The Vascularized Medial Femoral Corticoperiosteal Flap for Reconstruction of Bony Defects within the Upper and Lower Extremities

Towards Stem Cell Therapy for Critical-Sized Segmental Bone Defects: Current Trends and Challenges on the Path to Clinical Translation

The management and reconstruction of critical-sized segmental bone defects remain a major clinical challenge for orthopaedic clinicians and surgeons. In particular, regenerative medicine approaches that involve incorporating stem cells within tissue engineering scaffolds have great promise for fracture management. This narrative review focuses on the primary components of bone tissue engineering-stem cells, scaffolds, the microenvironment, and vascularisation-addressing current advances and translational and regulatory challenges in the current landscape of stem cell therapy for critical-sized bone defects. To comprehensively explore this research area and offer insights for future treatment options in orthopaedic surgery, we have examined the latest developments and advancements in bone tissue engineering, focusing on those of clinical relevance in recent years. Finally, we present a forward-looking perspective on using stem cells in bone tissue engineering for critical-sized segmental bone defects.

Non-vascularised corticocancellous (tricortical) iliac bone graft longer than 3 cm for non-union after failed surgical treatment

PURPOSE

We hypothesised that traditional iliac tricortical bone grafts (no vascularised) still have a reasonable role in promoting satisfactory bony healing in non-union defects of certain sizes. Here, we report the clinical/radiological outcomes through a retrospective case series.

METHODS

We screened 74 patients with definitive non-union in the long bones of the upper extremities who visited the outpatient department from 2008 to 2018. Among these patients, 25 who met our inclusion/exclusion criteria were investigated.

RESULTS

The mean age was 51.92 years, and there were 12, 9, 1, and 3 lesions of the radius, ulna, clavicle, and humerus, respectively. The tools for primary fixations were plate and intramedullary nails in 24 and 1 patients, respectively. Six patients presented with atrophic non-union. The mean period from a previous surgery was 6.84 months. The mean defective bone sizes were 1.81 and 3.50 cm pre-debridement and post-debridement, respectively. All devices had locking plates longer than the previous plate, and the graft was concurrently fixed by screws in three patients. At a mean of 15.92 weeks after the revision surgery, all patients experienced union. At the final follow-up, the clinical outcomes were satisfactory. No significant differences in clinical outcomes were found according to the lesion, type of non-union, period from the previous surgery, or harvest length of the iliac bone.

CONCLUSIONS

If the proper indications and some technical aspects are considered, a non-vascularised iliac bone graft longer than 3 cm could still be a reasonable option for treating diaphyseal non-union of the upper extremities.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Salvage of a Fractured Proximal Ulnar Osteoarticular Allograft Using a Medial Femoral Condyle Free Flap: A Case Report

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.

Vascularized Bone Grafts from the Lateral Femoral Condyle for the Treatment of Avascular Lunate Necrosis (Kienböck's)

Background

Avascular necrosis of the lunate (Kienböck's disease) is rare and one of the main causes of progressive painful arthritis, requiring surgical intervention. Various approaches have shown benefits in treating Kienbock's disease but with limitations. The article aims to analyze the functional outcome using lateral femoral condyle free vascularized bone grafts (VBGs) as the first choice of treatment for Kienböck`s.

Materials and methods

This was a retrospective analysis of 31 patients with Kienbock's who had microsurgical revascularization or reconstruction of the lunate between 2016 and 2021 using either corticocancellous or osteochondral VBGs from the lateral femoral condyle. The characteristics of lunate necrosis, choice of VBG and postoperative functional outcome were reviewed.

Results

Corticocancellous VBGs were used in 20 patients (64.5%), while osteochondral VBGs in 11 patients (35.4%). The lunate was reconstructed in 11 patients, revascularized in 19 patients, and one patient received augmentation of a luno-capitate arthrodesis with a corticocancellous graft. We noted postoperative irritation of the median nerve (n = 3) and screw loosening requiring removal (n = 1) as minor complications. All patients had complete graft healing at eight-month follow-up and acceptable functional outcomes.

