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Roger de Oña I, Garcia Villanueva A, Garcia Lopez JI, Garcia de Lucas F. Versatility of the medial corticoperiosteal flap: from recalcitrant non-unions up to large bony defects. Arch Orthop Trauma Surg 2024; 144:2655-2663. [PMID: 38772929 DOI: 10.1007/s00402-024-05351-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 04/25/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Reconstructive microsurgery techniques using vascularized bone grafts have revolutionized the treatment of complex cases associated with recalcitrant non-unions or osteomyelitis. The medial femoral corticoperiosteal flap (MFCP flap) has emerged as a valuable option in bone reconstruction. Its clinical applications have been extended over the years considering this flap from non-unions with minimal bone lost, up to large intercalary defects of the upper and lower extremities. This article aims to present the clinical applications and outcomes of the MFCP flap in various reconstructive scenarios. METHODS Seventy-nine patients with persistent non-union and bone defects of the upper and lower limb were evaluated from June 2008 to October 2020. All of them were reconstructed with a corticoperiosteal flap from the medial femoral condyle in our hospital. Previous procedures, bone gap and type of flap used were recorded. Postoperative functional status was assessed with time of bone healing, complications and clinical final outcome. RESULTS Radiological evidence of bone union was observed at 4.09 months (range 2-9). Healing rate was 97% with periosteal corticocancellous flaps (PCC flaps) and 93% with corticoperiosteal flaps (CP flaps). Average follow-up was 14.5 months (range 5-28). There were no significant donor site complications. CONCLUSIONS The MFCP flap offers a versatile and reliable option for bone reconstruction. Its ability to provide vascularized bone tissue with low morbidity enhances the healing process and improves outcomes. The MFCP flap has been increasing its applications and it serves as a valuable option in the treatment of recalcitrant non-unions or bony defects irrespective of site and size up to 5 cm in the upper and lower extremities.
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Affiliation(s)
- Ignacio Roger de Oña
- Microsurgery Unit, Department of Orthopaedic Surgery, FREMAP Hospital Madrid, Carretera de Pozuelo 61, Majadahonda, 28222, Madrid, Spain
| | - Andrea Garcia Villanueva
- Microsurgery Unit, Department of Orthopaedic Surgery, FREMAP Hospital Madrid, Carretera de Pozuelo 61, Majadahonda, 28222, Madrid, Spain.
| | - Jose Ignacio Garcia Lopez
- Upper Limb Unit, Department of Orthopaedic Surgery, FREMAP Hospital Madrid, Carretera de Pozuelo 61, Majadahonda, 28222, Madrid, Spain
| | - Fernando Garcia de Lucas
- Upper Limb Unit, Department of Orthopaedic Surgery, FREMAP Hospital Madrid, Carretera de Pozuelo 61, Majadahonda, 28222, Madrid, Spain
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2
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Woo SJ, Park KH, Woo SH. Simultaneous or Delayed Free Tissue Transfer in Combination with Replantation Surgery. Hand Clin 2024; 40:301-313. [PMID: 38553101 DOI: 10.1016/j.hcl.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
In hand and upper extremity replantation surgery, simultaneous free flap reconstruction restores the physiologic circulation to the amputated part, ensuring its survival, and promotes wound healing through anatomic restoration. Especially in digit replantation, an arterialized venous flap serves to reconstruct both vessel and soft tissue defects simultaneously. Delayed free flap reconstruction aims to enhance both functional improvement and cosmetic acceptance in a successfully replanted part using flaps that include functioning muscle, bone, joint, nerve, and soft tissue.
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Affiliation(s)
- Soo Jin Woo
- W Institute for Hand and Reconstructive Microsurgery, W General Hospital, Daegu, South Korea
| | - Kwang Hyun Park
- W Institute for Hand and Reconstructive Microsurgery, W General Hospital, Daegu, South Korea
| | - Sang Hyun Woo
- W Institute for Hand and Reconstructive Microsurgery, W General Hospital, Daegu, South Korea.
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3
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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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4
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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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5
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Higgins JP. Vascularized Medial Femoral Condyle Flap Reconstruction for Osseous Defects of the Hand and Wrist. Hand Clin 2024; 40:151-159. [PMID: 37979987 DOI: 10.1016/j.hcl.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
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.
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Affiliation(s)
- James P Higgins
- Curtis National Hand Center, MedStar Union Memorial Hospital, 3333 North Calvert Street, Johnston Professional Building, Mezzanine Level, Baltimore, MD 21218, USA.
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6
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Giesen T, Costa F, Fritsche E. Complex reconstruction of the clavicle with a prefabricated medial femur condyle chimeric flap including a superficial circumflex iliac artery perforator flap: A case report. Microsurgery 2024; 44:e31108. [PMID: 37668043 DOI: 10.1002/micr.31108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 08/01/2023] [Accepted: 08/24/2023] [Indexed: 09/06/2023]
Abstract
The medial femur condyle (MFC) cortico-periosteal flap is a popular flap for bone reconstruction. The use of a chimeric version of this flap with a skin island has been described, but anatomical arterial variation can occur that prevent its harvest. Furthermore, the donor area of the skin paddle has been debated as poor because of the scarring in a visible area and because of the difficulty in obtaining pliable thin skin. We present a fabricated chimeric MFC cortico-periosteal flap joined with a superficial inferior epigastric perforator (SCIP) flap to reconstruct and augment a sclerotic and insufficient small clavicula with the skin paddle acting as a monitor and as a substitute for the overlying skin. A 52-year-old female patient had a history of multiple refractures of the right hypoplastic clavicle with a diameter of 7 mm, resulting in a sclerotic bone with a fibrotic scar. The reconstruction was done in one surgical session using a cortico-periosteal flap from the left medial condyle and a thin SCIP flap from the left groin. The area of the clavicle to be reconstructed was 3 cm, and the direct overlying skin (approximately 6 × 3 cm) was severely scarred and painful. The MFC flap was 5 × 4 cm, while the SCIP flap was 7 × 3.5 cm. The SCIP flap artery was anastomosed on the table end-to-side to the descending genicular (DG) artery of the MFC, and the vein was anastomosed end-to-end to a comitans vein of the DG artery. The flap fully survived after an initial congestion. At 12 months, we observed a satisfactory reconstruction of the clavicle with an enhanced diameter of 12 mm. The patient recovered full function of the shoulder with no pain. Using a fabricated chimeric flap composed of a medial femoral condyle and a superficial circumflex artery perforator flap may be an additional option for tailored reconstruction of complex osteo-cutaneous defect of clavicle.
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Affiliation(s)
- Thomas Giesen
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | | | - Elmar Fritsche
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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7
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Kohlhauser M, Vasilyeva A, Kamolz LP, Bürger HK, Schintler M. Metacarpophalangeal Joint Reconstruction of a Complex Hand Injury with a Vascularized Lateral Femoral Condyle Flap Using an Individualized 3D Printed Model-A Case Report. J Pers Med 2023; 13:1570. [PMID: 38003885 PMCID: PMC10671979 DOI: 10.3390/jpm13111570] [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: 09/30/2023] [Revised: 10/22/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023] Open
Abstract
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.
