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Bottini GB, Joos V, Steiner C, Zeman-Kuhnert K, Gaggl A. Advances in Microvascular Reconstruction of the Orbit and Beyond: Considerations and a Checklist for Decision-Making. J Clin Med 2024; 13:2899. [PMID: 38792440 PMCID: PMC11122336 DOI: 10.3390/jcm13102899] [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: 03/26/2024] [Revised: 05/02/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024] Open
Abstract
This paper aims to discuss the microvascular reconstruction of the orbit and adjacent regions and to propose a checklist to aid the reconstructive surgeon in this challenging undertaking. The discussion is based on a literature review that includes 32 retrospective case series, 5 case reports published in the last 34 years in PubMed, and 3 textbook chapters. Additionally, it relies on the senior author's expertise, described in a case series, and two case reports published elsewhere. Classifications and treatment algorithms on microvascular orbit reconstruction generally disregard patient-related factors. A more holistic approach can be advantageous: patient-related factors, such as age, comorbidities, prognosis, previous interventions, radiotherapy, and the wish for maximal dental rehabilitation and a prosthetic eye, have the same importance as defect-related considerations and can inform the choice of a reconstructive option. In this manuscript, we examine defect- and patient-related factors and new technologies, provide a checklist, and examine future directions. The checklist is intended as a tool to aid in the decision-making process when reconstructing the orbital region with microvascular flaps.
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Affiliation(s)
- Gian Battista Bottini
- Department of Oral and Maxillofacial Surgery and Centre for Reconstructive Surgery, University Hospital of the Private Medical University Paracelsus, 5020 Salzburg, Austria; (G.B.B.); (C.S.); (K.Z.-K.)
| | - Veronika Joos
- Private Practice for Dentistry and Oral and Maxillofacial Surgery, 5026 Salzburg, Austria
| | - Christoph Steiner
- Department of Oral and Maxillofacial Surgery and Centre for Reconstructive Surgery, University Hospital of the Private Medical University Paracelsus, 5020 Salzburg, Austria; (G.B.B.); (C.S.); (K.Z.-K.)
| | - Katharina Zeman-Kuhnert
- Department of Oral and Maxillofacial Surgery and Centre for Reconstructive Surgery, University Hospital of the Private Medical University Paracelsus, 5020 Salzburg, Austria; (G.B.B.); (C.S.); (K.Z.-K.)
| | - Alexander Gaggl
- Department of Oral and Maxillofacial Surgery and Centre for Reconstructive Surgery, University Hospital of the Private Medical University Paracelsus, 5020 Salzburg, Austria; (G.B.B.); (C.S.); (K.Z.-K.)
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Yamagata H, Nishida N, Imagama T, Okazaki T, Matsuki Y, Kaneoka T, Kawakami T, Kumaran Y, Suzuki H, Sakai T. Fracture risk assessment of vascularized medial femoral condylar bone graft: A finite element analysis. J Plast Reconstr Aesthet Surg 2024; 91:83-93. [PMID: 38402817 DOI: 10.1016/j.bjps.2024.01.046] [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: 07/24/2023] [Revised: 12/15/2023] [Accepted: 01/29/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Vascularized medial femoral condyle (MFC) bone graft is useful for pseudarthrosis and osteonecrosis, but has the risk of fracture as a complication. This study aimed to create multiple three-dimensional (3D) finite element (FE) femur models to biomechanically evaluate the fracture risk in the donor site of a vascularized MFC bone graft. METHODS Computer tomography scans of the femurs of nine patients (four males and five females) with no left femur disease were enrolled in the study. A 3D FE model of the left femur was generated based on the CT images taken from the patients. The descending genicular artery (DGA), the main nutrient vessel in vascularized MFC bone grafts, divides into the proximal transversal branch (TB) and the distal longitudinal branch (LB) before entering the periosteum. Thirty-six different bone defect models with different sizes and locations of the harvested bone were created. RESULTS The highest stress was observed in the proximal medial and metaphyseal portions under axial and external rotation, respectively. In the bone defect model, the stress was most elevated in the extracted region's anterior or posterior superior part. Stress increased depending on proximal location and harvested bone size. CONCLUSION Increasing the size of the bone graft proximally raises the stress at the site of bone extraction. For bone grafting to non-load-bearing areas, bone grafting distally using LB can reduce fracture risk. If TB necessitates a larger proximal bone extraction, it is advisable to avoid postoperative rotational loads.
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Affiliation(s)
- Hiroki Yamagata
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan.
| | - Norihiro Nishida
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan
| | - Takashi Imagama
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan
| | - Tomoya Okazaki
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan
| | - Yuta Matsuki
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan
| | - Takehiro Kaneoka
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan
| | - Takehiro Kawakami
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan
| | - Yogesh Kumaran
- Departments of Bioengineering and Orthopedic Surgery, University of Toledo Colleges of Medicine and Engineering, 2801 W. Bancroft, Toledo, OH 43606, USA
| | - Hidenori Suzuki
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan
| | - Takashi Sakai
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube City, Yamaguchi Prefecture 755-8505, Japan
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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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Karunaratne YG, Romeo PB. Vascularized Reconstruction of Recalcitrant Clavicular Nonunion with the Medial Femoral Condyle Free Flap: A Systematic Review of the Literature. J Hand Microsurg 2024; 16:100016. [PMID: 38854380 PMCID: PMC11127545 DOI: 10.1055/s-0043-1760767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
Recalcitrant clavicular nonunion is an uncommon but challenging problem. Vascularized bone reconstruction is not first-line therapy due to complexity and donor morbidity, though it has utility in select cases. A systematic review of Embase and Medline databases was undertaken for cases of medial femoral condyle reconstruction for clavicle nonunion. Ten studies met inclusion, encompassing 26 patients. Mean age was 38.9 years. Ten patients were male and 16 female. Mean time of nonunion was 37.79 months prior to intervention; mean time to union following medial femoral condyle flap was 7.60 months. Two patients did not achieve union. Of the 11 patients who previously had at least one failed fixation with bone graft, considered the current "gold standard", 9 patients (81.81%) went on to achieve union, while 2 patients (18.19%) did not. There were six reported complications in five patients. Medial femoral condyle flap is a valuable option in recalcitrant clavicle nonunion.