Conclusions

Free VBG from the lateral femoral condyle represent a reliable method of lunate revascularisation or reconstruction in advanced Kienböck's. Their main advantages are the constant vascular anatomy, straightforward graft harvesting technique and possibility to harvest several graft types according to the requirements at the donor site. Postoperatively, the patients become pain-free and have an acceptable functional outcome.

Periosteum: Functional Anatomy and Clinical Application

Periosteum is a connective tissue that envelopes the outer surface of bones and is tightly bound to the underlying bone by Sharpey’s fibers. It is composed of two layers, the outer fibrous layer and the inner cambium layer. The periosteum is densely vascularised and contains an osteoprogenitor niche that serves as a repository for bone-forming cells, which makes it an essential bone-regenerating tissue and has immensely contributed to fracture healing. Due to the high vascularity of inner cambium layer of the periosteum, periosteal transplantation has been widely used in the management of bone defects and fracture by orthopedic surgeons. Nevertheless, the use of periosteal graft in the management of bone defect is limited due to its contracted nature after being harvested. This review summarizes the current state of knowledge about the structure of periosteum, and how periosteal transplantation have been used in clinical practices, with special reference on its expansion.

The Medial Femoral Condyle Flap: A Novel Versatile Tool for Complex Microvascular Maxillofacial Reconstruction

SUMMARY

The medial femoral condyle flap is well-described for reconstruction of small bone defects of the upper and lower extremities. There are limited case reports of its use in other anatomic sites, particularly for reconstruction of complex head and neck defects. In the setting of previous radiation and contaminated fields, vascularized bone is generally preferred to bone grafts, cadaveric allografts, or synthetic implants. The authors present a case series of complex craniofacial defects involving the midface that were reconstructed using medial femoral condyle flaps, focusing on the type of defect and lessons learned from their early experience to promote awareness of this flap among microsurgeons, who may wish to consider the potential of this flap and incorporate its use into their armamentarium.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Mechanical strain induces ex vivo expansion of periosteum

Segmental bone defects present complex clinical challenges. Nonunion, malunion, and infection are common sequalae of autogenous bone grafts, allografts, and synthetic bone implants due to poor incorporation with the patient's bone. The current project explores the osteogenic properties of periosteum to facilitate graft incorporation. As tissue area is a natural limitation of autografting, mechanical strain was implemented to expand the periosteum. Freshly harvested, porcine periosteum was strained at 5 and 10% per day for 10 days with non-strained and free-floating samples serving as controls. Total tissue size, viability and histologic examination revealed that strain increased area to a maximum of 1.6-fold in the 10% daily strain. No change in tissue anatomy or viability via MTT or Ki67 staining and quantification was observed among groups. The osteogenic potential of the mechanical expanded periosteum was then examined in vivo. Human cancellous allografts were wrapped with 10% per day strained, fresh, free-floating, or no porcine periosteum and implanted subcutaneously into female, athymic mice. Tissue was collected at 8- and 16-weeks. Gene expression analysis revealed a significant increase in alkaline phosphatase and osteocalcin in the fresh periosteum group at 8-weeks post implantation compared to all other groups. Values among all groups were similar at week 16. Additionally, histological assessment with H&E and Masson-Goldner Trichrome staining showed that all periosteal groups outperformed the non-periosteal allograft, with fresh periosteum demonstrating the highest levels of new tissue mineralization at the periosteum-bone interface. Overall, mechanical expansion of the periosteum can provide increased area for segmental healing via autograft strategies, though further studies are needed to explore culture methodology to optimize osteogenic potential.

Monitor selection according to the defect location in the medial femoral condyle flap. Injury 2022;53:4139-4145. [PMID: 36192200 DOI: 10.1016/j.injury.2022.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

Medial femoral condyle(MFC) flap is frequently used in hand reconstruction, but like other buried flaps, MFC is not easy to monitor and follow.In this study, we present our adipofascial and periosteal tissue technical modifications and results for MFC free flap monitoring and compare different monitoring methods.

