Vascularized medial femoral condyle graft for thumb metacarpal reconstruction: case report

Vascularized Medial Femoral Condyle Flap Reconstruction for Osseous Defects of the Hand and Wrist

Vascularized bone flaps from the descending genicular artery system are versatile and effective for the use of recalcitrant nonunions from the tubular bones of the hand to the long bones of the upper extremity. Familiarity with the vascular pedicle, various techniques of harvest and inset, and skin paddle harvest and application are essential for the reconstructive surgeon.

Vascularized Origami Medial Femoral Condyle Flap for Finger Joint Reconstruction

SUMMARY

Total finger joint reconstruction is challenging. Vascularized toe joint transfer is currently used for reconstruction, but it is difficult to perform, fails to achieve maximal joint flexibility, and is associated with donor-site complications. As an alternative, the authors developed a vascularized medial femoral condyle flap technique, wherein the vascularized corticoperiosteum is shaped via origami, with the donor tissue folded to fit the recipient site. In this article, the authors describe the use of this method for reconstruction of interphalangeal and metacarpophalangeal joints with a reduced range of motion. The mean age of the patients (three men and four women) was 51 years (range, 36 to 68 years), and the mean follow-up period was 3 years 1 month (range, 4 months to 5 years). In the reconstructed joints, the mean range of motion; Disabilities of the Arm, Shoulder, and Hand score; and pinch strength of the unaffected side were 55 degrees (range, 24 to 90 degrees), 2.3 (range, 0 to 6), and 98% (range, 70% to 38%), respectively. No donor-site morbidities were observed. Radiography and computed tomography scans revealed joint-like grafted tissue remodeling. The study findings suggest that the origami medial femoral condyle flap is useful for functional finger joint reconstruction. The procedure requires fabrication before grafting, but tissue harvest is relatively easy.

Metacarpophalangeal Joint Reconstruction of a Complex Hand Injury with a Vascularized Lateral Femoral Condyle Flap Using an Individualized 3D Printed Model-A Case Report

This case report describes the surgical management of a patient with a complex hand trauma. This injury included tendon, vascular, and nerve injuries, a partial amputation of the index finger, fractures of the third proximal phalanx, and destruction of the metacarpophalangeal joint of the fifth finger. Firstly, the acute treatment of a complex hand injury is described. Secondly, the planning and execution of a joint reconstruction using a vascularized lateral femoral condylar flap, assisted by an individual 3D model, is illustrated. Precise reconstruction of the affected structures resulted in good revascularization as well as an anatomical bone consolidation. Intensive physical therapy, including autonomous proprioceptive range-of-motion exercises by the patient, resulted in significant functional improvement of the hand in daily life. Overall, we report on the successful reconstruction of a metacarpophalangeal joint by using a vascularized flap from the lateral femoral condyle. Furthermore, this case report highlights the efficacy of integrating individualized 3D printing technology to plan complex reconstructions, opening up promising opportunities for personalized and optimized interventions.

Medial Femoral Condyle Free Flap for Persistent Osseous Nonunion of the First Metatarsophalangeal Joint: A Preliminary Report of a New Surgical Indication for the Medial Femoral Condyle Free Flap

Background

Recalcitrant or persistent nonunions of the metatarsophalangeal (MTP) joint occur following failed MTP surgery for MTP fusion, failed MTP prosthesis, for hallux rigidus or due to infection and erosion. A deficient soft tissue envelope and compromised vascular supply of tissues in this region compound further attempts to salvage the great toe and preserve function. The medial femoral condyle (MFC) free flap provides vascularized corticocancellous bone and periosteum and has been successfully used for a variety of complex hindfoot and ankle pathologies. We present an additional indication with a small cohort study demonstrating its use in persistent nonunions of the first MTP joint.

Methods

A retrospective review was completed of all MFC flaps used for revision of failed first MTP joint fusion from January 2019 to November 2022. Demographic information, comorbidities, as well as clinical and radiologic follow-up was obtained from the patient charts.

Results

Three patients were included with MTP nonunion and an average of 7.5 (range, 5-11) failed prior surgeries. Mean age at index surgery was 50 (range, 46-57) years. An osseous union was achieved in all patients after 82 (range, 75-88) days. Hardware removal was possible after 81 (range, 55-98) days. Mean follow-up was 17 (range, 5-31) months. We note a 100% flap success rate without returns to the operating room. The lengths of the bone flaps were 2 to 4 cm, the volumes were 8 to 12 cm3. Fixation was performed with 1 intramedullary K-wire. The recipient vessel in all patients was the dorsalis pedis artery or a tributary thereof. All arterial anastomoses were performed under the operating microscope.

Conclusion

The MFC free flap is a reasonable option for salvage of complex recalcitrant or persistent nonunions of the first MTP joint. More prospective long-term studies with functional outcomes are necessary to confirm these findings.

Level of Evidence

Level IV, retrospective case series.