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Affiliation(s)
- Yasiru Gehan Karunaratne
- Department of Plastic and Reconstructive Surgery, Bankstown-Lidcombe Hospital, Sydney, NSW, Australia
| | - Pascalino Bruno Romeo
- Department of Plastic and Reconstructive Surgery, Nepean Hospital, Sydney, NSW, Australia
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Cha SM, Pai A, Lee HJ, Shin HD. Non-vascularised corticocancellous (tricortical) iliac bone graft longer than 3 cm for non-union after failed surgical treatment. J Plast Reconstr Aesthet Surg 2024; 88:37-44. [PMID: 37950990 DOI: 10.1016/j.bjps.2023.10.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/03/2023] [Accepted: 10/07/2023] [Indexed: 11/13/2023]
Abstract
PURPOSE We hypothesised that traditional iliac tricortical bone grafts (no vascularised) still have a reasonable role in promoting satisfactory bony healing in non-union defects of certain sizes. Here, we report the clinical/radiological outcomes through a retrospective case series. METHODS We screened 74 patients with definitive non-union in the long bones of the upper extremities who visited the outpatient department from 2008 to 2018. Among these patients, 25 who met our inclusion/exclusion criteria were investigated. RESULTS The mean age was 51.92 years, and there were 12, 9, 1, and 3 lesions of the radius, ulna, clavicle, and humerus, respectively. The tools for primary fixations were plate and intramedullary nails in 24 and 1 patients, respectively. Six patients presented with atrophic non-union. The mean period from a previous surgery was 6.84 months. The mean defective bone sizes were 1.81 and 3.50 cm pre-debridement and post-debridement, respectively. All devices had locking plates longer than the previous plate, and the graft was concurrently fixed by screws in three patients. At a mean of 15.92 weeks after the revision surgery, all patients experienced union. At the final follow-up, the clinical outcomes were satisfactory. No significant differences in clinical outcomes were found according to the lesion, type of non-union, period from the previous surgery, or harvest length of the iliac bone. CONCLUSIONS If the proper indications and some technical aspects are considered, a non-vascularised iliac bone graft longer than 3 cm could still be a reasonable option for treating diaphyseal non-union of the upper extremities. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Soo Min Cha
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Centre, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
| | - Ashwin Pai
- Department of Plastic Surgery, West Suffolk NHS Foundation Trust, United Kingdom
| | - Hyun Jong Lee
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Centre, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
| | - Hyun Dae Shin
- Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Centre, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea.
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Özdemir A, Odabaşı E, Eravsar E, Safalı S, Acar MA. Treatment of recalcitrant femur nonunion with pedicled corticoperiosteal medial femoral condyle flap. Sci Rep 2023; 13:20326. [PMID: 37990029 PMCID: PMC10663536 DOI: 10.1038/s41598-023-47432-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 11/14/2023] [Indexed: 11/23/2023] Open
Abstract
Periosteal or osteoperiosteal medial femoral condyle (MFC) flaps may be good options for atrophic nonunion. The aim of this study was to evaluate the effectiveness and safety of pedicled MFC flap in the treatment of recalcitrant femur nonunion without bone defect. Thirteen patients (11 male and 2 female), who suffered recalcitrant femur nonunion and were treated with pedicled osteoperiosteal MFC flap between January 2014 and April 2018, were included in this study. Patient files were reviewed retrospectively. Atrophic or recalcitrant 2/3 distal femoral nonunion were the indications for this clinical procedure. Demographics and operative data, flap size, visual analog scale (VAS) score, time to union, and complications were evaluated. A total of 13 patients underwent femur nonunion treatment with MFC flap after an average of 3.4 previous surgical procedures. The median age was 34 (Q1: 32.5, Q3:43) years old. The mean flap size was 4.3 × 6.4 cm, all nonunions healed in a median 5 months (Q1: 4.5, Q3: 6). There were an intraoperative knee medial collateral ligament injury in a patient, hematoma in a patient, and seroma in two patients. The median length of the follow-up was 40 months (Q1: 30, Q3: 47). There wasn't any additional complication in long-term follow-up. Functional outcomes were satisfactory. The median preoperative VAS score was 7 (Q1: 6, Q3: 9.5), decreasing to 1 (Q1: 0, Q3: 1) at the 6-month follow-up, and further reducing to 0 (Q1: 0, Q3: 1) at the 24-month follow-up. The nonunion period ranged from 6 to 18 months. The pedicled MFC flap is a good option for recalcitrant femur nonunion where larger vascularized flaps are not warranted. It is easy to harvest, does not require microvascular anastomosis, is effective, and offers minimal donor site morbidity.