METHODS

Twenty one patients with wrist bone or metacarpal defect reconstructed with MFC flap were included in the study. Adipofascial tissue in wrist defect and periosteal tissue in metacarpal defect were selected as MFC flap's monitor. Patient characteristics, type of injury, flap size, early or late-period complications, flap elevation time,satisfaction scale, visual analogue scale (VAS) and postoperative X-ray view were noted.

RESULTS

There were 3 female and 18 male patients in the study. The mean age of the patients was 50.8 (38-68). The elevation times of flaps with adipofascial and periosteal monitors were 48 and 53.3 min, respectively. The satisfaction scale averages for the adipofascial and periosteal monitor groups were 3.5 and 3.54, respectively. The VAS scores of the adipofascial and periosteal monitor groups were 2.9 and 3.9, respectively. The flap sizes with periosteal and adipofascial monitors were 10.48 cm³ and 1.36 cm³, respectively. There was no statistically significant difference between flap elevation, VAS, and satisfaction scale (>0.05). There was a statistically significant difference in flap sizes. (<0.05) CONCLUSION: MFC free flap is frequently used in wrist and metacarpal reconstruction. Monitor selection according to the defect area positively affects the prognosis of the flap in the postoperative period.

Is it really necessary to perform venous anastomosis in vascularized corticoperiosteal bone flap? A randomized prospective 4-year follow-up study

BACKGROUND

This study aims to investigate the treatment results of atrophic nonunion of the lower and upper limb with vascularized bone flaps performed with only arterial anastomosis versus the execution of flaps performed with arterial and venous anastomosis, comparing the surgical time and the healing rate of these two techniques.

METHODS

49 patients were enrolled in this study and were randomly divided into two groups: group A, the control group, consisted of 27 patients, who underwent vascularized corticoperiosteal bone flap with both arterial and venous anastomosis; group B, consisted of 22 patients, who underwent vascularized corticoperiosteal bone flap with only arterial anastomosis. The surgical time, the time to harvest the graft and the microsurgical time were evaluated. Radiological and clinical follow-ups were performed with one independent and blinded investigator to avoid bias.

RESULTS

A significant reduction in the duration of the intervention in group B was found: a 13.63% reduction of the total surgical time and a 41.75% reduction of the microsurgical time. A significant difference was not found between groups A and B in bone healing time. All the patients of both groups were able to return to their daily life activities.

CONCLUSIONS

Our investigation suggests that it isn't necessary to perform the venous anastomosis between the flap pedicle and the recipient area. Presumably, the venous blood flow reaches the systemic circulation through the vascular bone marrow network. Our procedure avoids venous trauma during the dissection and execution of the anastomosis and, therefore, can minimize complications such as venous thrombosis.

Vascularized Medial Femoral Condyle Periosteal Flaps With Allograft Bone for Distal Radius Giant Cell Tumors: A Case Report

CASE

Distal radius reconstruction after giant cell tumor (GCT) resection is typically performed with free fibular flaps when a vascularized bone is needed. However, vascularized fibular flaps are contraindicated in patients with peroneal artery variants. We present 2 patients with GCTs of the radius and bilateral peronea arteria magna who underwent resection with wrist fusion using an allograft bone and vascularized free medial femoral condyle periosteal flaps. Both patients had excellent outcomes with minimal postoperative morbidity.

CONCLUSION

Allograft bone with vascularized medial femoral condyle periosteal flaps is an effective option for reconstructing distal radius defects after GCT resection when conventional methods fail.

Acute Thumb Reconstruction With Medial Femoral Condyle and Radial Forearm Free Flaps: A Case Report

Traumatic thumb injuries often result in significant functional disability. With segmental bone loss, reconstructive options include antibiotic cement with delayed bone graft, revision amputation with webspace deepening, metacarpal distraction osteogenesis, index pollicization, bone flap, and free toe transfer. We present a case of a subtotal thumb amputation just distal to the metacarpal phalangeal joint resulting in loss of both soft tissue and a segmental bone defect of the proximal and distal phalanx. Reconstruction was initially performed with a chimeric bone free flap from the medial femoral condyle with a vastus medialis muscle cuff to provide soft tissue coverage. A revision soft tissue coverage procedure was required and a radial forearm free flap was utilized. His reconstruction restored his missing bone and soft tissue, and provided stability with sufficient grip strength and metacarpophalangeal function resulting in a satisfactory functional outcome.