Reconstruction of the Fourth Metacarpal Using a Chimeric Medial Femoral Condyle Vascularized Osteochondral Cutaneous Graft: Case Report

BACKGROUND

The medial femoral condyle has become a matter of great interest, thanks to the possibility of harvesting versatile chimeric flaps for reconstruction of metacarpal defects with minimal donor site morbidity. This case stands out because of the complete reconstruction of the metacarpal head, harvesting with a skin paddle for tension-free closure and monitoring, and the use of external fixation for better predictability of the reconstruction and early postoperative mobilization.

CASE PRESENTATION

We report the case of a 20-year-old male patient who presented with an aneurysmal bone cyst involving the fourth metacarpal bone. The patient underwent resection en bloc of the metaphysis and distal epiphysis of the fourth metacarpal bone, and the bone defect was reconstructed using a 3.4-cm vascularized osteochondral cutaneous graft from the medial femoral condyle.

RESULTS

At 1-year follow-up, the patient showed no impairment in hand range of motion and had a Disabilities of Arm, Shoulder and Hand score inferior to that of the male healthy population. Almost 5 years after the procedure, the radiographic examination did not reveal signs of arthrosis. This case report shows that the medial femoral condyle is an excellent and versatile source of vascularized osteochondral grafts for reconstruction of metacarpal defects.

Medial femoral trochlea flap reconstruction: Clinical outcomes and perspectives

INTRODUCTION

We report our experience with use of the medial femoral trochlea (MFT) osteochondral flap for carpal applications.

METHODS

Outcomes of all patients treated with MFT flaps were reviewed. Healing, range of motion, grip strength, carpal alignment, pain, and complication data were collected.

RESULTS

MFT flaps were performed on seven patients with a mean age of 26.1 (range, 17-42) years. Indications included scaphoid proximal pole nonunion (n = 3), Kienböck's disease (n = 3), and Preiser's disease (n = 1). The mean follow-up was 32.3 (range, 5-70) months. Union was achieved in five patients at a mean of 12 (range 6-22) weeks. All five patients had increased grip strength and absence of pain at follow-up. There were two failures due to graft resorption.

CONCLUSIONS

The MFT osteochondral flap is a technically challenging yet powerful tool to replace the loss of both carpal articular cartilage and adjacent bone.

Reverse radiodorsal artery-pedicled thumb metacarpal vascularized bone graft for osteochondral fracture of the thumb interphalangeal joint with a bone defect: A case report

Osteochondral fractures of the fingers are challenging to treat, and it is mandatory to acquire early bone union and joint surface reconstruction to obtain satisfactory outcomes. These injuries sometimes occur as open fractures with poor soft tissue condition and bone defect adjacent to osteochondral fragment. For such cases, surgical treatment can be more difficult, and vascularized bone graft (VBG) could be a useful method for joint reconstruction. Here, we report reverse-pedicled VBG based on the radiodorsal artery of the thumb for reconstructing a traumatic bone defect of the thumb. A 36-year-old man, who had ulcerative colitis and was taking immunosuppressive agents, sustained open fracture-dislocation of the thumb interphalangeal joint with a free osteochondral fragment of the proximal phalanx and 6 × 5 × 4 mm of subcondylar bone defect. We harvested 5 × 5 × 5 mm VBG at the base of the first metacarpal bone and dissected running the radiodorsal artery. The vascularized bone was grafted into the bone defect site through the subcutaneous tunnel created on the radial aspect of the proximal phalanx and fixed with a Kirschner wire. Bony union was obtained 2 months after surgery. At 7 months after the operation, the patient complained no pain, and the range of motion of the thumb interphalangeal joint was extension 0° and flexion 42°. Radiographs showed no avascular necrosis of the united fragment and osteoarthritis of the interphalangeal joint. This method could be a useful option for reconstruction of the thumb with bone defects.

[Metacarpal shaft reconstruction using medial femoral condyle flap: A case report]

We report the technique applied to reconstruct a whole shaft defect of the 4th metacarpal bone in a 22-year-old women after aneurysmal bone cyst resection. Local invasion leads to possible poor revascularization possibilities, justifying the use of a vascularized bone transfer. Surgical procedure consisted in a 5-centimeter free medial femoral bone flap transfer. Two months after surgery, no after effect was found at donor site and bone consolidation was complete. Bone fixation allowed early active motion and a complete recovery of flexion-extension range was present 1 year after surgery. Free medial femoral condyle was described several times as a solution for metacarpal defects, in osseous or osteocutaneous versions, it represents a useful option in hand surgeons' armamentarium.

Donor-Site Morbidity of Vascularized Bone Flaps from the Distal Femur: A Systematic Review

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.

Reexploring the Anatomy of the Distal Humerus for its Role in Providing Vascularized Bone

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.

The Medial Femoral Condyle Corticoperiosteal Free Flap for Frontal Sinus Reconstruction

Although the medial femoral condyle has been used for reconstruction in various areas of the body, to the authors' knowledge it has not been used for frontal sinus reconstruction. The authors describe a novel approach to a complex patient using the medial femoral condyle cortiocoperiosteal free flap to reconstruct an anterior frontal sinus defect in conjunction with a recalcitrant mucocele.