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Affiliation(s)
- Michael Kohlhauser
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria
| | - Anna Vasilyeva
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria
| | - Lars-Peter Kamolz
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria
- COREMED—Cooperative Centre for Regenerative Medicine, Joanneum Research Forschungsgesellschaft mbH, 8010 Graz, Austria
| | - Heinz K. Bürger
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria
- Division of Hand Surgery, Private Hospital Maria Hilf, 9020 Klagenfurt am Wörthersee, Austria
| | - Michael Schintler
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria
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8
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Tee R, Harvey JN, Tham SK, Ek ET. Medial Femoral Condyle Corticoperiosteal Flap for Failed Total Wrist Fusions. J Wrist Surg 2023; 12:288-294. [PMID: 37564622 PMCID: PMC10411124 DOI: 10.1055/s-0043-1760737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 12/03/2022] [Indexed: 01/22/2023]
Abstract
Background Recalcitrant nonunion following total wrist arthrodesis is a rare but challenging problem. Most commonly, in the setting of failed fusion after multiple attempts of refixation and cancellous bone grafting, the underlying cause for the failure is invariably multifactorial and is often associated with a range of host issues in addition to poor local soft-tissue and bony vascularity. The vascularized medial femoral condyle corticoperiosteal (MFC-CP) flap has been shown to be a viable option in a variety of similar settings, which provides vascularity and rich osteogenic progenitor cells to a nonunion site, with relatively low morbidity. While its utility has been described for many other anatomical locations throughout the body, its use for the treatment of failed total wrist fusions has not been previously described in detail in the literature. Methods In this article, we outline in detail the surgical technique for MFC-CP flap for the management of recalcitrant aseptic nonunions following failed total wrist arthrodesis. We discuss indications and contraindications, pearls and pitfalls, and potential complications of this technique. Results Two illustrative cases are presented of patients with recalcitrant nonunions following multiple failed total wrist fusions. Conclusion When all avenues have been exhausted, a free vascularized corticoperiosteal flap from the MFC is a sound alternative solution to achieve union, especially when biological healing has been compromised. We have been able to achieve good clinical outcomes and reliable fusion in this difficult patient population.
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Affiliation(s)
- Richard Tee
- Division of Hand Surgery, Department of Orthopaedic Surgery, Dandenong Hospital, Monash Health, Melbourne, Victoria, Australia
| | - Jason N. Harvey
- Division of Hand Surgery, Department of Orthopaedic Surgery, Dandenong Hospital, Monash Health, Melbourne, Victoria, Australia
- Orthosport Victoria, Richmond, Melbourne, Victoria, Australia
| | - Stephen K. Tham
- Division of Hand Surgery, Department of Orthopaedic Surgery, Dandenong Hospital, Monash Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash Medical Centre, Monash University, Melbourne, Victoria, Australia
- Victorian Hand Surgery Associates, Fitzroy, Melbourne, Victoria, Australia
| | - Eugene T. Ek
- Division of Hand Surgery, Department of Orthopaedic Surgery, Dandenong Hospital, Monash Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash Medical Centre, Monash University, Melbourne, Victoria, Australia
- Melbourne Orthopaedic Group, Windsor, Melbourne, Victoria, Australia
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9
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Hoftiezer YAJ, Posada Alvarez C, Werenski JO, Schreuder HWB, Eberlin KR, Lee SG, Lozano-Calderón SA. Salvage of a Fractured Proximal Ulnar Osteoarticular Allograft Using a Medial Femoral Condyle Free Flap: A Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00024. [PMID: 37531445 DOI: 10.2106/jbjs.cc.22.00796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
CASE We present the case of a 47-year-old paraplegic woman who underwent resection of an intermediate-grade chondrosarcoma in the proximal ulna, which was initially reconstructed with an osteoarticular allograft. However, after more than 25 years without complications, she sustained an intra-articular fracture of the allograft, which was then successfully treated using a vascularized medial femoral condyle (MFC) flap and anterolateral thigh flap. The patient has subsequently recovered her baseline elbow function, has no pain, and can use her wheelchair without restrictions. CONCLUSION Free MFC flaps are viable options to salvage osteoarticular allografts that are affected by intra-articular fractures.
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Affiliation(s)
- Yannick Albert J Hoftiezer
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Plastic, Reconstructive and Hand Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolina Posada Alvarez
- Department of Orthopaedics, University Medical Center Groningen/University of Groningen, Groningen, the Netherlands
| | - Joseph O Werenski
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - H W B Schreuder
- Department of Orthopaedic Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Sang-Gil Lee
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Santiago A Lozano-Calderón
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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10
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Rodriguez JR, Chan JKK, Huang RW, Chen SH, Lin CH, Lin YT, Lin CH, Hsu CC. Free Medial Femoral Condyle Flap for Phalangeal and Metacarpal Bone Reconstruction. J Plast Reconstr Aesthet Surg 2022. [DOI: 10.1016/j.bjps.2022.08.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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11
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Dezulovic M, Hönck K, Palle W, Bürger H. [Hematogenous osteomyelitis due to clavicular fracture : A rare complication after conservative treatment]. Unfallchirurg 2022; 125:915-920. [PMID: 35175405 DOI: 10.1007/s00113-022-01149-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 11/29/2022]
Abstract
We present a case of a nondislocated clavicular fracture that was conservatively treated for 4 weeks with a sling. The patient was a smoker and suffered from type 2 diabetes mellitus. After 2 months a suppurative infection occurred due to an escalation based on a clavicular osteomyelitis. Through antibiotic treatment and an aggressive surgical approach the infection was cured but ended up with a painful malunion of the clavicle. The bone reconstruction was achieved with a long locking plate with an additional vascularized medial femoral condyle free flap. After 18 months the patient was subjectively very satisfied with the outcome, had no pain and excellent functional results in the Constant Murley and DASH (Disabilities of Arm, Shoulder and Hand) scores. The X‑ray assessment showed full bone union.
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Affiliation(s)
- M Dezulovic
- Abteilung für Orthopädie und Traumatologie, Krankenhaus des Deutschen Ordens Friesach, St. Veiter Straße 12, 9360, Friesach, Österreich.
| | - K Hönck
- Abteilung für Orthopädie und Traumatologie, Universitätsklinik Graz, Graz, Österreich
| | - W Palle
- Abteilung für Orthopädie und Traumatologie, Krankenhaus des Deutschen Ordens Friesach, St. Veiter Straße 12, 9360, Friesach, Österreich
| | - H Bürger
- Privatklinik Maria Hilf Klagenfurt, Klagenfurt, Österreich
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12
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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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13
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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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Quintero JI, Childs D, Moreno R. The medial femoral condyle free flap: An excellent option for difficult cases: case series. SAGE Open Med Case Rep 2020; 8:2050313X20933763. [PMID: 32647579 PMCID: PMC7325544 DOI: 10.1177/2050313x20933763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 05/20/2020] [Indexed: 11/17/2022] Open
Abstract
The use of the medial femoral condyle free flap is a versatile option for the treatment of upper extremity non unions and reconstructive procedures associated with bone loss or osteonecrosis. The benefit of this type of flap is the viability of the bone which favors primary ossification and increases bone density. Vascularized free bone flaps are especially useful for the treatment of recalcitrant nonunions, or nonunions that have failed three or more treatments to obtain consolidation. We present a case series of three patients treated with medial femoral condyle free flap for reconstruction of the upper extremity of different etiologies at the level of the distal humerus, distal radius and distal phalanx of the thumb.
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Affiliation(s)
- Jorge I Quintero
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA.,Division of Hand Surgery, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Dylan Childs
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA.,Division of Hand Surgery, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Rodrigo Moreno
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA.,Division of Hand Surgery, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
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Keller M, Kastenberger T, Anoar AF, Kaiser P, Schmidle G, Gabl M, Arora R. Clinical and radiological results of the vascularized medial femoral condyle graft for scaphoid non-union. Arch Orthop Trauma Surg 2020; 140:835-842. [PMID: 32124031 PMCID: PMC7244456 DOI: 10.1007/s00402-020-03386-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION This study evaluated the use of a free vascularized bone graft with and without cartilage from the medial femoral condyle (MFC) in patients with recalcitrant scaphoid non-union, with a special focus on union rates and the osteochondral graft for proximal pole destruction. MATERIALS AND METHODS Thirty-eight avascular scaphoid non-unions in 37 patients who were treated with a free osteoperiosteal or osteochondral MFC graft were retrospectively evaluated (mean follow-up 16 months). Bone union, the scapholunate and the radiolunate angles were evaluated on X-ray images. The range of motion, grip strength, VAS, DASH and PRWE scores were evaluated clinically. RESULTS The overall union rate was 95%. Bone union was achieved in 27 out of 29 (93%) scaphoids treated with a free osteoperiosteal MFC grafts and in 9 out of 9 (100%) scaphoids treated with a free osteochondral MFC graft. The range of motion remained almost unchanged, while grip strength increased significantly (34 kg vs. 44 kg) and the VAS (22-5), DASH (59-19) and PRWE (62-30) score decreased significantly. The scapholunate (71°-65°) and radiolunate (28°-18°) angle decreased. No major donor site morbidity was observed. Postoperative complications were observed in eight cases (21%). CONCLUSIONS The vascularized medial femoral bone graft leads to a good functional outcome in the treatment of scaphoid non-unions. The graft provides adequate blood supply and structural stability to the scaphoid. A proximal pole destruction can be replaced using an osteochondral graft with promising short-term results preventing carpal osteoarthritis and collapse.