Treatment of Recalcitrant Femoral Shaft Nonunion With Medial Femoral Condyle Pedicled Autograft: Technical Trick

SUMMARY

Nonunited fractures of the femoral shaft and distal femur are usually successfully addressed with stabilization with or without autogenous bone grafting. For the small subset of these problems that prove recalcitrant to front-line treatment, a pedicled medial femoral condyle (MFC) bone flap can provide a source of vascularized autograft with minimal donor site morbidity. The MFC has gained recent widespread adoption as a free vascularized bone transfer, and here, we present a surgical technique and retrospective analysis of patients treated with a pedicled MFC technique. This serves as a useful treatment option for these difficult problems and may be especially helpful in low resource environments or where microsurgical anastomosis is not feasible.

"Use of pedicled corticoperiosteal flap in resistant cases of distal femur non-union: Our learning experience"

INTRODUCTION

Nonunion of distal femur is a complex problem with the added burden of poor bone stock, osteopenia, and joint contracture. Various procedures are described ranging from osteosynthesis using auto/allograft, to use of mega prosthesis. Use of vascularized corticoperiosteal flap based on descending genicular artery and superomedial genicular artery is a new technique to provide living vascular graft for the nonunion site. Although few free corticoperiosteal flap reconstructions have been reported in the past for these distal femur nonunions, this flap has seldom been used as a pedicled variety. Through this article, we aimed at highlighting the main obstacles faced while using pedicled corticoperiosteal flap for these patients given its dearth in literature.

MATERIALS AND METHODS

Five patients of at least two previously failed osteosynthesis for distal femur fracture non-union were selected for performing corticoperiosteal flaps. The intraoperative findings that were both favourable and unfavourable were documented along with the outcome of procedure in the form of callus formation or fracture healing.

RESULTS

Dissection of the flap was more tedious in these cases than when performed for a different indication in a virgin territory. However, despite the previous trauma resulting in decreased pliability of their vessels, all flaps were viable at the end of procedure with favourable cosmetic and functional outcomes.

CONCLUSION

Despite the complexities in flap harvest, use of the less morbid and technically easier "Pedicled corticoperiosteal flap" and osteosynthesis along with the auto technique is a worthwhile option for retaining the native joint with favourable outcome in non-unions of distal femur.

The Medial Femoral Condyle Free Flap for Reconstruction of Recalcitrant Defects in the Head and Neck

BACKGROUND

Small recalcitrant defects of the mandible and maxilla may be secondary to tumor, trauma, infection, and congenital origin. Vascularized bone grafting has been shown to effectively manage these defects; however, donor sites are limited. The vascularized medial femoral condyle (MFC) provides adequate cortical cancellous bone with the option of a skin island, consistent anatomy, and minimal donor site morbidity. This article outlines the use of the MFC flap for maxillomandibular reconstruction.

METHODS

A retrospective chart review of patients who required segmental maxillomandibular reconstruction with the MFC flap was conducted. A total of 9 patients (5 men and 5 women) with an average age of 45.3 years were identified. The etiology of the defects, flap sizes, and postoperative outcomes were recorded.

RESULTS

Three patients had osteoradionecrosis of the neomandible after irradiation of the free fibula reconstruction, 3 patients had defects after cancer extirpation (1 mandible, 2 maxillary), 1 patient had a maxillary defect from trauma, and 2 patients had a residual cleft palate defect. All defects failed initial treatment with nonvascularized bone grafts. The average dimensions of the MFC flaps were 1.2 × 2.5 × 4 cm. Two of 9 flaps included a skin island. Eight flaps survived completely, but 1 patient suffered from flap failure requiring debridement and resulted in an oroantral fistula. Four patients received endosseous dental implants. Average time to union was 6.7 months, and average time to implant was 6.75 months. The average follow-up time was 24.9 months.