Vascularized Medial Femoral Condyle Bone Graft for Resistant Nonunion of the Distal Radius

Background: Nonunion involving the metaphyseal region of the distal radius is exceedingly rare, usually involving co-morbidity. Patients that have failed multiple prior conventional surgical interventions represent an even more difficult subset to treat; this investigation examined the utility of a specially designed free vascularized medial femoral condyle flap consisting of a central structural block graft with an extended corticoperiosteal sleeve to wrap around the junctions.

Methods: Six patients (5 males, 1 female) with a mean age of 52 years had failed to achieve union involving the distal radius metaphysis after a mean of 3.7 prior surgeries occurring over a mean period of 24 months. Comorbidities included smoking, alcoholism, chronic nutritional deficiency, and prior osteomyelitis. The unique descending genicular artery medial femoral condyle flap designed to address these patients consisted of a central structural block graft in continuity with an extended corticoperiosteal sleeve. The structural block filled the bone defect, and the corticoperiosteal sleeve wrapped around the bone junctions and the neighboring bone margins. The mean flap size was 5.3 (+/- 1.3) cm long by 4.5 (+/- 0.9) cm wide. Pre-operative to post-operative DASH scores were compared using the paired student’ s t-test, with p < 0.05.

Results: All flaps achieved union at a mean of 6.8 (+/- 2.1) weeks following surgery, using the criteria of bridging trabeculae on all 3 radiographs: coronal, sagittal, and oblique. The mean pre-operative DASH score of 63 (+/- 10) was statistically significantly different compared to the mean post-operative DASH score of 18 (+/- 8).

Conclusions: With few alternative solutions able to address this unique and difficult problem, the structural block of vascularized bone with the extended corticoperiosteal sleeve proved able to achieve a union that had failed multiple previous attempts and able to resist reactivation of infection, in a challenging group of patients with comorbidities.

Skeletal Fixation in a Mutilated Hand

Hand fracture fixation in mutilating injuries is characterized by multiple challenges due to possible skeletal disorganization and concomitant severe injury of soft tissue structures. The effects of skeletal disruption are best analyzed as divided into specific locales in the hand: radial, ulnar, proximal, and distal. Functional consequences of injuries in each of these regions are discussed. Although a variety of implants are now in vogue, K-wire fixation has stood the test of time and is especially useful in multiple fracture situations. Segmental bone loss is quite common in such injuries, which can be safely reconstructed in a staged manner.

Distal Radius Fractures: Approaches, Indications, and Techniques

Distal radius fractures remain among the most common fractures of the upper extremity. The indications for operative management continue to evolve based on outcomes from the most recent clinical studies. Advancements over the past decade have expanded the variety of fixation options available; however, the clinical superiority of a particular treatment modality remains without consensus. Each approach requires the use of unique surgical techniques, and the choice of a particular implant system should be based on the surgeon's familiarity with the implant design and its limitations. As our understanding of the management of distal radius fractures improves, so will our indications for each specific treatment modality.

Treatment of complex metacarpal defects with free chimeric iliac osteocutaneous flaps

OBJECTIVE

The aim of this report is to present the clinical results of using free chimeric iliac osteocutaneous flaps based on the periosteal branch of the superficial circumflex iliac artery (SCIA) in complex metacarpal reconstructions.

METHODS

Reconstruction using free chimeric iliac osteocutaneous flaps was performed in a series of seven patients who underwent metacarpal reconstruction for complex metacarpal defects between March 2009 and March 2012. The procedure was performed for bone and soft tissue losses associated with posttraumatic infections (four patients) and posttraumatic bone and soft tissue defects (three patients).

RESULTS

The skin paddles of the chimeric flaps had a median size of 3 × 7 cm, and the iliac segments had a mean size of 1 × 1 × 3 cm. The median follow-up time was 18 months. All the flaps survived completely with no signs of infection. Osseous union occurred within a mean period of 3 months, and the range of motion achieved for the metacarpal phalangeal joints was 0-80°. The patients were satisfied with the aesthetic outcome.

CONCLUSIONS

Chimeric iliac osteocutaneous flaps may be a useful alternative for treating complex metacarpal defects because they yield a thinner skin paddle and less bulky bone segment than traditional flaps.

The Vascularized Medial Femoral Corticoperiosteal Flap for Thumb Reconstruction

Supplemental Digital Content is available in the text.

We present an interesting method of shaping a vascularized medial femoral condyle (MFC) flap into a “neophalanx” for phalangeal reconstruction. Our patient presented with limited strength and function secondary to fracture nonunion of the proximal phalanx of the dominant thumb. Following excision of the pseudarthrosis, an MFC corticoperiosteal flap was harvested, sculpted into a prism shape and inset. The superomedial genicular pedicle was anastomosed to the princeps pollicis artery and a cephalic tributary. On follow-up, new bone growth was seen on radiographs and the patient had substantially improved function, with full metacarpophalangeal extension, a Kapandji score of 9, and a markedly reduced Disabilities of the Arm, Shoulder and Hand score of 2.68. The MFC flap is useful for reconstruction of bony defects, with minimal donor morbidity. This versatile vascularized flap can be crafted to requisite shapes and is useful for small defects in the hand, including phalangeal reconstruction.