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Affiliation(s)
- Marco Keller
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria ,grid.440128.b0000 0004 0457 2129Department of Orthopaedics and Traumatology, Kantonsspital Baselland, Rheinstrasse 26, 4410 Liestal, Switzerland
| | - Tobias Kastenberger
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Anizar Faizi Anoar
- grid.412516.50000 0004 0621 7139Department of Orthopaedics and Traumatology, Kuala Lumpur Hospital, Jalan Pahang, 50586 Kuala Lumpur, Malaysia
| | - Peter Kaiser
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Gernot Schmidle
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Markus Gabl
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Rohit Arora
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
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Chieh-Ting Huang T, Sabbagh MD, Lu CK, Steinmann SP, Moran SL. The vascularized medial femoral condyle free flap for reconstruction of segmental recalcitrant nonunion of the clavicle. J Shoulder Elbow Surg 2019; 28:2364-2370. [PMID: 31371161 DOI: 10.1016/j.jse.2019.04.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/10/2019] [Accepted: 04/15/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recalcitrant clavicular nonunion is a rare but complicated problem of clavicular fracture fixation. Nonunion is most often treated with clavicular shortening or in extreme cases vascularized bone grafting. Herein we describe our experience using the vascularized medial femoral condyle (MFC) free flap for the reconstruction of segmental defects in cases of recalcitrant clavicular nonunion. METHODS A retrospective chart review was conducted of patients with symptomatic recalcitrant nonunion of the clavicle who underwent reconstruction with the vascularized MFC free flap from June 2003 to January 2018. Patients' demographics, time to union, and postoperative complications were collected. RESULTS A total of 7 patients (6 women; 39.8 ± 9.01 years old) underwent clavicular reconstruction after an average of 3.7 ± 1.3 previous surgical procedures. Average preoperative visual analog scale score for pain was 4.1. The graft size ranged from 2 to 5 cm in length with approximately 1 cm in width and depth. The average time of total nonunion was 66 ± 48.2 months before surgery. All flaps survived and all clavicles healed with an average time to radiographic union of 15 ± 6.7 months. Patients regained full shoulder motion, and average postoperative visual analog scale score was 1.6 ± 1.8. All patients returned to their preoperative employment status. Donor site morbidity from the knee was minimal. CONCLUSION The MFC free flap is a good option for recalcitrant bone nonunion of the clavicle where larger vascularized flaps are not warranted. It is effective and offers minimal donor site morbidity.
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Affiliation(s)
| | - M Diya Sabbagh
- Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Chun-Kuan Lu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Steven L Moran
- Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA.
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Cherubino M, Stocco C, Tamborini F, Maggiulli F, Sallam D, Corno M, Bignami M, Battaglia P, Valdatta L. Medial femoral condyle free flap in combination with paramedian forehead flap for total/subtotal nasal reconstruction: Level of evidence: IV (therapeutic studies): Level of evidence: IV (therapeutic studies). Microsurgery 2019; 40:343-352. [PMID: 31705579 DOI: 10.1002/micr.30532] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 08/11/2019] [Accepted: 10/25/2019] [Indexed: 11/12/2022]
Abstract
BACKGROUND The nose is a functionally complex organ with also a critical role in aesthetics. For reconstruction of full thickness nasal defects, multiple stages are needed and there is risk for resorption resulting in residual deformity. The aim of this report was to develop and evaluate a new method for full thickness total/subtotal nose reconstruction using the medial femoral condyle free flap (MFCFF) in combination with a paramedian forehead flap. METHODS Between November 2015 and January 2018, eight patients (four males, four females) mean age 52 years (range 40-73 years) undergoing a total/subtotal nasal excision and subsequential reconstruction with MFCFF plus paramedian forehead flap were enrolled. Six cases were squamous cell carcinomas while two were basal cell carcinomas. The MFCFF was stabilized, with the periosteum as inner layer, with plates and a paramedian forehead flap was used as external skin coverage. All patients were evaluated for with postoperative nasal endoscopy and CT scan. A postoperative questionnaire was given 6 months after surgery. RESULTS The mean MFCFF size was 2-3.8 cm × 2.25-2.5 cm with a mean pedicle length of 6.3 cm (range 4.1-9.4 cm). The postoperative period was uneventful. The mean follow-up was 16 months, no bone displacement or resorption was observed at the CT scan, no evidence of nasal stenosis occurred. All patients had a satisfying aesthetic evaluation and a good subjective nasal function. CONCLUSIONS In this series, the MFCFF in combination with the paramedian forehead flap appeared to provide a valid subtotal nose reconstruction, allowing for the recreation of all the three nasal layers and maintaining the nose projection and airway patency in the long term.
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Affiliation(s)
- Mario Cherubino
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.,Microsurgery and Lymphatic Surgery Research Center, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.,Plastic Surgery Unit, Microsurgery and Hand Surgery Unit, ASST Settelaghi Varese, Varese, Italy
| | - Chiara Stocco
- Department of Medical, Surgical and Health Sciences, Plastic, and Reconstructive Surgery Unit, University of Trieste, Trieste, Italy
| | - Federico Tamborini
- Plastic Surgery Unit, Microsurgery and Hand Surgery Unit, ASST Settelaghi Varese, Varese, Italy
| | - Francesca Maggiulli
- Plastic Surgery Unit, Microsurgery and Hand Surgery Unit, ASST Settelaghi Varese, Varese, Italy
| | - Davide Sallam
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Martina Corno
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Maurizio Bignami
- Department of Otorhinolaryngology, University of Insubria, ASST Settelaghi Varese, Varese, Italy
| | - Paolo Battaglia
- Department of Otorhinolaryngology, University of Insubria, ASST Settelaghi Varese, Varese, Italy
| | - Luigi Valdatta
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.,Microsurgery and Lymphatic Surgery Research Center, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
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Aribert M, Corcella D, Bouyer M. Free composite medial femoral trochlea osteochondral cutaneous flap for wrist scaphoid and lunate cartilage lesions: Advantages of a skin paddle. HAND SURGERY & REHABILITATION 2019; 38:262-267. [DOI: 10.1016/j.hansur.2019.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 03/27/2019] [Accepted: 05/02/2019] [Indexed: 12/01/2022]
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Yin S, Zhang W, Zhang Z, Jiang X. Recent Advances in Scaffold Design and Material for Vascularized Tissue-Engineered Bone Regeneration. Adv Healthc Mater 2019; 8:e1801433. [PMID: 30938094 DOI: 10.1002/adhm.201801433] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 02/24/2019] [Indexed: 12/21/2022]
Abstract
Bone tissue is a highly vascularized tissue and concomitant development of the vascular system and mineralized matrix requires a synergistic interaction between osteogenesis and angioblasts. Several strategies have been applied to achieve vascularized tissue-engineered bone, including the addition of cytokines as well as pre-vascularization strategies and co-culture systems. However, the scaffold is another extremely important component to consider, and development of vascularized bone scaffolds remains one of the greatest challenges for engineering clinically relevant bone substitutes. Here, this review highlights the biomaterial selection, preparation of pre-vascularized scaffolds, composition modification of the scaffold, structural design, and the comprehensive use of the above synergistic modifications of scaffold materials for vascular scaffolds in bone tissue engineering. Moreover, a strategy is proposed for the design of future scaffold structures, in which promoting the regeneration of vascularized bone by regulating the microenvironment should be the main focus. This overview can help illuminate progress in this field and identify the most recently developed scaffolds that show the greatest potential for achieving clinically vascularized bone.