CONCLUSIONS

The MFC flap is useful in the reconstruction of small segmental maxillomandibular defects and for the salvage of a neomandible after osteoradionecrosis. The MFC flap provides a reliable platform for endosseous dental implants and serves as an alternative source of vascularized bone reconstruction in the head and neck.

Medial Closed Wedge Distal Femoral Osteotomy Using a Novel Plate With an Optimal Compression System

Medial closed wedge distal femoral osteotomy (MCWDFO) has been widely performed for lateral-compartment osteoarthritis since the development of a biplanar osteotomy technique using existing MCWDFO-specific plates. To further improve this system and the technique, we have developed a newly designed MCWDFO plate (TriS-MDFO; Olympus Terumo Biomaterials). The improved shape of the plate consists of a larger head-shaft angle to fit the distal femur after MCWDFO, more distally oriented distal screws to enable longer screw insertion, and a diamond-shaped plate head to avoid interference with the medial patellofemoral ligament. Technically, to overcome the difficulty in inserting proximal screws through the vastus medialis muscle, a cannulated screw system was employed. This system can prevent difficulties in removing the screw due to cross-threading when plate removal is required. Furthermore, we designed a novel compression hook device with a bulb-shaped head to hook on a screw hole to apply a compressive force to the osteotomized site. On the plate side, a characteristic 1.5 mm-thickness stopper is installed to prevent slippage of the hook device. This optimal compression system can minimize the risk of lateral hinge fracture during the compression procedure. These improvements in the TriS-MDFO may increase the ease and safety of MCWDFO.

Reconstruction using a free vascularised medial femoral condyle corticoperiosteal flap for osteomyelitis of the juxta-articular distal radius: A case report and literature review

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.

Vascularized bone grafts for post-traumatic defects in the upper extremity

Vascularized bone grafts (VBGs) are widely employed to reconstruct upper extremity bone defects. Conventional bone grafting is generally used to treat defects smaller than 5–6 cm, when tissue vascularization is adequate and there is no infection risk. Vascularized fibular grafts (VFGs) are mainly used in the humerus, radius or ulna in cases of persistent non-union where traditional bone grafting has failed or for bone defects larger than 6 cm. Furthermore, VFGs are considered to be the standard treatment for large bone defects located in the radius, ulna and humerus and enable the reconstruction of soft-tissue loss, as VFGs can be harvested as osteocutaneous flaps. VBGs enable one-stage surgical reconstruction and are highly infection-resistant because of their autonomous vascularization. A vascularized medial femoral condyle (VFMC) free flap can be used to treat small defects and non-unions in the upper extremity. Relative contraindications to these procedures are diabetes, immunosuppression, chronic infections, alcohol, tobacco, drug abuse and obesity. The aim of our study was to illustrate the use of VFGs to treat large post-traumatic bone defects and osteomyelitis located in the upper extremity. Moreover, the use of VFMC autografts is presented.

[Microvascular reconstruction of foot defects using a free femoral periostal flap]

BACKGROUND

The reconstruction of defects in the foot region is a challenge due to the anatomical peculiarities of the soft tissue covering.

OBJECTIVE

This article presents the results of the reconstruction of postoperative foot defects using the free femoral periosteal flap (FFPF).

MATERIAL AND METHODS

In a patient collective (n = 10) with postoperative wound healing disorders of the foot, the defect zone was covered using a vascularized FFPF from the distal femoral region. The wound healing process was retrospectively analyzed.

RESULTS

The mean follow-up time was 20.2 ± 8.22 months (7-35 months). All patients had a soft tissue defect in the foot region with a mean area of 17.9 ± 3.72 cm² (12-24 cm²). On average, a wound healing disorder occurred 2 weeks after the primary surgery. In the group of patients followed up the vascularized FFPF enabled a stable, definitive and aesthetically pleasing reconstruction and contributed to the bony consolidation. The duration of inpatient care after defect closure was 8-10 days and was significantly less than the duration of wound management prior to transplantation of the FFPF.