Free Vascularized Medial Femoral Condyle Structural Flaps for Septic Terminal Digital Bone Loss

A unique clinical problem exists when the majority of distal bone stock in a digit is destroyed by osteomyelitis, leaving a residual soft tissue envelope with tenuous, random perfusion surrounding a nidus of scar tissue. Pulp pinch is lost in the absence of bony support, and limited options exist. Apart from toe transfer or revision amputation with shortening, non-vascularized bone grafting inside the residual soft tissue envelope risks graft resorption and reactivation of infection. The purpose of this investigation was to evaluate the clinical outcomes of free vascularized medial femoral condyle structural bone flaps to restore lost pulp pinch in such cases. Nine patients (8 males, 1 female) with a mean age of 43 years sustained extensive terminal bone loss near digital tips following osteomyelitis. The mean length of bone defect was 28 mm (± 8.4). The patients were reconstructed at a mean of 12 weeks from initial trauma/infection, having undergone a mean of two prior surgeries. A structural block of vascularized bone from the medial femoral condyle replaced the missing bone at the digital tip defect, temporarily fixed with K-wires. The bone flap was encased by the residual soft tissue envelope after removing scar tissue from the prior trauma and infection. All bone flaps incorporated fully, restoring pulp pinch function to the respective digits with a mean time to union of 8.6 (± 2.1) weeks; range 6-11 weeks. With few alternative solutions able to address this unique and difficult problem, the structural block of vascularized bone proved able to resist resorption, nonunion, and reactivation of infection; the problems normally encountered under this scenario.

Lateral Femoral Condyle Flap: An Alternative Source of Vascularized Bone From the Distal Femur

PURPOSE

To elucidate the vascular anatomy of the superolateral geniculate artery (SLGA) and its supply to the periosteum of the lateral femoral condyle (LFC) and to provide guidelines for flap design and describe an illustrative case.

METHODS

Thirty-one fresh cadaveric limbs were dissected. The vascular anatomy of the SLGA and its distal branches to skin, muscle, and periosteum were identified. Fluoroscopic images were taken during continuous perfusion of a radiopaque contrast dye into the SLGA. Intra-arterial injections of latex rubber were performed in 12 cadaver limbs. The vascular territory was traced from the SLGA to its distal branches, and surrounding soft tissues were dissected.

RESULTS

The SLGA originated from the popliteal artery 4.9 ± 1.2 cm (range, 2.8-7 cm) from the knee joint and its pedicle diameter was 1.8 ± 0.5 mm (range, 1-3 mm). SGLA pedicle-specific fluoroscopic angiography demonstrated a dense filigree of vessels over the lateral distal femur. Arterial latex injections confirmed that the SLGA supplied the periosteum of the LFC and distal femur shaft. The proximal-most extent of periosteal perfusion was 11.7 ± 2.1 cm (range, 9.3-14.1 cm) from the knee joint. The average pedicle length of LFC osteoperiosteal flaps was 4.8 ± 0.9 cm (range, 3.5-6.3 cm).

CONCLUSIONS

The LFC flap consistently demonstrated almost 12 cm of femur length perfusion based on the SLGA pedicle. The anatomy of this flap enables chimeric designs combining soft tissue, bone, and cartilage.

CLINICAL RELEVANCE

The vascularized LFC flap is an option for reconstruction of osseous defects of the upper extremity.

Reconstruction of scaphoid non-union and total scaphoid avascular necrosis in a pediatric patient: a case report

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.

Functional reconstruction of subtotal thumb metacarpal defect with a vascularized medial femoral condyle flap: case report

Devastating hand injuries require customized reconstructive strategies to maximize functional outcomes. We report a case of thumb metacarpal reconstruction using a vascularized medial femoral condyle osteocutaneous flap in the setting of nearly complete metacarpal loss. In addition to achieving the traditional goals of reconstructing thumb length and providing stability, the medial femoral condyle flap allowed motion at the carpometacarpal joint. The patient's hand function was further optimized by a component transfer of a proximally injured but distally preserved index finger to the amputated middle finger position. The patient regained satisfactory grip and thumb function with minimal donor site morbidity. This case highlights the role of both creative and established approaches to reconstruct composite tissues following devastating hand injury.

Vascularized medial femoral trochlea osteochondral flap reconstruction of advanced Kienböck disease

PURPOSE

To describe the operative technique and report the results of 16 consecutive cases of arthroplasty for advanced Kienböck disease using a vascularized osteochondral graft from the medial femoral trochlea (MFT) with a minimum 12-month follow-up.