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Affiliation(s)
- Ali Özdemir
- Department of Orthopaedics and Traumatology and Hand Surgery Konya, Selcuk University, Konya, Turkey.
| | - Egemen Odabaşı
- Department of Orthopaedics and Traumatology, Konya Beyhekim Training and Research Hospital, Konya, Turkey
| | - Ebubekir Eravsar
- Department of Orthopaedics and Traumatology, Konya City Hospital, Konya, Turkey
| | - Selim Safalı
- Department of Orthopaedics and Traumatology and Hand Surgery Konya, Selcuk University, Konya, Turkey
| | - Mehmet Ali Acar
- Department of Orthopaedics and Traumatology and Hand Surgery Konya, Selcuk University, Konya, Turkey
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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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Kobayashi Y, Uchiyama Y, Ishii T, Nakajima D, Yanagisawa S, Saito I, Watanabe M. Three cases of free flap anastomoses to the descending genicular artery for knee joint trauma with severe soft tissue injury. J Orthop Sci 2022; 27:734-738. [PMID: 31474521 DOI: 10.1016/j.jos.2019.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 08/06/2019] [Accepted: 08/08/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Yuka Kobayashi
- Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
| | - Yoshiyasu Uchiyama
- Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Takayuki Ishii
- Department of Orthopaedic Surgery, Tokai University Hachioji Hospital, Japan
| | - Daisuke Nakajima
- Department of Orthopaedic Surgery, Tokai University Hachioji Hospital, Japan
| | - Syou Yanagisawa
- Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Ikuo Saito
- Department of Orthopaedic Surgery, Isehara Kyodo Hospital, Japan
| | - Masahiko Watanabe
- Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
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Bottini GB, Hutya V, Kummer D, Steiner C, Zeman-Kuhnert K, Wittig J, Gaggl A. Microvascular reconstruction of the orbit and adjacent regions: A case series. ADVANCES IN ORAL AND MAXILLOFACIAL SURGERY 2022. [DOI: 10.1016/j.adoms.2022.100297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Reid I, Loh I, Bruscino-Raiola F. Vascularised periosteal free flap reconstruction for medication-related osteonecrosis of the jaw: a case series. AUSTRALASIAN JOURNAL OF PLASTIC SURGERY 2022. [DOI: 10.34239/ajops.v5n1.251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction: The standard of care for medication-related osteonecrosis of the jaw (MRONJ) involves anti-biotics and local debridement to promote tissue healing over exposed bone. We compare outcomes for patients with advanced MRONJ managed with vascularised periosteal radial forearm free flap (RFFF) ver-sus local nasolabial flap and conservative dental measures.
Methods: A retrospective case series of patients presenting to the Alfred Hospital for evaluation and man-agement of stage II or above MRONJ between 1 January 2014 and 30 June 2018. The hospital database was searched And a medical record review performed. Results of pre- and post-treatment imaging were ana-lysed bya single senior radiologist blinded to treatment modality . Asymptomatic wound closure, radio-logical evidence of disease cessation and patient satisfaction at six months post-treatment according to treatment type were assessed.
Results: Of the ten patients included in the study, four received dental measures, three received local na-solabial flap and three received RFFF flap. All flap reconstruction (6/6) showed asymptomatic wound clo-sure and patient satisfaction at six months follow-up compared to patients managed with dental measures (1/4). All RFFF patients (3/3) showed increased bone deposition radiologically at six months compared to the dental group who showed a mixed (3/4) picture or worsened (1/4) picture. Nasolabial flap patients showed a mixed (2/3) or improved radiological picture (1/3).
Conclusion: MRONJ is a relapsing disease. Preliminary evidence suggests that radical debridement with local nasolabial flap or RFFF reconstruction for advanced MRONJ is more effective at halting the disease and alleviating morbidity than conservative dental measures alone.
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Sakamoto S, Hattori Y, Doi K, Yamagata H, Nishida N, Sakai T. Iatrogenic distal femur fracture following medial femoral supracondylar bone graft harvest: a case report and finite element analysis. J Rural Med 2022; 17:270-275. [PMID: 36397795 PMCID: PMC9613362 DOI: 10.2185/jrm.2022-032] [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: 07/05/2022] [Accepted: 07/20/2022] [Indexed: 11/06/2022] Open
Abstract
Objective: This report presents a case of supracondylar femur fracture with finite element analysis and discusses its causes and prevention. Patient and Methods: A 53-year-old man presented with right talar osteonecrosis after osteosynthesis for a talus fracture. A medial femoral condyle-free vascularized bone graft
(size, 20 × 12 × 17 mm) from the contralateral femur was performed, including the posteromedial cortical corner. The patient suffered a donor-site supracondylar femoral fracture while
standing up from a cross-legged sitting position on the bed on postoperative day 6. The fracture was treated with intramedullary nailing. We analyzed the effects of the location of the bone
graft harvest in an intact model using the three-dimensional finite element method (FEM). Results: The talar necrosis and the femur fracture healed. The FEM result revealed that the longitudinal axial pressure had minimal effect on the femur; however, the stress
around the bone defect increased with rotation, especially in the posteromedial bone defect model. Conclusion: Harvesting the bone graft should not include the posteromedial corner of the supracondylar femur. The patient should strictly limit the motion of torsional stress,
such as standing from a cross-legged sitting position or pivoting turn.