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Affiliation(s)
- Shi Yin
- Department of ProsthodonticsShanghai Ninth People's HospitalCollege of StomatologyShanghai Jiao Tong University School of Medicine No. 639, Manufacturing Bureau Road Huangpu District Shanghai China
- Shanghai Key Laboratory of Stomatology and Shanghai Research Institute of Stomatology No. 639, Manufacturing Bureau Road Huangpu District Shanghai China
- Shanghai Engineering Research Center of Advanced Dental Technology and MaterialsNational Clinical Research Center of Stomatology Shanghai 200011 China
| | - Wenjie Zhang
- Department of ProsthodonticsShanghai Ninth People's HospitalCollege of StomatologyShanghai Jiao Tong University School of Medicine No. 639, Manufacturing Bureau Road Huangpu District Shanghai China
- Shanghai Key Laboratory of Stomatology and Shanghai Research Institute of Stomatology No. 639, Manufacturing Bureau Road Huangpu District Shanghai China
- Shanghai Engineering Research Center of Advanced Dental Technology and MaterialsNational Clinical Research Center of Stomatology Shanghai 200011 China
| | - Zhiyuan Zhang
- Shanghai Engineering Research Center of Advanced Dental Technology and MaterialsNational Clinical Research Center of Stomatology Shanghai 200011 China
| | - Xinquan Jiang
- Department of ProsthodonticsShanghai Ninth People's HospitalCollege of StomatologyShanghai Jiao Tong University School of Medicine No. 639, Manufacturing Bureau Road Huangpu District Shanghai China
- Shanghai Key Laboratory of Stomatology and Shanghai Research Institute of Stomatology No. 639, Manufacturing Bureau Road Huangpu District Shanghai China
- Shanghai Engineering Research Center of Advanced Dental Technology and MaterialsNational Clinical Research Center of Stomatology Shanghai 200011 China
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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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Femoral Osteonecrosis after Medial Femoral Condyle Bone Graft Harvest. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1792. [PMID: 30276041 PMCID: PMC6157952 DOI: 10.1097/gox.0000000000001792] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/03/2018] [Indexed: 11/26/2022]
Abstract
The medial femoral condyle vascularized graft has become a useful resource in reconstructive microsurgery due to the rate of bony union, and the low rate of complication. We report osteonecrosis of the medial femoral condyle in a 65-year-old woman after harvesting a corticocancellous medial femoral condyle graft to treat a tarsometatarsal nonunion. We were not able to define whether a vascular or mechanical disorder could be the ultimate cause. However, because of the severity of the complication, we suggest informing patients who will undergo a medial femoral condyle flap about this infrequent complication.
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Mattos D, Ko JH, Iorio ML. Wrist arthrodesis with the medial femoral condyle flap: Outcomes of vascularized bone grafting for osteomyelitis. Microsurgery 2018; 39:32-38. [PMID: 30176071 DOI: 10.1002/micr.30368] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 05/28/2018] [Accepted: 06/20/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND Osteomyelitis of the wrist is rare but destructive. Subsequent bone defects often require vascularized bone for successful healing. Recent literature has pointed to the successful use of the medial femoral condylar (MFC) flap for difficult non-unions, yet it has not been specifically described for wrist fusion. We present our experience with this technique for limited and complete wrist arthrodesis. PATIENTS AND METHODS We reviewed 4 cases of radiocarpal bone loss from osteomyelitis. All cases utilized debridement of nonviable tissues, and at least 6 weeks of intravenous antibiotics, followed by vascularized bone grafting with a MFC flap. The flap was based on the horizontal periosteal branch of the descending geniculate artery, and utilized to directly bridge the bony defects following resection. RESULTS Three patients healed primarily, and 1 patient required secondary cancellous bone grafting to reach union. One patient required revision of the donor site closure. None of the patients had a recurrence of infection or other complications. Average follow up was 8.5 months after reconstruction. Average time to union was 11.5 weeks. Three patients demonstrated full composite fist, and 1 patient had incomplete finger range of motion following several flexor and extensor tendon grafts. CONCLUSIONS These cases illustrate the use of the MFC in wrist arthrodesis after osteomyelitis defects. In all cases, there was complete union in a short time, no recurrence of infection, and low donor-site morbidity.
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Affiliation(s)
- David Mattos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jason H Ko
- Division of Plastic and Reconstructive Surgery, Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Matthew L Iorio
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Division of Plastic and Reconstructive Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colorado
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Descending genicular artery. Branching patterns and measuring parameters: A systematic review and meta-analysis of several anatomical studies. J Plast Reconstr Aesthet Surg 2018; 71:967-975. [PMID: 29655665 DOI: 10.1016/j.bjps.2018.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 02/15/2018] [Accepted: 03/10/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND The medial femoral condyle (MFC) flap is based on the descending genicular artery (DGA), which is a vessel with different variations in its course and branching patterns. Many studies have dealt with the vascular anatomy of the MFC. However, the results of the investigations differ markedly. METHODS The authors performed a systematic literature search in MEDLINE for articles published until May 2017 on the vascular anatomy of the DGA. After the screening, 23 relevant studies with a similar topic were included into this comprehensive analysis. RESULTS The systematic review examined the lengths and diameters of the individual arteries with regard to the vascularized bone flap of the MFC. The DGA is present in 94% of cases with an average length of 1.8 cm. In 63% of the investigated cases, the DGA divides into three terminal branches. The articular branch has an average length of 7.7 cm, the saphenous branch has a length of 10.7 cm, and the muscular branch has a length of 3.2 cm. CONCLUSION To ensure a secured survival of this free flap, a detailed understanding of the convoluted vascular anatomy above the MFC is necessary. We recommend the Dubois classification for a systematic classification of the anatomical patterns of the DGA.We present a summary of all anatomical studies dealing with the vascular supply to the MFC and the DGA to date.
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The Medial Femoral Condyle Corticoperiosteal Free Flap for Frontal Sinus Reconstruction. J Craniofac Surg 2018; 28:813-816. [PMID: 28277474 DOI: 10.1097/scs.0000000000003375] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Le BQ, Nurcombe V, Cool SM, van Blitterswijk CA, de Boer J, LaPointe VLS. The Components of Bone and What They Can Teach Us about Regeneration. MATERIALS (BASEL, SWITZERLAND) 2017; 11:E14. [PMID: 29271933 PMCID: PMC5793512 DOI: 10.3390/ma11010014] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 12/20/2017] [Accepted: 12/21/2017] [Indexed: 12/18/2022]
Abstract
The problem of bone regeneration has engaged both physicians and scientists since the beginning of medicine. Not only can bone heal itself following most injuries, but when it does, the regenerated tissue is often indistinguishable from healthy bone. Problems arise, however, when bone does not heal properly, or when new tissue is needed, such as when two vertebrae are required to fuse to stabilize adjacent spine segments. Despite centuries of research, such procedures still require improved therapeutic methods to be devised. Autologous bone harvesting and grafting is currently still the accepted benchmark, despite drawbacks for clinicians and patients that include limited amounts, donor site morbidity, and variable quality. The necessity for an alternative to this "gold standard" has given rise to a bone-graft and substitute industry, with its central conundrum: what is the best way to regenerate bone? In this review, we dissect bone anatomy to summarize our current understanding of its constituents. We then look at how various components have been employed to improve bone regeneration. Evolving strategies for bone regeneration are then considered.
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Affiliation(s)
- Bach Quang Le
- Institute of Medical Biology, Agency for Science, Technology and Research (A*STAR), 8A Biomedical Grove, #6-06 Immunos, Singapore 138648, Singapore.
| | - Victor Nurcombe
- Institute of Medical Biology, Agency for Science, Technology and Research (A*STAR), 8A Biomedical Grove, #6-06 Immunos, Singapore 138648, Singapore.
| | - Simon McKenzie Cool
- Institute of Medical Biology, Agency for Science, Technology and Research (A*STAR), 8A Biomedical Grove, #6-06 Immunos, Singapore 138648, Singapore.
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block, Level 11, 1E Kent Ridge Road, Singapore 119288, Singapore.
| | - Clemens A van Blitterswijk
- Department of Complex Tissue Regeneration, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands.
| | - Jan de Boer
- Department of Cell Biology-Inspired Tissue Engineering, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands.
| | - Vanessa Lydia Simone LaPointe
- Department of Complex Tissue Regeneration, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands.