METHODS

Chart reviews of 16 cases of osteochondral MFT flap transfers for lunate reconstruction were performed in 2 institutions. Mean patient age was 35 years (range, 19-51 y). Preoperative Lichtman staging was 2 in 7 patients, 3a in 8 patients, and 3b in 1. Five of 16 patients had undergone a previous procedure for Kienböck disease (3 radial shortening osteotomies, 1 wrist denervation, and 1 distal radius vascularized bone grafting). Ulnar variance recorded at the time of the MFT reconstruction was negative in 8 patients, positive in 6 patients, and neutral in 2 patients. Follow-up data were recorded at a minimum of 12 months (average, 19 mo). Radiographic parameters recorded included preoperative ulnar variance, preoperative and final follow-up radioscaphoid angle, lunate height, lunate diameter, and the Stahl index and Lichtman stage.

RESULTS

Healing was confirmed in 15 of 16 reconstructed lunates. Lichtman staging remained unchanged in 10 patients, improved in 4 patients from grade 3a and 3b to 2, and worsened in 2 patients from grade 3a to 3b. All but 1 patient experienced improvement in wrist pain (12/16 complete relief; 3/16 incomplete relief). Wrist motion at follow-up averaged 50° extension and 38° flexion, similar to preoperative measurements. Grip strength at follow-up was 85% of the contralateral side.

CONCLUSIONS

Osteochondral vascularized MFT flaps provided a reliable means of lunate reconstruction in advanced Kienböck disease. This flap allowed resection of the proximal portion of the collapsed lunate and reconstruction with an anatomically analogous convex segment of vascularized cartilage-bearing bone.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Expanding the utility of modified vascularized femoral periosteal bone-flaps: An analysis of its form and a comparison with a conventional-bone-graft

BACKGROUND

Vascularized medial femoral condyle (MFC) corticoperiosteal bone-flap is a well-accepted technique when dealing with tissue defects or infection. Its role in refractory conditions and in the possible use for options concerning modifications of this bone-flap compared to a conventional iliac bone graft (conventional-graft) are rarely discussed.

METHODS

We reviewed 21 consecutive cases concerning alternatives with some modifications of original MFC bone-flap surgery used to treat refractory conditions with bone defects, necrosis, or infection in the extremities. We present our devised approaches for this boneflap, and especially modifications of the grafted bone (including strut bone, perforator to the vastus medialis muscle, and the use of one vascular pedicle for some bone flaps) as well as the combined use of artificial bone as hybrid bone transplantation. We also compared the clinical results of 21 cases that received a conventional-graft.

RESULTS AND CONCLUSIONS

Following flap placement, 100% of the nonunion sites healed in an average of 2 months, which was significantly shorter than 5.5 months for the conventional-graft. The results showed the expanding possibility for options with regard to the form and options of this bone-flap as well as the shortening the duration of treatment, especially at the site of an infected distal tibia, insertion of the Achilles tendon on the posterior aspect of calcaneal osteomyelitis, distal end of the clavicle, clavicle or forearm with a bone defect, small bones with refractory conditions, and a femur without implant failure. However, it was not efficient for treating a forearm without bone defect.

Vascular bone transfer options in the foot and ankle: a retrospective review and update on strategies

BACKGROUND

The foot and ankle area has a tenuous blood supply that can easily be damaged with trauma or open exposures. The navicular and talus are susceptible to avascular necrosis, making arthrodesis difficult. In addition, in this region, large bone gaps occur as a result of avascular necrosis, trauma, or infection. Often, vascularized bone flaps are required for reconstruction or salvage.

METHODS

A retrospective review of all vascularized bone flaps to the foot and ankle performed by the senior surgeon (L.S.L) from July of 2006 to July of 2012 was performed. Twelve cases were identified (seven fibula flaps and five medial femoral condyle flaps). Indications included talus avascular necrosis with tibiotalar and subtalar arthritis (n = 8), talus avascular necrosis with tibiotalar arthritis (n = 1), navicular avascular necrosis (n = 1), talus persistent nonunion (n = 1), and a traumatic bone defect (n = 1).

RESULTS

There were no flap failures or thrombotic events. Ankle stabilization was performed with plates (n = 5), compression screws (n = 2), external fixator (n = 4), and a cast (n = 1). There were three complications requiring return to the operating room. All patients ultimately obtained union, and full weight bearing was allowed at 18.7 ± 13.6 weeks after surgery.

CONCLUSIONS

The authors have successfully used the medial femoral condyle flap and fibula flap for tibiotalar arthrodesis, pantalar arthrodesis, navicular revascularization, and persistent nonunion of the talus. The medial femoral condyle is ideal when a small segment of vascularized bone is required, but when structural support is necessary, the fibula offers a larger cortical surface area, providing more rigidity. Both flaps are valid options for foot and ankle reconstruction and salvage.

Free-flap cover of complex defects around the knee using the descending genicular artery as the recipient pedicle

BACKGROUND

Selection of ideal recipient vessels is one of the most important factors determining success in free-flap reconstruction of the lower limb. At the knee, the choice of vessels has traditionally been either the common femoral or the popliteal vessels and their branches but these are often difficult to use or cannot be used.

METHODS

A series of 32 free flaps for cover of complex injuries of the knee involving the distal femur, the knee joint and the upper tibia were reconstructed using the descending genicular branch of the femoral artery in the adductor canal and its muscular branches to the vastus medialis as the recipient vessels.