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Affiliation(s)
- Sotetsu Sakamoto
- Department of Orthopedic Surgery, JA Ogori Daiichi General Hospital, Japan
| | - Yasunori Hattori
- Department of Orthopedic Surgery, JA Ogori Daiichi General Hospital, Japan
| | - Kazuteru Doi
- Department of Orthopedic Surgery, JA Ogori Daiichi General Hospital, Japan
| | - Hiroki Yamagata
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Japan
| | - Norihiro Nishida
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Japan
| | - Takashi Sakai
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Japan
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Zhou KJ, Graham DJ, Stewart D, Lawson RD, Sivakumar BS. Free Medial Femoral Condyle Flap for Reconstruction of Scaphoid Nonunion: A Systematic Review. J Reconstr Microsurg 2021; 38:593-603. [PMID: 34905783 DOI: 10.1055/s-0041-1740130] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The free medial femoral condyle (MFC) bone flap is an attractive option for reconstruction of scaphoid nonunion utilizing vascularized bone to augment bony healing, especially in cases of failed prior treatment or osteonecrosis. This review aims to determine the role and reliability of the free MFC flap for treatment of scaphoid nonunion. METHODS A search of electronic databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles examining free MFC bone flaps for treatment of scaphoid nonunion were included for analysis. Outcomes of interest included flap failure, postoperative union rate, time to union, carpal indices, functional outcomes, and complications. RESULTS Twelve articles met the inclusion criteria. A total of 262 patients underwent free MFC flaps for treatment of scaphoid nonunion. The most common site of nonunion was the proximal pole of the scaphoid with 47% of patients receiving prior attempts at operative management. Overall bony union rate was 93.4% with a mean time to union of 15.6 weeks. There were no flap failures reported. Improvements in carpal indices including scapholunate (p < 0.0004), radiolunate (p < 0.004), lateral interscaphoid angles (p < 0.035), and revised carpal ratio height (p < 0.024) were seen postoperatively. Visual analog scale improved postoperatively from 6.5 to 2.3 (p < 0.015). Postoperative complications were observed in 69 cases (26.3%), with 27 patients (10.3%) requiring further operative intervention. However, no major donor or recipient site morbidity was appreciated. CONCLUSION MFC flaps provide a highly versatile and reliable option for reconstruction of scaphoid nonunion with excellent bony union rates and acceptable complication rates. The present literature suggests that MFC reconstruction of scaphoid nonunion restores radiocarpal anatomy and improves wrist function without causing significant donor or recipient site morbidity.
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Affiliation(s)
- Kiane J Zhou
- Central Clinical School, University of Sydney, Camperdown, New South Wales, Australia
| | - David J Graham
- Department of Orthopaedic Surgery, Gold Coast University Hospital, Southport, Queensland, Australia
| | - David Stewart
- Department of Hand & Peripheral Nerve Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Richard D Lawson
- Department of Hand & Peripheral Nerve Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Brahman S Sivakumar
- Department of Hand & Peripheral Nerve Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia.,Department of Orthopaedic Surgery, Hornsby Ku-Ring-Gai Hospital, Hornsby, New South Wales, Australia
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Klarendić A, Dovšak T. Femur Fracture Following Medial Femoral Condyle Flap Harvest: A Case Report. OPEN ACCESS SURGERY 2021. [DOI: 10.2147/oas.s333899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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14
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Neuwirth M, Ziegler T, Benedikt S, Winter R, Kamolz LP, Schintler M, Rab M, Mueller-Eggenberger M, Mischitz M, Palle W, Hoenck K, Schoellnast H, Janek E, Borenich A, Buerger H. Donor site morbidity after the harvest of microvascular flaps from the medial and lateral femoral condyle region: Objective, radiologic, and patient-reported outcome of a multi-center trial. J Plast Reconstr Aesthet Surg 2021; 75:160-172. [PMID: 34635456 DOI: 10.1016/j.bjps.2021.08.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 06/27/2021] [Accepted: 08/26/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND With the experience-based hypothesis of low donor site morbidity (DSM) for free flaps from the distal femur, this cohort study aimed to evaluate the DSM according to objective and reproducible criteria. METHODS One hundred and fifty-six patients who had a flap harvest from either the medial or lateral femoral condyle region between 2005 and 2017 were included. A retrospective chart review was performed for all patients. In total, 97 patients were available for a follow-up examination. Outcomes were assessed according to objective (Knee Society Score; Larson Knee Score; OAK Score; 0-100 points), patient-reported (IKDC Score; KOOS Score; 0-100 points), and radiologic criteria (Kellgren and Lawrence Score; MRI Osteoarthritis Knee Score). RESULTS The median follow-up time was 1,529 days (range: 248-4,810). The mean Knee Society Score (94.8 ± 10.1), Larson Knee Score (94.5 ± 10.1), and OAK Score (95.5 ± 6.6) showed nearly unimpaired knee function. The overall patient-reported DSM was low (IKDC Score: 86.7 ± 17.4; KOOS Score: 89.3 ± 17.1). Osteochondral (OC) flaps had a significantly higher DSM, regardless of the donor site. Bone flaps did not show any relevant radiologic morbidity in the Kellgren and Lawrence Score. Besides the procedure-associated cartilage lesions at the OC donor sites, MRI Osteoarthritis Knee Score did not show any significant presence of further knee pathologies in the bilateral MRI Scans. The obvious cartilage lesions did not have a relevant impact on the knee function of most patients. CONCLUSION The DSM for bone and soft-tissue flaps from the femoral condyle region is negligible. OC flaps are associated with a significantly higher DSM, although a clinically relevant impact on knee function was not evident in the majority of patients.