CONCLUSION

The FFPF is an effective and elegant method for the regenerative reconstruction of defects with accompanying osseous components in the foot region. The FFPF has the advantage of instant thin and pliable tissue coverage in contrast to many other reconstructive methods. The FFPF can promote wound consolidation through the regenerative properties of a vascularized periosteal sheath in the context of a one-step and permanent infection control.

Donorsite defect of medial femoral condyle corticoperiostal flap in the treatment of lower limb infected nonunions

BACKGROUNDS

 Chronic osteomyelitis is a major challenge in orthopaedic surgery; it is the result of open fracture, periprosthetic infection and septic arthritis. Osteomyelitis leads to fracture nonunion. The treatment of bone infection and infected nonunion consists primarily of the complete removal of infected and avascular bone and soft tissue from the surgical site, followed by local and systemic pathogen-specific antibiotic therapy and temporary stabilisation, but may lead to massive skeletal and soft tissue defects. The use of free or pedicled vascularised bone transfers and callus distraction techniques (bone transport) has been recommended for large bone defects. The aim of this study is to evaluate the results of patients affected by infected non-unions of the lower limbs, treated with a corticoperiosteal flap from the medial femoral condyle and to investigate the donor site morbidity of this flap.

MATERIALS AND METHODS

 The patients were 11 males (average age of 45.6 years), who presented a nonunion of the tibial diaphysis in 7 cases and non-union of femoral diaphysis in 4 cases, treated with free or pedicled corticoperiosteal flap. In all patients, surgical debridement was performed before the flap of infected bone and soft tissues that would not contribute to wound healing. Clinical and radiographic evaluations of the recipient site were performed. Preoperative and postoperative X-ray and MRI scans after the 3-year follow-up of the donor site were performed, in order to observe possible bone restoration and any complications.

RESULTS

 The patients reported complete clinical and radiographic bone healing in 90.9 % of cases. As regards donor site, there were no differences between the medial femoral donor condyle compared to the contralateral site, due to complete regeneration of donor site bone. MRI investigation showed complete restoration of the donor site with vascularised bone in all patients.

CONCLUSIONS

 Our results suggest that the use of bone flaps for the treatment of infected non-unions is an effective procedure, that must be performed after accurate debridement of the non-union site. The corticoperiosteal flap seems to have few morbidities on the donor site and a high percentage of successful bone healing.

Free vascularised medial femoral condyle periosteal flaps in recalcitrant long bone non-union: a systematic review

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.

The medial femoral condyle free flap: An excellent option for difficult cases: case series

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.

Medial Femoral Condyle Periosteal Free Flap for the Treatment of Talus Avascular Necrosis

BACKGROUND

In patients with avascular necrosis (AVN) of the talus in the precollapse stage unresponsive to conservative measures, joint preservation should be considered. Good results have previously been reported for vascularized bone grafting. The medial femoral condyle (MFC) free flap has recently been introduced, which consists of corticoperiosteal bone. We present a novel surgical technique using a periosteal-only MFC (pMFC) free flap in the treatment of talus AVN.

METHODS

We retrospectively reviewed all pMFC free flaps performed from 2016 to 2018 in the precollapse stage of talus AVN. Surgical management included an ankle arthroscopy, talus core decompression, and ipsilateral pMFC free flap to the talus. Foot and Ankle Ability Measure (FAAM)-Activities of Daily Living (ADL) and visual analog scale (VAS) pain scores were evaluated, and pre- and postoperative imaging studies were assessed by a musculoskeletal-trained radiologist for all patients. Six pMFC free flaps in 5 patients were included in this case series. AVN etiology included idiopathic, posttraumatic, and sepsis-related treatment. All patients were female with an average age of 44.2 (range, 37-67) years. Average postoperative follow-up was 16.9 (range, 6-28) months.

RESULTS

Pre- to postoperative FAAM-ADL, ADL single assessment numeric evaluation, and VAS scores showed statistically significant improvement (P < .039). No reoperations or flap complications were observed. There was 1 minor complication, which included postoperative paresthesias at the pMFC harvest site. Postoperative x-rays showed no subsequent collapse, and magnetic resonance imaging (MRI) illustrated progressive improvement of bone marrow edema, decreased surrounding areas of AVN, and decreased joint effusion when compared to preoperative MRI.