RESULT

All but one flap survived with no major complications.

CONCLUSION

The use of the descending genicular artery as the recipient vessel for reconstruction with free flaps around the knee has various advantages including: (i) it is mostly remote from the zone of trauma, (ii) it is constant in location, (iii) the recipient vessels are an excellent size match for end-to-end anastomosis, (iv) there is no need for changes of position of the patient when using most free flaps commonly used for knee reconstruction, (v) it is easy to harvest these simultaneously, (vi) secondary exposure of the underlying skeleton from all quadrants is unlikely to divide the flap pedicle as it is superior and (vii), perhaps most important of all, it obviates the need for exploration of the popliteal fossa.

Proximal scaphoid arthroplasty using the medial femoral trochlea flap

Background The medial trochlea of the femur (medial femoral trochlea, MFT) provides a source of convex osteocartilaginous vascularized bone that has been demonstrated to have a similar contour to the proximal scaphoid. This provides a potential solution for difficult recalcitrant proximal pole scaphoid nonunions. Materials and Methods Sixteen consecutive patients who underwent MFT proximal scaphoid arthroplasty were reviewed. Follow-up data were recorded at a minimum of 6 months, with an average of 14 months. The results of this cohort were previously reported in detail but are summarized herein. Description of Technique The ability to reconstruct both bone and cartilage of the nonunion enables the surgeon to resect the nonunited proximal pole to prepare for scaphoid reconstruction. A segment of osteocartilaginous MFT is harvested in dimensions required by the scaphoid defect. The MFT segment is harvested on the transverse branch of the descending geniculate vessels. Fixation may be achieved with ease due to the size of the reconstructed segment. Results Computed tomography imaging demonstrated 15 of 16 reconstructed scaphoids achieving osseous union. Follow-up range of motion (ROM) of the wrist averaged 46.0° extension (range 28-80°) and 43.8° flexion (range 10-80°), which was similar to preoperative (average 45.7° extension and 43.0° flexion). Scapholunate angles remained unaffected (51.6° preoperatively and 48.6° postoperatively), indicating preservation of carpal relationships. Conclusions Vascularized MFT flaps provide a useful tool in the treatment of difficult proximal pole scaphoid nonunions. Early follow-up demonstrates high rate of achieving union with acceptable ROM and good pain relief.

Medial femoral condyle flap donor-site morbidity: a radiographic assessment

BACKGROUND

The medial femoral condyle has become a reliable source of vascularized bone with many advantages to the reconstructive microsurgeon. The authors examined the donor-site morbidity of medial femoral condyle flap harvest.

METHODS

A retrospective review of all patients who underwent medial femoral condyle free flap procedures between April of 2009 and December of 2010 was conducted. Study participants underwent computed tomographic scans of their bilateral distal femurs and knee joints to evaluate the donor site and examine differences between the operated and nonoperated sides.

RESULTS

Fifteen patients underwent medial femoral condyle free flap procedures. Ten of them agreed to participate in the study. The average time between surgery and computed tomographic scans was 18.0 months (range, 12.2 to 30.4 months). Average bone harvested per procedure was 16.1 cm3 (range, 2 to 34 cm3), representing an average condylar volume of 9 percent (range, 1 to 18 percent). Reparative bone formation was minimal, with an average thickness of 4.5 mm (range, 4 to 6 mm). There were no findings of new degenerative joint disease on computed tomographic scans resulting from medial femoral condyle harvest. The flap success rate was 100 percent (10 of 10) for patency and achieving osseous union. There were no major or flap-related complications. Two patients reported numbness of the donor site at long-term follow-up (average, 17.5 months; range, 12.2 to 30.4 months).

CONCLUSIONS

Medial femoral condyle harvest creates minimal donor-site morbidity according to radiographic measures at more than 1-year follow-up. Surgeons can anticipate minimal unassisted bone regeneration at the donor site at this time interval.

Vascularized medial femoral trochlea osteocartilaginous flap reconstruction of proximal pole scaphoid nonunions

PURPOSE

The descending geniculate artery's branching pattern includes periosteal vessels supplying the cartilage-bearing trochlea of the medial patellofemoral joint. Previous cadaveric studies described anatomic similarities between the greater curvature of the proximal scaphoid and the convex surface of the medial femoral trochlea (MFT). We describe the technique and report our first 16 consecutive cases of vascularized osteocartilaginous arthroplasty for chronic scaphoid proximal pole nonunions using the MFT, with a minimum of 6 months of follow-up.

METHODS

Chart reviews of 16 consecutive cases of osteocartilaginous MFT flap transfers for scaphoid reconstruction were performed at 2 institutions. Follow-up data were recorded at a minimum of 6 months, with an average of 14 months (range, 6-72 mo). Patient age and sex, duration of nonunion, number of previous surgical procedures, surgical technique, achievement of osseous union, preoperative and postoperative scapholunate angles, preoperative and postoperative range of motion, and pain relief were recorded.