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Affiliation(s)
- Maximilian Neuwirth
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria; Departement of Plastic, Aesthetic and Reconstructive Surgery, General Hospital Klagenfurt am Woerthersee, Feschnigstraße 11, Klagenfurt 9020, Austria.
| | - Thomas Ziegler
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
| | - Stefan Benedikt
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
| | - Raimund Winter
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
| | - Lars P Kamolz
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
| | - Michael Schintler
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
| | - Matthias Rab
- Departement of Plastic, Aesthetic and Reconstructive Surgery, General Hospital Klagenfurt am Woerthersee, Feschnigstraße 11, Klagenfurt 9020, Austria
| | - Michael Mueller-Eggenberger
- Departement of Plastic, Aesthetic and Reconstructive Surgery, General Hospital Klagenfurt am Woerthersee, Feschnigstraße 11, Klagenfurt 9020, Austria
| | - Madeleine Mischitz
- Departement of Plastic, Aesthetic and Reconstructive Surgery, General Hospital Klagenfurt am Woerthersee, Feschnigstraße 11, Klagenfurt 9020, Austria
| | - Wolfgang Palle
- Department of Trauma Surgery, Hospital Friesach, Austria
| | - Karina Hoenck
- Department of Trauma Surgery, Hospital Friesach, Austria
| | - Helmut Schoellnast
- Division of General Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Elmar Janek
- Division of General Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Andrea Borenich
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Austria
| | - Heinz Buerger
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria; Departement of Plastic, Aesthetic and Reconstructive Surgery, General Hospital Klagenfurt am Woerthersee, Feschnigstraße 11, Klagenfurt 9020, Austria; Division of Hand and Microsurgery, Private Hospital Maria Hilf, Austria
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Singh K, Huang TCT, Meaike JD, Mills AM, Nathan JM, Lettieri SC, Arce K, Moran SL. The Medial Femoral Condyle Free Flap for Reconstruction of Recalcitrant Defects in the Head and Neck. Ann Plast Surg 2021; 87:291-297. [PMID: 34397517 DOI: 10.1097/sap.0000000000002736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Small recalcitrant defects of the mandible and maxilla may be secondary to tumor, trauma, infection, and congenital origin. Vascularized bone grafting has been shown to effectively manage these defects; however, donor sites are limited. The vascularized medial femoral condyle (MFC) provides adequate cortical cancellous bone with the option of a skin island, consistent anatomy, and minimal donor site morbidity. This article outlines the use of the MFC flap for maxillomandibular reconstruction. METHODS A retrospective chart review of patients who required segmental maxillomandibular reconstruction with the MFC flap was conducted. A total of 9 patients (5 men and 5 women) with an average age of 45.3 years were identified. The etiology of the defects, flap sizes, and postoperative outcomes were recorded. RESULTS Three patients had osteoradionecrosis of the neomandible after irradiation of the free fibula reconstruction, 3 patients had defects after cancer extirpation (1 mandible, 2 maxillary), 1 patient had a maxillary defect from trauma, and 2 patients had a residual cleft palate defect. All defects failed initial treatment with nonvascularized bone grafts. The average dimensions of the MFC flaps were 1.2 × 2.5 × 4 cm. Two of 9 flaps included a skin island. Eight flaps survived completely, but 1 patient suffered from flap failure requiring debridement and resulted in an oroantral fistula. Four patients received endosseous dental implants. Average time to union was 6.7 months, and average time to implant was 6.75 months. The average follow-up time was 24.9 months. CONCLUSIONS The MFC flap is useful in the reconstruction of small segmental maxillomandibular defects and for the salvage of a neomandible after osteoradionecrosis. The MFC flap provides a reliable platform for endosseous dental implants and serves as an alternative source of vascularized bone reconstruction in the head and neck.