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Vasculature of a Medial Femoral Condyle Free Flap in Intact and Osteotomized Flaps. Plast Reconstr Surg 2017; 139:992-997. [DOI: 10.1097/prs.0000000000003155] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chaudhry T, Uppal L, Power D, Craigen M, Tan S. Scaphoid Nonunion With Poor Prognostic Factors: The Role of the Free Medial Femoral Condyle Vascularized Bone Graft. Hand (N Y) 2017; 12:135-139. [PMID: 28344523 PMCID: PMC5349415 DOI: 10.1177/1558944716661994] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background: To report on the results of free medial femoral condyle (MFC) vascularized bone graft for scaphoid nonunions with 1 or more poor prognostic factors. Methods: We have used the free MFC vascularized bone graft for scaphoid nonunions that have 1 or more factors associated with a poor prognosis. These were, a delay in presentation of over 5 years, a proximal pole nonunion, the presence of avascular necrosis (AVN), or previous nonunion surgery. We used this technique on 20 patients over a 4.5-year period. Results: Our overall union rate was 88.5% (17 of 19 patients), with 1 patient failing to attend for follow-up. Our mean union time was 7 months (2-18). All patients had at least 1 poor prognostic factor and over half had 2 or more. Of those with AVN with or without other factors, the union rate was 85% (11 of 13). There were 2 donor site complications that required a further procedure and 2 patients with residual wrist pain that required a scapho-trapezio-trapezoid joint fusion and a radial styloidectomy, respectively. Both nonunions were offered further surgery, and 1 elected to undergo successful revision surgery. Conclusions: Overall, this technique showed good results, in a subgroup of patients that typically have poorer outcomes, with a low incidence of donor site morbidity. Our union rate compares favorably with other techniques for this difficult subset of patients with 1 or more poor prognostic factors, although results are clearly not as good as those of studies using the MFC graft for all scaphoid nonunions. We continue to reserve this technique for nonunions with 1 or more poor prognostic factors, and we believe that this technique should at least be considered in these patients.
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Affiliation(s)
- Tahseen Chaudhry
- University Hospital Birmingham, UK,Tahseen Chaudhry, University Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK.
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Nau C, Henrich D, Seebach C, Schröder K, Barker JH, Marzi I, Frank J. Tissue engineered vascularized periosteal flap enriched with MSC/EPCs for the treatment of large bone defects in rats. Int J Mol Med 2017; 39:907-917. [PMID: 28259928 PMCID: PMC5360440 DOI: 10.3892/ijmm.2017.2901] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 02/02/2017] [Indexed: 01/21/2023] Open
Abstract
Vascularized periosteal flaps are used for complex cases if the reconstruction of large bone defects is necessary in modern trauma and orthopedic surgery. In this study, we combined this surgical procedure with β-TCP scaffold and mesenchymal stem cells (MSCs) + endothelial progenitor cells (EPCs) as a tissue engineering approach to obtain optimum conditions for bone healing in rats. A critical size femoral defect was created in 80 rats allocated into 4 groups. Defects were treated according to the following protocol: i) vascularized periosteal flap alone; ii) vascularized periosteal flap + β-TCP scaffold; iii) vascularized periosteal flap + β-TCP scaffold + ligated vascular pedicle; and ii) vascularized periosteal flap + β-TCP scaffold + MSCs/EPCs. After 8 weeks, femur bones were extracted and analyzed for new bone formation, vascularization, proliferation and inflammatory processes and strength. Bone mineral density (BMD) and biomechanical stability at week 8 were highest in group 4 (flap + β-TCP scaffold + MSCs/EPCs) compared to all the other groups. Stability was significantly higher in group 4 (flap + β-TCP scaffold + MSCs/EPCs) in comparison to group 3 (ligated flap + β-TCP scaffold). BMD was found to be significantly lower in group 3 (ligated flap + β-TCP scaffold) compared to group 1 (flap) and group 4 (flap + β-TCP scaffold + MSCs/EPCs). The highest density of blood vessels was observed in group 4 (flap + β-TCP + MSCs/EPCs) and the values were significantly increased in comparison to group 3 (ligated flap), but not to group 1 (flap) and group 2 (flap + β-TCP). The highest amounts of proliferating cells were observed in group 4 (flap + β-TCP scaffold + MSC/EPCs). The percentage of proliferating cells was significantly higher in group 4 (flap + β-TCP scaffold + MSCs/EPCs) in comparison to all the other groups after 8 weeks. Our data thus indicate that critical size defect healing could be improved if MSCs/EPCs are added to β-TCP scaffold in combination with a periosteal flap. Even after 8 weeks, the amount of proliferating cells was increased. The flap blood supply is essential for bone healing and the reduction of inflammatory processes.
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Affiliation(s)
- Christoph Nau
- Department of Trauma, Hand and Reconstructive Surgery, Johann Wolfgang Goethe‑University, Frankfurt/Main, Germany
| | - Dirk Henrich
- Department of Trauma, Hand and Reconstructive Surgery, Johann Wolfgang Goethe‑University, Frankfurt/Main, Germany
| | - Caroline Seebach
- Department of Trauma, Hand and Reconstructive Surgery, Johann Wolfgang Goethe‑University, Frankfurt/Main, Germany
| | - Katrin Schröder
- Institute for Cardiovascular Physiology, Goethe-University, Frankfurt/Main, Germany
| | - John H Barker
- Frankfurt Institute for Regenerative Medicine, Johann Wolfgang Goethe‑University, Frankfurt/Main, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Johann Wolfgang Goethe‑University, Frankfurt/Main, Germany
| | - Johannes Frank
- Department of Trauma, Hand and Reconstructive Surgery, Johann Wolfgang Goethe‑University, Frankfurt/Main, Germany
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Henry M. Vascularized Medial Femoral Condyle Bone Graft for Resistant Nonunion of the Distal Radius. J Hand Surg Asian Pac Vol 2017; 22:23-28. [DOI: 10.1142/s0218810417500046] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Mark Henry
- Hand and Wrist Center of Houston, Houston, USA
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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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Medial Femoral Condyle Free Flap for Nasal Reconstruction: New Technique for Full-Thickness Nasal Defects. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e855. [PMID: 27757320 PMCID: PMC5054985 DOI: 10.1097/gox.0000000000000858] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 06/17/2016] [Indexed: 11/26/2022]
Abstract
The nose is a functionally complex organ implicated in breathing, olfaction, and phonation, with a critical role also in the aesthetic appearance of a person. This latter aspect should be carefully considered whenever a total or subtotal rhinectomy is performed for resection of locally advanced nasal cancer. To reconstruct large nasal defects, several techniques were described, including the use of cartilaginous grafts, bony grafts, local flaps, and free flaps. In cases of extensive full-thickness resections, free flaps probably represent the most adequate option. The aim of this report is to present the functional and aesthetical outcomes of a reconstruction of the nose after rhinectomy, using the medial femoral condyle free flap associated with the forehead flap.
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Tremp M, Haumer A, Wettstein R, Zhang YX, Honigmann P, Schaefer DJ, Kalbermatten DF. The medial femoral trochlea flap with a monitor skin island-Report of two cases. Microsurgery 2016; 37:431-435. [PMID: 27571547 DOI: 10.1002/micr.30093] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 06/25/2016] [Accepted: 08/04/2016] [Indexed: 11/05/2022]
Abstract
In this report, we present two cases of the bony reconstruction with the medial trochlea (MFT) flap including a skin island that was used to monitor the perfusion of flap in the postoperative period. Between March 2013 and April 2015, we performed surgery on two patients who suffered from scaphoid and talus non-union after trauma and initial treatment by osteosynthesis. A skin island (1 cm × 1 cm and 3 cm × 1 cm, respectively) was included with the osseous flap (1.6 cm × 1 cm × 1 cm and 2 cm × 3 cm × 2 cm, respectively) to assess the perfusion of the flap. The design of the skin island was based on either the saphenous artery perforator or a cutaneous perforator of the descending genicular artery. Both flaps remained viable throughout the postoperative period, and there were no donor site complications. After a follow-up of 36 and 11 months, bony union was observed in both patients with a high degree of satisfaction. Thus, a MFT flap with a skin island could be a tool to assess the perfusion of the flap in the early postoperative period. © 2016 Wiley Periodicals, Inc. Microsurgery 37:431-435, 2017.