RESULTS

Computed tomography imaging confirmed healing in 15 of 16 reconstructed scaphoids. Mean patient age was 30 years (range, 18-47 y). The average number of previous surgical procedures was 1 (range, 0-3). All patients experienced some wrist pain improvement (12/16 complete relief, 4/16 incomplete relief). Wrist range of motion at follow-up averaged 46° extension (range, 28° to 80°) and 44° flexion (range, 10° to 80°), which was similar to preoperative measurements (average 46° extension and 43° flexion). Scapholunate relationship remained unchanged with average scapholunate angles of 52° before surgery and 49° after surgery.

CONCLUSIONS

Osteochondral vascularized MFT flaps provide a reliable means of achieving resolution of difficult proximal pole scaphoid nonunions. These flaps allow resection of the proximal portion of the unhealed scaphoid and reconstruction with an anatomically analogous convex segment of cartilage-bearing bone. This technique provides the advantages of vascularized bone and ease of fixation. Early follow-up demonstrates a high rate of union with acceptable motion and pain relief.

CLINICAL RELEVANCE

Early follow-up suggests that the vascularized MFT osteocartilaginous flap is a valuable tool for treating challenging proximal pole scaphoid nonunions.

The scaphoid

The scaphoid is vitally important for the proper mechanics of wrist function. Its unique morphology from its boat like shape to its retrograde blood supply can present with challenges in the presence of a fracture. Almost completely covered with articular cartilage, this creates precise surface loading demands and intolerance to bony remodeling. Fracture location compounds risk of malunion and non-union. Scaphoid fractures may significantly impair wrist function and activities of daily living, with both individual and economic consequences.

Corticocancellous olecranon autograft for metacarpal defect reconstruction: a case report

BACKGROUND

High-energy injuries to the hand frequently lead to bone defects as well as soft tissue loss. Early bone grafting of defects is well established in the literature; however, few options are available for autologous corticocancellous grafts. Most frequently cited studies describe the iliac crest or the distal radius donor sites.

METHODS

In this case report, we describe a new technique of obtaining corticocancellous bone graft from the olecranon.

RESULTS

Complete union of the segmental defect was achieved with this technique.

CONCLUSIONS

The olecranon donor site is outside the zone of injury and therefore safe to access, but within the upper extremity, thus avoiding the need for harvest from a distant site such as the iliac crest or the distal femur. Additional benefits of this site are the greater volume of graft that can be harvested compared to the distal radius as well as a more optimal ratio of cancellous to cortical graft available, compared to the iliac crest where the graft may be excessively cortical in nature.

Free vascularized medial femoral condyle autograft for challenging upper extremity nonunions

Free vascularized bone grafts from the medial femoral condyle have increasingly demonstrated utility in the successful treatment of challenging nonunions and bony defects. The consistent, robust vascular anatomy and the versatility to function as either a thin, flexible periosteal or corticoperiosteal graft or as a structural corticocancellous graft have made this graft a valuable option for addressing recalcitrant nonunions. The rationale, indications, vascular anatomy, and surgical technique of harvesting these grafts from the medial femoral condyle are presented.

Use of the medial femoral condyle vascularized bone flap in traumatic avascular necrosis of the navicular: a case report

The medial femoral condyle vascularized bone flap has a high success rate in published literature regarding its use in nonunions and avascular necrosis of the upper and lower extremities. It is reported to have minimal donor site morbidity and the ability to provide structural support and torsional strength to load-bearing areas. The flap has found particular success in the treatment of scaphoid nonunions. The tarsal navicular, similar to the scaphoid, is largely articular cancellous bone with little surface area for vascular inflow. These anatomic features make the navicular prone to nonunion and avascular necrosis in traumatic scenarios. We describe a case of nonunion and avascular necrosis of the tarsal navicular occurring as sequelae of a high-impact midfoot injury sustained in an automobile accident. After an initial attempt at open reduction and internal fixation with midfoot bridge plating, subsidence and nonunion resulted. An attempt at arthrodesis of the talonavicular and naviculocuneiform joints was then undertaken. This too failed, leading to the development of additional collapse and avascular necrosis. The site was treated with a medial femoral condyle vascularized bone flap. In this single case, the patient returned to pain-free ambulation and reported excellent outcomes and functional capacity. Although we present a successful case, a larger case series is necessary to establish the use of this flap as a reliable option for the treatment of nonunion and avascular necrosis of the tarsal navicular.

Cutaneous angiosome territory of the medial femoral condyle osteocutaneous flap

PURPOSE

The medial femoral condyle flap is used for treatment of nonunions with or without intercalary bone loss. Most reported uses have been without a skin segment, but this flap can provide a skin component supplied by the saphenous artery branch (SAB) of the descending genicular artery (DGA) pedicle. Experience with this flap suggests that an additional distinct, reliable, more-distal, DGA-cutaneous branch can be found at condyle level, capable of supporting skin without using the SAB. This cadaver study evaluated SAB and DGA-cutaneous branch angiosome territories. A clinical case series assesses the DGA-cutaneous branch's clinical utility.

