructive ladder. The microsurgical reconstruction ladder is based upon the early work on revascularization and replantation extending through the procedures that are described in this article.
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Affiliation(s)
- Scott M Tintle
- University of Pennsylvania, Philadelphia, PA, United States
| | - L Scott Levin
- University of Pennsylvania, Philadelphia, PA, United States.
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