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Affiliation(s)
- Kuldeep Singh
- From the Division of Plastic Surgery, Department of Surgery
| | - Tony C T Huang
- From the Division of Plastic Surgery, Department of Surgery
| | - Jesse D Meaike
- From the Division of Plastic Surgery, Department of Surgery
| | - Andrew M Mills
- From the Division of Plastic Surgery, Department of Surgery
| | - John M Nathan
- Section of Head and Neck Oncologic Surgery and Reconstruction, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - Kevin Arce
- Section of Head and Neck Oncologic Surgery and Reconstruction, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Steven L Moran
- From the Division of Plastic Surgery, Department of Surgery
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Abstract
BACKGROUND The use of free flaps from the medial femoral condyle has grown in popularity and is now a workhorse in the reconstruction of skeletal defects. The utility of this technique has not yet been described for the pediatric patient population. The authors present their series of pediatric patients who underwent surgery using a medial femoral condyle free flap or a variant thereof in skeletal reconstruction and demonstrate the efficacy of this technique in this population. METHODS A multi-institutional retrospective review of patients aged 18 years or younger who required a medial femoral condyle flap for skeletal reconstruction was undertaken. Operative technique, radiographs, and clinical outcomes were recorded. A novel technique (Innocenti) was used to avoid the distal femoral physis in which a Kirschner wire was placed under fluoroscopic guidance just proximal to the growth plate. RESULTS Thirteen patients met inclusion criteria, with an average age of 14.7 years (range, 7 to 18 years) and mean follow-up of 28 months (range, 3 to 120 months). Six were skeletally immature at the time of medial femoral condyle harvest, with the last patient having organic bone disease, putting her at risk for pathologic fracture. All 13 patients achieved bony union, and no patients suffered pathologic fractures or physeal injuries; no patients developed length discrepancies. CONCLUSIONS The authors present the first series of corticocancellous medial femoral condyle free flaps in the pediatric population along with a novel technique to avoid injury to the physis in skeletally immature patients. This technique is effective for a variety of skeletal defects or nonunions and is safe for growing patients without causing physeal arrest or growth disturbance. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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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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Politikou O, Wirth S, Giesen T, Guggenberger R, Giovanoli P, Calcagni M. Corticoperiosteal medial femoral condyle flap for recalcitrant nonunion in ankle and foot: Outcomes and radiological evaluation of donor site morbidity. Foot Ankle Surg 2020; 26:918-923. [PMID: 32067885 DOI: 10.1016/j.fas.2019.12.008] [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: 09/11/2019] [Revised: 11/11/2019] [Accepted: 12/29/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the effectiveness and safety of free corticoperiosteal medial femoral condyle (MFC) flap for ankle, hindfoot and midfoot reconstruction in patients with recalcitrant nonunion. METHODS Patients who underwent ankle and foot reconstruction using the MFC flap at our clinic were recruited for assessment of the union rate, time to union and functional outcome. Furthermore, a clinical and radiological examination of the donor knee was performed using both computed tomography and magnetic resonance imaging. RESULTS Thirteen patients with a mean follow-up time of 2.5 years were included; 10 of them had a previously failed ankle and foot arthrodesis. Union was achieved in 11 patients in an average time of 10 months after MFC flap surgery. Donor site morbidity was minor with no radiological evidence for soft tissue or bone complication. CONCLUSION MFC flaps are a useful and safe reconstructive tool and may be considered after failed ankle and foot arthrodesis.
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Affiliation(s)
- Olga Politikou
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
| | - Stephan Wirth
- Division Foot and Ankle Surgery, Orthopaedics Department, University Hospital Balgrist, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Thomas Giesen
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
| | - Roman Guggenberger
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
| | - Pietro Giovanoli
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
| | - Maurizio Calcagni
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
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Guzzini M, Arioli L, Rugiero C, Rossini M, Argento G, Ferretti A. Donorsite defect of medial femoral condyle corticoperiostal flap in the treatment of lower limb infected nonunions. HANDCHIR MIKROCHIR P 2020; 53:376-382. [PMID: 33184802 DOI: 10.1055/a-1240-0181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUNDS Chronic osteomyelitis is a major challenge in orthopaedic surgery; it is the result of open fracture, periprosthetic infection and septic arthritis. Osteomyelitis leads to fracture nonunion. The treatment of bone infection and infected nonunion consists primarily of the complete removal of infected and avascular bone and soft tissue from the surgical site, followed by local and systemic pathogen-specific antibiotic therapy and temporary stabilisation, but may lead to massive skeletal and soft tissue defects. The use of free or pedicled vascularised bone transfers and callus distraction techniques (bone transport) has been recommended for large bone defects. The aim of this study is to evaluate the results of patients affected by infected non-unions of the lower limbs, treated with a corticoperiosteal flap from the medial femoral condyle and to investigate the donor site morbidity of this flap. MATERIALS AND METHODS The patients were 11 males (average age of 45.6 years), who presented a nonunion of the tibial diaphysis in 7 cases and non-union of femoral diaphysis in 4 cases, treated with free or pedicled corticoperiosteal flap. In all patients, surgical debridement was performed before the flap of infected bone and soft tissues that would not contribute to wound healing. Clinical and radiographic evaluations of the recipient site were performed. Preoperative and postoperative X-ray and MRI scans after the 3-year follow-up of the donor site were performed, in order to observe possible bone restoration and any complications. RESULTS The patients reported complete clinical and radiographic bone healing in 90.9 % of cases. As regards donor site, there were no differences between the medial femoral donor condyle compared to the contralateral site, due to complete regeneration of donor site bone. MRI investigation showed complete restoration of the donor site with vascularised bone in all patients. CONCLUSIONS Our results suggest that the use of bone flaps for the treatment of infected non-unions is an effective procedure, that must be performed after accurate debridement of the non-union site. The corticoperiosteal flap seems to have few morbidities on the donor site and a high percentage of successful bone healing.