CONCLUSION

The pMFC free flap is a novel modification of a previously described technique, which appears to have similar results compared to the traditional MFC free flap. It was safe and effective in the short term with excellent clinical and radiographic outcomes.

LEVEL OF EVIDENCE

Level IV, case series.

Free vascularized medial femoral condyle corticoperiosteal flap with non-vascularized iliac crest graft for the treatment of recalcitrant clavicle non-union

Clavicle non-union is a challenging problem. Open reduction with internal fixation and autologous bone grafting is usually the first line treatment. In case of failure, the medial femoral condyle corticoperiosteal flap in association with a non-vascularized bone graft is one of the therapeutic options, which is well adapted to the clavicle anatomical characteristics. We performed a retrospective study of all patients treated with this technique in our department. Between 2014 and 2017, five patients with recalcitrant post traumatic clavicle non-unions received this surgical treatment. The average nonunion time period was 50.2 month (range 10 to 108 months), and the mean defect length was 3.4 cm (between 2 and 5 cm), defects were all located in the medial third of the clavicle Three patients achieved full consolidation with an average time of consolidation of 8,7 months (range 6 to12 months). Patients with radiological consolidation had better functional improvement and pain reduction with an average DASH score improved from 53,6 before surgery to 19,6 after consolidation (at the last follow up visit). There was one donor site complications (hematoma). The medial femoral condyle corticoperiosteal flap with non-vascularized iliac crest graft is a good option for the management of recalcitrant clavicle non-union, especially when the bone defect is small.

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

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

The medial femoral condyle free corticoperiosteal flap versus traditional bone graft for treatment of nonunions of long bones: a retrospective comparative cohort study

Fracture healing is a complex process and many factors change the local biology of the fracture and reduce the physiologic repair process. Since 1991 the free vascularised corticoperiosteal graft has been proposed to treat nonunions. In this study we compare the healing rate and the healing time of the free vascularised corticoperiosteal graft harvested from medial femoral condyle versus the traditional cancellous bone graft from the iliac crest combined with other biologic or pharmacologic factors. We performed a retrospective cohort study. The main measures of outcomes were the rate of bone union and the mean healing time from surgery. The authors performed 10 free vascularised corticoperiosteal grafts in the cohort A and 10 patients received traditional cancellous bone graft plus other biologic or pharmacologic treatment in the same period in the cohort B. The mean follow up in cohort A was 18.6 months with a healing rate of 100% (10/10). In cohort B the mean follow up was 22.5 month with a healing rate of 90%. The mean time to obtain union (healing time) in the group that was treated with the free flap procedure was significantly shorter, 3.2 months versus a mean time of 8.8 months in the other group. Some studies describe a high healing rate of recalcitrant nonunions with treatments different from vascularized bone flaps: it is difficult to compare the results of vascularized bone transfers with the results of other case series. Our groups are very homogeneous even if it is difficult to define correct inclusion criteria because there is still no agreement about what is defined a recalcitrant or difficult nonunion, and the number of trials of previous surgery before to perform a vascularized free flap. Even if our study cohort is small, we have demonstrated that the MFCCF generally seems to give a better healing chance with a shorter healing time compared to other treatments.

The vascularized medial femoral condyle free flap for reconstruction of segmental recalcitrant nonunion of the clavicle

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.

Colony Formation, Migratory, and Differentiation Characteristics of Multipotential Stromal Cells (MSCs) from "Clinically Accessible" Human Periosteum Compared to Donor-Matched Bone Marrow MSCs