METHODS

The DGA and SAB were isolated in 12 cadaveric legs, divided, and separately cannulated. Red dye and methylene blue were selectively injected into each vessel manually. Skin perfusion was measured and photographed.

RESULTS

In all specimens, the DGA was present, originating 14.2 cm proximal to the joint line, and demonstrated a distinct cutaneous branch at condyle level. This vessel provided an average perfusion area of 70 cm(2), centered over the medial knee. The SAB was identified in 11 specimens (92%), with an average perfusion area of 361 cm(2) along the medial aspect of the distal thigh and proximal leg. The DGA communicating branch was present and used for perfusion of the skin paddle in 17 of 20 cases. The SAB was present in 18 of 20 cases, used with DGA-communicating branch in 4 cases, and the sole source of skin perfusion in 1 case. In 2 remaining cases, neither the SAB nor DGA communicating branch was adequate for perfusion of a skin segment.

CONCLUSIONS

The medial femoral condyle flap can be harvested with a large skin paddle based on the SAB. A smaller skin segment can be harvested using the more distal DGA-communicating branch at condyle level.

CLINICAL RELEVANCE

Improved understanding of the skin island associated with the DGA's saphenous and cutaneous branches can provide a rapid, reliable method of skin-segment harvest.

Reconstruction of an entire metacarpal and metacarpophalangeal joint using a fibular osteocutaneous free flap and silicone arthroplasty

Radical resection of the entire ring finger metacarpal for a giant cell tumor resulted in a bony defect extending from the distal surface of the hamate to the proximal surface of the proximal phalanx. We reconstructed the metacarpal with a custom-contoured free fibular osteocutaneous flap and maintained motion at the new fibulophalangeal joint using a silicone arthroplasty. At 4.5 years postoperatively, the patient has shown no signs of recurrence of the giant cell tumor. The silicone arthroplasty has maintained 15° to 85° of motion at the new joint. Because of its similar shape to a metacarpal and because it allows faster bony healing compared with a nonvascularized fibular bone graft, a free vascularized fibular bone graft is an ideal candidate for reconstruction of extensive defects of the metacarpals, and placement of a silicone spacer in its distal medullary cavity can preserve motion at the new metacarpophalangeal joint.

Free vascularized metacarpal bone graft combined with extended dorsal metacarpal artery flap for phalangeal bone and soft tissue loss: case report

A 45-year-old man suffered from a complex bone and soft tissue defect of the middle phalanx of his left middle finger after an electric saw injury. Here, we present the patient's clinical and radiological outcomes after reconstruction with a free vascularized metacarpal II bone graft and an extended distally based second dorsal metacarpal artery skin flap (DMCA). To our knowledge, this is the first description of a free vascularized metacarpal bone graft combined with DMCA for distal finger reconstruction.

The limits of medial femoral condyle corticoperiosteal flaps

PURPOSE

The medial femoral condyle (MFC) vascularized corticoperiosteal flap has been well described for the treatment of nonunion with minimal bone loss. Recent applications of this donor site as a corticocancellous flap for large intercalary defects bring into question the vascular territory of bone supplied by the descending genicular artery (DGA). This study's purpose is to delineate the proximal extent of periosteal blood supply of the medial column of the femur provided by the DGA system.

METHODS

In 18 cadaveric specimens, the DGA was isolated, measured, and cannulated. Using subtraction techniques of fluoroscopic angiography, the vascular network and proximal-most extent of periosteal perfusion were recorded using radiopaque contrast dye.

RESULTS

The DGA branched from the superficial femoral artery 14.2 ± 2.4 cm proximal to the joint line of the knee. The length of the vascular pedicle to its attachment onto the periosteum was 7.7 ± 2.2 cm. All specimens demonstrated a filigree of periosteal vessels dominated by a transverse and a longitudinal branch at the level of the condyle. Proximal perfusion was consistently noted by a large, longitudinal medial metaphyseal periosteal artery. The medial metaphyseal periosteal artery demonstrated that the proximal-most perfusion of the DGA was 13.7 ± 1.3 cm proximal to the joint line. Average femur length was 47.1 ± 3.1 cm. The DGA provided perfusion of 29% ± 2% of the total length of the medial femur.

CONCLUSIONS

The DGA provides a large and reliable region of periosteal perfusion, suggesting that corticocancellous MFC harvest might provide the benefits of vascularized bone for large, intercalary nonunion defects conventionally treated with fibula flaps.

CLINICAL RELEVANCE

Harvest of MFC osseous flaps extending up to 13.7 cm proximal to the joint line can be perfused from the DGA pedicle. The MFC donor site might, therefore, be a reliable option for vascularized reconstruction of larger bone defects.

Vascularized genicular osseous-periosteal flap for pseudarthrosis of the proximal phalanx of the little finger: a case report

This study describes pseudoarthrosis of the proximal phalanx of the little finger and its successful treatment using a free vascularized genicular osseous-periosteal flap. Since this thin and pliable flap can be harvested as a small vascularized unit, it is ideal for the treatment of phalangeal pseudoarthrosis.