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Affiliation(s)
- Matteo Guzzini
- Università degli Studi di Roma La Sapienza Ortopedia e Traumatologia
| | - Leopoldo Arioli
- Università degli Studi di Roma La Sapienza Ortopedia e Traumatologia
| | - Clelia Rugiero
- Università degli Studi di Roma La Sapienza Ortopedia e Traumatologia
| | - Marco Rossini
- Università degli Studi di Roma La Sapienza Ortopedia e Traumatologia
| | | | - Andrea Ferretti
- Università degli Studi di Roma La Sapienza Ortopedia e Traumatologia
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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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Deng AD, Innocenti M, Arora R, Gabl M, Tang JB. Vascularized Small-Bone Transfers for Fracture Nonunion and Bony Defects. Clin Plast Surg 2020; 47:501-520. [PMID: 32892797 DOI: 10.1016/j.cps.2020.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Vascularized small-bone grafting is an efficient and often necessary surgical approach for nonunion or necrosis of several bones in particular sites of the body, including scaphoid, lunate, distal ulna, and clavicle. The medial femoral condyle is an excellent graft source that can be used in treating scaphoid, ulna, clavicle, or lower-extremity bone defects, including nonunion. Vascularized bone grafting to the small bones, particularly involving reconstruction of damaged cartilage surfaces, should enhance subchondral vascular supply and help prevent cartilage regeneration. Vascularized osteoperiosteal and corticoperiosteal flaps are useful for treating nonunion of long bones.
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Affiliation(s)
- Ai Dong Deng
- Department of Hand Surgery, Affiliated Hospital of Nantong University, 20 West Temple Road, Nantong 226001, Jiangsu, China
| | - Marco Innocenti
- Plastic Surgery, University of Florence Careggi University Hospital, CTO, Largo Palagi 150139, Florence, Italy
| | - Rohit Arora
- Department of Trauma Surgery and Sports Medicine, Medical University Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Markus Gabl
- Department of Trauma Surgery and Sports Medicine, Medical University Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria
| | - Jin Bo Tang
- Department of Hand Surgery, Affiliated Hospital of Nantong University, 20 West Temple Road, Nantong 226001, Jiangsu, China.
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Iatrogenic Femur Fracture Following Medial Femoral Condyle Flap Harvest. J Hand Surg Am 2020; 45:885.e1-885.e3. [PMID: 32089380 DOI: 10.1016/j.jhsa.2019.12.001] [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: 10/15/2019] [Accepted: 12/03/2019] [Indexed: 02/02/2023]
Abstract
A case of iatrogenic femoral fracture after harvest of a medial femoral condyle flap is presented. The procedure was performed for a recalcitrant nonunion of the clavicle that required a flap of 6 × 1 × 1 cm. The patient suffered a supracondylar fracture at the proximal extent of the flap harvest site 3 weeks after surgery, requiring surgical fixation of the femur.
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Medial Femoral Condyle Vascularized Bone Graft for Treatment of Midshaft Clavicle Recalcitrant Nonunion With Use of the Transverse Cervical Artery as an Anastomosis. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:JAAOSGlobal-D-19-00049. [PMID: 32656481 PMCID: PMC7322782 DOI: 10.5435/jaaosglobal-d-19-00049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 10/24/2019] [Indexed: 12/01/2022]
Abstract
Vascularized medial femoral condyle bone grafts have been reported to be a reliable treatment for recalcitrant bony nonunions of the extremities. Although clavicle fracture nonunions are rare after treatment with open reduction internal fixation, symptomatic nonunions can be a challenge. The medial femoral condyle vascularized bone graft has been described as a treatment option for clavicle nonunions with the thoracoacromial trunk as the recipient anastomosis site. This case illustrates how the transverse cervical artery and accompanying veins can be used as an anastomosis when the thoracoacromial trunk is inaccessible because of previous surgical- and infection-related scaring. At the final follow-up, the patient had returned to full duty and resumed competitive triathlons. Radiographs demonstrated complete healing of clavicle fracture.
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Use of a Free Vascularized Medial Femoral Condyle Flap for Revision Surgery in a Pediatric Patient with Congenital Pseudarthrosis of the Clavicle. Case Rep Orthop 2020; 2020:8872934. [PMID: 32685226 PMCID: PMC7341426 DOI: 10.1155/2020/8872934] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 11/17/2022] Open
Abstract
The most common surgical treatment for congenital pseudarthrosis of the clavicle (CPC) is resection of the pseudarthrosis, placement of an autologous bone graft, and Kirschner wire or plate fixation. However, in some cases, bone fusion cannot be achieved at the first surgery, and an additional surgery is required. We present a case report of a boy with a right CPC who failed radiographic bone union after the first surgery. He subsequently underwent revision surgery with resection of the pseudarthrosis, plate fixation, and establishment of a vascularized medial femoral condyle (MFC) flap to ensure bone union. Three months after the revision surgery, a radiographic bone union was achieved, and no symptoms were observed for one year after the operation. There have been no previous reports of the use of a vascularized MFC flap as a treatment for CPC. We believe that this technique effectively ensures bone union during revision surgery for CPC.
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Jaloux C, Bettex Q, Levadoux M, Cerlier A, Iniesta A, Legre R, Mayoly A, Gay A. Free vascularized medial femoral condyle corticoperiosteal flap with non-vascularized iliac crest graft for the treatment of recalcitrant clavicle non-union. J Plast Reconstr Aesthet Surg 2020; 73:1232-1238. [PMID: 32414702 DOI: 10.1016/j.bjps.2020.03.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/24/2020] [Accepted: 03/26/2020] [Indexed: 11/19/2022]
Abstract
Clavicle non-union is a challenging problem. Open reduction with internal fixation and autologous bone grafting is usually the first line treatment. In case of failure, the medial femoral condyle corticoperiosteal flap in association with a non-vascularized bone graft is one of the therapeutic options, which is well adapted to the clavicle anatomical characteristics. We performed a retrospective study of all patients treated with this technique in our department. Between 2014 and 2017, five patients with recalcitrant post traumatic clavicle non-unions received this surgical treatment. The average nonunion time period was 50.2 month (range 10 to 108 months), and the mean defect length was 3.4 cm (between 2 and 5 cm), defects were all located in the medial third of the clavicle Three patients achieved full consolidation with an average time of consolidation of 8,7 months (range 6 to12 months). Patients with radiological consolidation had better functional improvement and pain reduction with an average DASH score improved from 53,6 before surgery to 19,6 after consolidation (at the last follow up visit). There was one donor site complications (hematoma). The medial femoral condyle corticoperiosteal flap with non-vascularized iliac crest graft is a good option for the management of recalcitrant clavicle non-union, especially when the bone defect is small.