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Affiliation(s)
- M Tremp
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - A Haumer
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - R Wettstein
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - Y X Zhang
- Department of Plastic and Reconstructive Surgery, School of Medicine, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, Shanghai, China
| | - P Honigmann
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, 4031, Switzerland.,Department of Hand Surgery, Kantonsspital Baselland Liestal, Rheinstrasse 26, Liestal, 4410, Switzerland
| | - D J Schaefer
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - D F Kalbermatten
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, 4031, Switzerland
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van der Woude JAD, van Heerwaarden RJ, Bleys RLAW. Periosteal vascularization of the distal femur in relation to distal femoral osteotomies: a cadaveric study. J Exp Orthop 2016; 3:6. [PMID: 26915006 PMCID: PMC4735087 DOI: 10.1186/s40634-016-0042-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/26/2016] [Indexed: 11/23/2022] Open
Abstract
Background The purpose of this study was to investigate periosteal vessels location as intra-operative landmarks in distal femoral osteotomies and focused on the branching pattern of the vascular supply of the medial and lateral femoral condyle, its constancy, and the relationship to the height of distal femoral osteotomies. Anastomoses of relevant vessels were studied to analyze the risk of vascular insufficiency after transection of landmark vessels. Methods A human cadaver dissection study on the vascular supply of the medial and lateral side of the distal femur was conducted. Surgical dissection was performed in eight knees in total. Distances between the vascular supply and bony landmarks were calculated. Relation of the vascular structures to the transverse bone cuts of distal femoral osteotomies was described, as well as anastomoses of relevant vessels. Results On the medial side of the distal femur the periosteum was primarily supplied by the descending genicular artery (DGA) in 87.5 % of the specimens. In the absence of the DGA, the superior medial genicular artery was the supplier. Vascularization took place through two constant branches, the upper transverse artery (UTA) and the central longitudinal artery. The UTA originated at a mean distance of 6.9 cm (range 5.9–7.9 cm) above the knee joint line. On the lateral side of the distal femur the superior lateral genicular artery was the main vessel. In all dissected knees it gave off the lateral transverse artery (LTA). The LTA originated at a mean distance of 6.9 cm (range 5.8–7.6 cm) above the knee joint line. Anastomoses between the UTA, LTA and the longitudinal arch of the femoral shaft were found that could prevent vascular insufficiencies after transection of the UTA and LTA. Conclusions The vascular supply of the medial and lateral aspects of the femoral condyle is highly constant. Both the UTA, on the medial side, and the LTA, on the lateral side, can serve as a landmark for orthopedic surgeons in determining the height of the osteotomy cuts in distal femoral osteotomies. Transection of these landmark vessels during the osteotomy will not result in vascular insufficiency because of a collateral supply.
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Affiliation(s)
- J A D van der Woude
- Department of Orthopedic Surgery, Limb Reconstruction Center, Maartenskliniek Woerden, Polanerbaan 2, 3447, GN, Woerden, The Netherlands
| | - R J van Heerwaarden
- Department of Orthopedic Surgery, Limb Reconstruction Center, Maartenskliniek Woerden, Polanerbaan 2, 3447, GN, Woerden, The Netherlands.
| | - R L A W Bleys
- Department of Anatomy, University Medical Center, Utrecht, The Netherlands
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Nau C, Henrich D, Seebach C, Schröder K, Fitzsimmons SJ, Hankel S, Barker JH, Marzi I, Frank J. Treatment of Large Bone Defects with a Vascularized Periosteal Flap in Combination with Biodegradable Scaffold Seeded with Bone Marrow-Derived Mononuclear Cells: An Experimental Study in Rats. Tissue Eng Part A 2015; 22:133-41. [PMID: 26486307 DOI: 10.1089/ten.tea.2015.0030] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The surgical treatment of large bone defects continues to pose a major challenge in modern trauma and orthopedic surgery. In this study we test the effectiveness of a tissue engineering approach, using three-dimensional (3D) β-tricalcium phosphate (β-TCP) scaffolding plus bone marrow-derived mononuclear cells (BM-MNCs), combined with a vascularized periosteal flap, in a rat femur critical size defect model. METHODS Eighty rats were randomly allocated into four equal groups. Under general anesthesia, critical size defects were created on their femurs and were treated with (1) Vascularized periosteal flap alone, (2) Vascularized periosteal flap+β-TCP scaffolding, (3) Vascularized periosteal flap+β-TCP scaffolding+ligated vascular pedicle, and (4) Vascularized periosteal flap+β-TCP scaffolding+BM-MNCs. After 4 and 8 weeks animals were euthanized and the bone defects were harvested for analysis of new bone formation, vascularization, and strength using histology, immunohistology, micro-CT, and biomechanical testing, respectively. RESULTS Group 1: (P. flap) Increase in new bone formation and vascularization. Group 2: (P. flap+scaffold) Increase in new bone formation and vascularization. Group 3: (P. flap+scaffold+ligated vascular pedicle) No new bone formation and no vascularization. Group 4: (P. flap+scaffold+BM-MNCs) A significant (p < 0.05) increase was seen in new bone formation, vascularization, and strength in bones treated with flaps, scaffold, and BM-MNCs, when compared with the other treatment groups. CONCLUSION Combining a vascularized periosteal flap with tissue engineering approach (β-TCP scaffolding and BM-MNC) results in significantly improved bone healing in our rat femur critical size bone defect model.
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Affiliation(s)
- Christoph Nau
- 1 Department of Trauma, Hand and Reconstructive Surgery, Johann Wolfgang Goethe-University , Frankfurt/Main, Germany
| | - Dirk Henrich
- 1 Department of Trauma, Hand and Reconstructive Surgery, Johann Wolfgang Goethe-University , Frankfurt/Main, Germany
| | - Caroline Seebach
- 1 Department of Trauma, Hand and Reconstructive Surgery, Johann Wolfgang Goethe-University , Frankfurt/Main, Germany
| | - Katrin Schröder
- 2 Institut für Kardiovaskuläre Physiologie, Fachbereich Medizin der Goethe-Universität , Frankfurt am Main, Germany
| | - Sammy-Jo Fitzsimmons
- 3 Frankfurt Initiative for Regenerative Medicine, Johann Wolfgang Goethe-University , Frankfurt/Main, Germany
| | - Svenja Hankel
- 1 Department of Trauma, Hand and Reconstructive Surgery, Johann Wolfgang Goethe-University , Frankfurt/Main, Germany
| | - John H Barker
- 3 Frankfurt Initiative for Regenerative Medicine, Johann Wolfgang Goethe-University , Frankfurt/Main, Germany
| | - Ingo Marzi
- 1 Department of Trauma, Hand and Reconstructive Surgery, Johann Wolfgang Goethe-University , Frankfurt/Main, Germany
| | - Johannes Frank
- 1 Department of Trauma, Hand and Reconstructive Surgery, Johann Wolfgang Goethe-University , Frankfurt/Main, Germany
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Kloczko E, Nikkhah D, Yildirimer L. Scaffolds for hand tissue engineering: the importance of surface topography. J Hand Surg Eur Vol 2015; 40:973-85. [PMID: 25770899 DOI: 10.1177/1753193415571308] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 01/14/2015] [Indexed: 02/03/2023]
Abstract
Tissue engineering is believed to have great potential for the reconstruction of the hand after trauma, congenital absence and tumours. Due to the presence of multiple distinct tissue types, which together function in a precisely orchestrated fashion, the hand counts among the most complex structures to regenerate. As yet the achievements have been limited. More recently, the focus has shifted towards scaffolds, which provide a three-dimensional framework to mimic the natural extracellular environment for specific cell types. In particular their surface structures (or topographies) have become a key research focus to enhance tissue-specific cell attachment and growth into fully functioning units. This article reviews the current understanding in hand tissue engineering before focusing on the potential for scaffold topographical features on micro- and nanometre scales to achieve better functional regeneration of individual and composite tissues.
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Affiliation(s)
- E Kloczko
- UCL School of Life and Medical Sciences, University College London, London, UK
| | - D Nikkhah
- The Queen Victoria Hospital, East Grinstead, UK
| | - L Yildirimer
- Centre for Nanotechnology & Regenerative Medicine, UCL Division of Surgery & Interventional Science, University College London, London, UK Department of Plastic and Reconstructive Surgery, Royal Free Hospital Hampstead NHS Trust, London, UK
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Henry M. Free Vascularized Medial Femoral Condyle Structural Flaps for Septic Terminal Digital Bone Loss. J Hand Microsurg 2015; 7:306-13. [PMID: 26578834 DOI: 10.1007/s12593-015-0207-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 10/20/2015] [Indexed: 10/22/2022] Open
Abstract
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.
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Affiliation(s)
- Mark Henry
- Hand and Wrist Center of Houston, 1200 Binz Street, 13th Floor, Houston, TX 77004 USA
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Roger I, Worden A, Panattoni J, Garcia I, Aranda F, Delgado PA. Subtalar fusion with iliac bone free flap after a recalcitrant nonunion: Report of two cases. Microsurgery 2015; 36:501-6. [PMID: 26456638 DOI: 10.1002/micr.22513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 07/07/2015] [Accepted: 09/25/2015] [Indexed: 11/09/2022]
Abstract
Fractures of the calcaneus are associated with secondary osteoarthritis of the subtalar joint. In a persistent nonunion, vascularized bone flaps offer superior biologic and mechanical properties as well as accelerates joint fusion and decreases morbidity. In this report, we present results of the use of vascularized iliac bone free flap for treating subtalar failed fusions in two patients. Two patients sustained calcaneal fractures due to foot trauma, which were initially or subsequently treated with subtalar arthrodesis. Case one developed septic subtalar nonunion during treatment and case two failed three attempts at subtalar arthrodeses. The iliac crest bone flap harvested measured 4 × 4 cm (case one) and 3 × 3 cm (case two). The flap was pedicled by the deep circumflex iliac artery, which was anastomosed to the anterior tibial artery at the recipient site. No flap donor or recipient site complications occurred. Fusion was confirmed on CT scan and weight bearing was initiated at 5-6 months. At latest follow up (1-2 years), no complications occurred. Our results show that subtalar nonunion treatment with a vascularized iliac bone flap may be feasible and such a reconstruction could be clinically successful. © 2015 Wiley Periodicals, Inc. Microsurgery 36:501-506, 2016.
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Affiliation(s)
- Ignacio Roger
- Departments of Microsurgery Unit at Hospital Fremap Majadahonda, Madrid, Spain
| | - Alicia Worden
- Department of Orthopaedic Surgery at Saint Louis University School of Medicine, Saint Louis, MO.
| | - Joao Panattoni
- Department of Orthopaedic Surgery at Saint Louis University School of Medicine, Saint Louis, MO
| | - Ignacio Garcia
- Departments of Microsurgery Unit at Hospital Fremap Majadahonda, Madrid, Spain
| | - Fernando Aranda
- Departments of Orthopaedic Surgery at Hospital Ramon Y Cajal Madrid, Spain
| | - Paula A Delgado
- Departments of Plastic Surgery at Hospital Ramon Y Cajal Madrid, Spain
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Elgammal A, Lukas B. Vascularized medial femoral condyle graft for management of scaphoid non-union. J Hand Surg Eur Vol 2015; 40:848-54. [PMID: 25487319 DOI: 10.1177/1753193414561900] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 10/08/2014] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to assess the results of the management of difficult scaphoid non-unions using a vascularized medial femoral condyle graft. We operated on 30 patients with necrosis of the proximal pole or with severe humpback deformity or who presented with persistent non-union despite previous surgery. Twenty-four cases in our series showed full consolidation and six cases showed persistent non-union. The free vascularized medial femoral condyle bone graft can provide not only structural support, but also a consistent and good blood supply that results in excellent rates of union. Level of evidence: IV.
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Affiliation(s)
- A Elgammal
- Ain Shams University Hospitals Egypt, Landshut Achdorf Klinik, Munich, Germany
| | - B Lukas
- Hand, Elbow and Plastic Surgery Department, Schön Klinik München Harlaching, Munich, Germany
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Ben-Amotz O, Ho C, Sammer DM. Reconstruction of scaphoid non-union and total scaphoid avascular necrosis in a pediatric patient: a case report. Hand (N Y) 2015; 10:477-81. [PMID: 26330781 PMCID: PMC4551645 DOI: 10.1007/s11552-014-9711-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND The medial femoral condyle vascularized bone graft has grown in popularity for treating recalcitrant fracture non-unions and has become particularly useful in treating scaphoid non-union with avascular necrosis of the proximal pole. The medial femoral condyle is an excellent source of dense, well-vascularized bone and results in minimal donor site morbidity. METHODS We describe an unusual case of chronic scaphoid non-union and total scaphoid avascular necrosis in a skeletally immature patient. Scaphoid reconstruction was performed with a vascularized medial femoral condyle graft, with successful graft incorporation, and restoration of pain-free wrist motion. CONCLUSIONS Technical considerations for harvest of the medial femoral condyle bone graft in the skeletally immature patient are discussed.
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Affiliation(s)
- Oded Ben-Amotz
- Department of Plastic Surgery, University of Texas Southwestern Medical Center at Dallas, 1801 Inwood Rd., Dallas, TX 75390 USA
| | - Christine Ho
- Department of Orthopedic Surgery, Texas Scottish Rite Hospital for Children-Children’s Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Douglas M. Sammer
- Department of Plastic Surgery, University of Texas Southwestern Medical Center at Dallas, 1801 Inwood Rd., Dallas, TX 75390 USA
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Sananpanich K, Kraisarin J. Descending genicular artery free flaps: Multi-purpose tissue transfers in limb reconstruction. J Plast Reconstr Aesthet Surg 2015; 68:846-52. [DOI: 10.1016/j.bjps.2015.02.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 11/15/2014] [Accepted: 02/03/2015] [Indexed: 11/26/2022]
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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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Houdek MT, Wagner ER, Wyles CC, Nanos GP, Moran SL. New options for vascularized bone reconstruction in the upper extremity. Semin Plast Surg 2015; 29:20-9. [PMID: 25685100 DOI: 10.1055/s-0035-1544167] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Originally described in the 1970s, vascularized bone grafting has become a critical component in the treatment of bony defects and non-unions. Although well established in the lower extremity, recent years have seen many novel techniques described to treat a variety of challenging upper extremity pathologies. Here the authors review the use of different techniques of vascularized bone grafts for the upper extremity bone pathologies. The vascularized fibula remains the gold standard for the treatment of large bone defects of the humerus and forearm, while also playing a role in carpal reconstruction; however, two other important options for larger defects include the vascularized scapula graft and the Capanna technique. Smaller upper extremity bone defects and non-unions can be treated with the medial femoral condyle (MFC) free flap or a vascularized rib transfer. In carpal non-unions, both pedicled distal radius flaps and free MFC flaps are viable options. Finally, in skeletally immature patients, vascularized fibular head epiphyseal transfer can provide growth potential in addition to skeletal reconstruction.