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Affiliation(s)
- Charlotte Jaloux
- Department of Hand Surgery and Plastic and reconstructive surgery of the limbs - La Timone University Hospital - Assistance Publique Hôpitaux de Marseille, France.
| | - Quentin Bettex
- Department of Hand Surgery and Plastic and reconstructive surgery of the limbs - La Timone University Hospital - Assistance Publique Hôpitaux de Marseille, France
| | - Michel Levadoux
- Department of hand, upper limb and peripheral nerves surgery - Clinique Saint Roch, Toulon, France
| | - Alexandre Cerlier
- Department of Hand Surgery and Plastic and reconstructive surgery of the limbs - La Timone University Hospital - Assistance Publique Hôpitaux de Marseille, France
| | - Aurélie Iniesta
- Department of Hand Surgery and Plastic and reconstructive surgery of the limbs - La Timone University Hospital - Assistance Publique Hôpitaux de Marseille, France
| | - Régis Legre
- Department of Hand Surgery and Plastic and reconstructive surgery of the limbs - La Timone University Hospital - Assistance Publique Hôpitaux de Marseille, France
| | - Alice Mayoly
- Department of Hand Surgery and Plastic and reconstructive surgery of the limbs - La Timone University Hospital - Assistance Publique Hôpitaux de Marseille, France
| | - André Gay
- Department of Hand Surgery and Plastic and reconstructive surgery of the limbs - La Timone University Hospital - Assistance Publique Hôpitaux de Marseille, France
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26
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Son JH, Giladi AM, Higgins JP. Iatrogenic femur fracture following medial femoral condyle flap harvest eventually requiring total knee arthroplasty in one patient. J Hand Surg Eur Vol 2019; 44:320-321. [PMID: 30497318 DOI: 10.1177/1753193418813687] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Ji H Son
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Aviram M Giladi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - James P Higgins
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, USA
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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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Versatility of the Medial Femoral Condyle Flap for Extremity Reconstruction and Identification of Risk Factors for Nonunion, Delayed Time to Union, and Complications. Ann Plast Surg 2018; 80:364-372. [DOI: 10.1097/sap.0000000000001332] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zhao D, Cao M, Wang T, Wang B, Liu B, Lineaweaver WC. Pedicled iliac crest bone flap transfer for the treatment of upper femoral shaft fracture nonunion: An anatomic study and clinical applications. Microsurgery 2017; 38:882-888. [PMID: 29214678 DOI: 10.1002/micr.30278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 10/14/2017] [Accepted: 11/17/2017] [Indexed: 11/12/2022]
Abstract
PURPOSE We present the results of a study on the anatomy of the ascending branch of the lateral circumflex femoral artery (AB-LCFA) and the use of the pedicled iliac bone flap transfer perfused by AB-LCFA combined with external fixation for the treatment of the nonunion of upper femoral shaft fractures. METHODS The orientation, diameter, length, and distribution of the AB-LCFA from 40 lower limbs of adult cadavers were dissected and measured. From 2000 to 2012, 13 patients with nonunion of upper femoral shaft fractures underwent pedicled iliac bone flap transfer perfused by the AB-LCFA combined with external fixation. The time of bone fracture union was recorded based on X-ray examination. The functional results of the femoral shaft were evaluated by the Klemm classification. RESULTS The lateral circumflex femoral artery (LCFA) divided into ascending, transverse, and descending branches in 32 specimens (80%). The diameter of the AB-LCFA at the origin was 3.15 ± 0.9 mm and the length of the AB-LCFA was 8.51 ± 3.06 cm. The postoperative course of the procedure was uneventful in all 13 patients. The average follow-up was 15 months. Bone union was achieved in all patients and the average union time was 5.3 months. 12 patients achieved excellent or good functional results based on the Klemm classification. CONCLUSION The AB-LCFA has a consistent orientation and abundant blood flow. The transfer of the iliac crest bone flap perfused by the AB-LCFA while combined with external fixation could be an option for treating the nonunion of upper femoral shaft fractures.
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Affiliation(s)
- Dewei Zhao
- Department of Orthopedic Surgery, Zhongshan Hospital of Dalian University, Dalian, People's Republic of China
| | - Meng Cao
- Department of Orthopedic Surgery, Zhongshan Hospital of Dalian University, Dalian, People's Republic of China
| | - Tienan Wang
- Department of Orthopedic Surgery, Zhongshan Hospital of Dalian University, Dalian, People's Republic of China
| | - Benjie Wang
- Department of Orthopedic Surgery, Zhongshan Hospital of Dalian University, Dalian, People's Republic of China
| | - Baoyi Liu
- Department of Orthopedic Surgery, Zhongshan Hospital of Dalian University, Dalian, People's Republic of China
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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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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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