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Affiliation(s)
- Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Eric R Wagner
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Cody C Wyles
- School of Medicine, Mayo Clinic, Rochester, Minnesota
| | - George P Nanos
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Steven L Moran
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota ; Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
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Bürger HK, Windhofer C, Gaggl AJ, Higgins JP. Vascularized medial femoral trochlea osteochondral flap reconstruction of advanced Kienböck disease. J Hand Surg Am 2014; 39:1313-22. [PMID: 24855965 DOI: 10.1016/j.jhsa.2014.03.040] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 03/27/2014] [Accepted: 03/27/2014] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Heinz K Bürger
- Privat Hospital Maria Hilf, Klagenfurt, Austria; Trauma Department, Unfallkrankenhaus, Austria; Department of Oral and Maxillofacial Surgery, University Hospital Salzburg, Austria; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Christian Windhofer
- Privat Hospital Maria Hilf, Klagenfurt, Austria; Trauma Department, Unfallkrankenhaus, Austria; Department of Oral and Maxillofacial Surgery, University Hospital Salzburg, Austria; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Alexander J Gaggl
- Privat Hospital Maria Hilf, Klagenfurt, Austria; Trauma Department, Unfallkrankenhaus, Austria; Department of Oral and Maxillofacial Surgery, University Hospital Salzburg, Austria; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - James P Higgins
- Privat Hospital Maria Hilf, Klagenfurt, Austria; Trauma Department, Unfallkrankenhaus, Austria; Department of Oral and Maxillofacial Surgery, University Hospital Salzburg, Austria; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
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The effect of delayed treatment on clinical and radiological effects of anterior wedge grafting for non-union of scaphoid fractures. Arch Orthop Trauma Surg 2014; 134:1023-30. [PMID: 24823907 DOI: 10.1007/s00402-014-2007-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The aim of the treatment of displaced scaphoid non-unions is the restoration of normal scaphoid anatomy. Restoration of normal scaphoid anatomy at an earlier stage might have functional benefits as maladaptive carpal ligament contractures and the development of preliminary osteoarthritis could be avoided. The purpose of this retrospective study was to determine if late reconstruction (delayed reconstruction group) was as effective as early reconstruction (early reconstruction group) of scaphoid non-union in restoring clinical and radiological outcome. PATIENTS AND METHODS The early reconstruction group included patients who underwent surgery between 6 and 12 months after the original fracture. This group consisted of 14 male and 2 female patients. The delayed reconstruction group included patients who underwent surgery 12 or more months after the original fracture. This group consisted of 9 male and 1 female patients. Average time from injury to surgery in the early reconstruction group was 10 months (range 6-12 months) and mean postoperative follow-up period averaged 58 months (range 19-72 months). Average time from injury to surgery in the delayed reconstruction group was 69 months (range 12-88 months) and mean postoperative follow-up period averaged 62 months (range 24-80 months). All patients showed a humpback deformity as well as a DISI deformity with the radiolunate angle being greater than 15°. The outcome was assessed on the basis of measurement of active wrist range of motion and grip power. Wrist pain was evaluated using a visual analogue scale. Functional subjective outcome was evaluated with the DASH and PRWE scores. Results were compared to preoperative measurements as well as to the uninjured contralateral side. Pre- and post-operative radiographs were assessed for scapholunate angle (SLA) as a measure of palmar rotation and radiolunate angle (RLA). The presence of DISI was defined by a difference of >60° for the SLA or of >10° for the RLA between the affected and unaffected wrist. RESULTS In the early reconstruction group bone union and correction of DISI deformity could be achieved for all patients (n = 16). In the delayed reconstruction group bone union could only be achieved without correction of the DISI deformity in six patients (60 %). In four patients (40 %) of the delayed reconstruction group non-union persisted. For the early reconstruction group at final follow-up mean flexion-extension arc, mean ulnar-radial-deviation arc and mean grip strength were 82, 91.5 and 82 % of uninjured side, respectively. Mean pain level decreased from 6 points before surgery to 1 point at final follow-up. The preoperative DASH changed from 48 to 17 and the preoperative PRWE changed from 30 to 14. The SLA changed from 51° to 48° and the RLA from 18° to 9°. Six patients from delayed reconstruction group showed bone union, but no correction of DISI deformity at final follow-up. Functional and radiological results showed only slight improvement. The remaining four patients from delayed reconstruction group with a persistent non-union continued to experience pain, reduced grip strength and limited range of wrist movement and DISI deformity persisted. CONCLUSION In conclusion, wedge-shaped bone grafting of scaphoid non-union leads to increased functional scores as well as to improved carpal angles as long as bony union can be achieved. Remaining non-union and the inability to correct DISI deformity are severely correlated with an increased time frame between fracture and surgical treatment. Furthermore, the vascularization of the proximal fragment and patients' smoking habits has to be taken into consideration preoperatively.
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Hamada Y, Hibino N, Kobayashi A. Expanding the utility of modified vascularized femoral periosteal bone-flaps: An analysis of its form and a comparison with a conventional-bone-graft. J Clin Orthop Trauma 2014; 5:6-17. [PMID: 25983463 PMCID: PMC4009458 DOI: 10.1016/j.jcot.2014.01.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 01/12/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Vascularized medial femoral condyle (MFC) corticoperiosteal bone-flap is a well-accepted technique when dealing with tissue defects or infection. Its role in refractory conditions and in the possible use for options concerning modifications of this bone-flap compared to a conventional iliac bone graft (conventional-graft) are rarely discussed. METHODS We reviewed 21 consecutive cases concerning alternatives with some modifications of original MFC bone-flap surgery used to treat refractory conditions with bone defects, necrosis, or infection in the extremities. We present our devised approaches for this boneflap, and especially modifications of the grafted bone (including strut bone, perforator to the vastus medialis muscle, and the use of one vascular pedicle for some bone flaps) as well as the combined use of artificial bone as hybrid bone transplantation. We also compared the clinical results of 21 cases that received a conventional-graft. RESULTS AND CONCLUSIONS Following flap placement, 100% of the nonunion sites healed in an average of 2 months, which was significantly shorter than 5.5 months for the conventional-graft. The results showed the expanding possibility for options with regard to the form and options of this bone-flap as well as the shortening the duration of treatment, especially at the site of an infected distal tibia, insertion of the Achilles tendon on the posterior aspect of calcaneal osteomyelitis, distal end of the clavicle, clavicle or forearm with a bone defect, small bones with refractory conditions, and a femur without implant failure. However, it was not efficient for treating a forearm without bone defect.
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Affiliation(s)
- Yoshitaka Hamada
- Department of Orthopedics, Tokushima Prefectural Central Hospital, 1-10-3, Kuramoto-cho, Tokushima 770-8539, Japan,Corresponding author. Tel.: +81 88 631 7151; fax: +81 88 631 8354. http://www.tph.gr.jp/kenchu/
| | - Naohito Hibino
- Department of Orthopedics, Tokushima Naruto Hospital, Tokushima, Japan
| | - Anna Kobayashi
- Center for Clinical Education, Tokushima Prefectural Central Hospital, Tokushima, Japan
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Abstract
Free vascularized bone graft from the medial femoral condyle has been described as a superior method for treatment of recalcitrant scaphoid nonunion with proximal pole avascularity and humpback deformity. Few complications and high union rates have been reported. In a series of three patients we describe an undesired volar ossification as a potential complication of the method. The risk of developing the ectopic bone formation can be minimized if the surgeon is aware of the strong osteogenic capacity of the periosteum. Meticulous dissection of the vascular bundle to the graft is mandatory to avoid the complication. Caution is warranted so as not to leave a periosteal sleeve under the vessels at the margin of the graft.
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Affiliation(s)
- Torbjörn Vedung
- Department of Hand Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Bertil Vinnars
- Department of Hand Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Julka A, Ozer K. Infected nonunion of the upper extremity. J Hand Surg Am 2013; 38:2244-6. [PMID: 23770324 DOI: 10.1016/j.jhsa.2013.03.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 03/28/2013] [Indexed: 02/02/2023]
Affiliation(s)
- Abhishek Julka
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan
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Venkatramani H, Sabapathy SR, Nayak S. Free-flap cover of complex defects around the knee using the descending genicular artery as the recipient pedicle. J Plast Reconstr Aesthet Surg 2013; 67:93-8. [PMID: 24090722 DOI: 10.1016/j.bjps.2013.09.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 05/17/2013] [Accepted: 09/03/2013] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- H Venkatramani
- Department of Plastic, Hand and Reconstructive Microsurgery and Burns, Ganga Hospital, 313, Mettupalayam Road, Coimbatore 641043, Tamil Nadu, India
| | - S R Sabapathy
- Department of Plastic, Hand and Reconstructive Microsurgery and Burns, Ganga Hospital, 313, Mettupalayam Road, Coimbatore 641043, Tamil Nadu, India.
| | - S Nayak
- Department of Plastic, Hand and Reconstructive Microsurgery and Burns, Ganga Hospital, 313, Mettupalayam Road, Coimbatore 641043, Tamil Nadu, India
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