Periosteum is vital for fracture healing, as a highly vascular and multipotential stromal cell- (MSC-) rich tissue. During surgical bone reconstruction, small fragments of periosteum can be “clinically accessible,” yet periosteum is currently not ultilised, unlike autologous bone marrow (BM) aspirate. This study is aimed at comparing human periosteum and donor-matched iliac crest BM MSC content and characterising MSCs in terms of colony formation, growth kinetics, phenotype, cell migration patterns, and trilineage differentiation capacity. “Clinically accessible” periosteum had an intact outer fibrous layer, containing CD271+ candidate MSCs located perivasculary; the inner cambium was rarely present. Following enzymatic release of cells, periosteum formed significantly smaller fibroblastic colonies compared to BM (6.1 mm² vs. 15.5 mm², n = 4, P = 0.0006). Periosteal colonies were more homogenous in size (range 2-30 mm² vs. 2-54 mm²) and on average 2500-fold more frequent (2.0% vs. 0.0008%, n = 10, P = 0.004) relative to total viable cells. When expanded in vitro, similar growth rates up to passage 0 (P0) were seen (1.8 population doublings (PDs) per day (periosteum), 1.6 PDs per day (BM)); however, subsequently BM MSCs proliferated significantly slower by P4 (4.3 PDs per day (periosteum) vs. 9.3 PDs per day (BM), n = 9, P = 0.02). In early culture, periosteum cells were less migratory at slower speeds than BM cells. Both MSC types exhibited MSC phenotype and trilineage differentiation capacity; however, periosteum MSCs showed significantly lower (2.7-fold) adipogenic potential based on Nile red : DAPI ratios with reduced expression of adipogenesis-related transcripts PPAR-γ. Altogether, these data revealed that “clinically accessible” periosteal samples represent a consistently rich source of highly proliferative MSCs compared to donor-matched BM, which importantly show similar osteochondral capacity and lower adipogenic potential. Live cell tracking allowed determination of unique morphological and migration characteristics of periosteal MSCs that can be used for the development of novel bone graft substitutes to be preferentially repopulated by these cells.

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)

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.

The Anterolateral Thigh-Medial Femoral Condyle Chimeric Flow-through Flap for Posttraumatic Wrist Arthrodesis

Wrist arthrodesis in the setting of segmental bone loss can have high failure rates. Therefore, vascularized bone grafting has been advocated for select patients. Patients suffering concomitant large soft tissue loss present even greater challenge. To that end, we describe for the first time successful anterolateral thigh-medial femoral condyle chimeric flow-through flap for posttraumatic wrist arthrodesis and soft tissue coverage. This is a case report of a 19-year-old male laborer who suffered a large blast injury resulting in significant bone and soft tissue injury to the dominant right hand and wrist. After multiple debridements, there was a segmental bone defect from the distal radius and ulna to the metacarpal bases, as well as a 12×8 cm dorsal soft tissue defect. This was reconstructed with a anterolateral thigh-medial femoral condyle chimeric flow-through flap and concomitant wrist arthrodesis in a single stage. Besides a donor site thigh seroma, recovery was uneventful with clinical and radiographic evidence of fusion by >9 weeks postoperation.

Objective and quantifiable measuring mechanism for assessing flap pliability: Our experience with 92 patients

BACKGROUND

Pliability describes a flaps' ability to bend under spatial limitations, yet a quantifiable measurement for this flexibility does not exist.

METHODS

Between January 2015 and January 2017, we applied a novel measuring mechanism to two free flaps for head and neck reconstruction. We allocated a flap pliability score (FPS) to these flaps and observed correlations to common variables.

RESULTS

Forty profunda artery perforator (PAP) and 52 anterolateral thigh (ALT) flaps were allotted a score depending on how pliable they performed on our test. Proximal PAP and distal ALT were more pliable than their respective opposite ends. Other interesting conclusions regarding these flaps were also made.

CONCLUSIONS

With our technique, pliability of the proximal and distal ends of PAP and ALT flaps was ascertained. Herein, we describe an innovative measuring mechanism via which we can allocate a FPS to any flap and thus obtain information regarding how suitable they are for a given recipient site.

Vascular coverage of the anterior knee region - an anatomical study

Descriptions of vessel angiosomes or perforasomes throughout the human body are quite frequent, and led to the development of flaps nowadays commonly used to surgically cover skin and soft tissue defects. In these procedures, the surgeon requires a profound anatomical knowledge of the respective blood vessels and the extent of the perfused area to define the size of the graft. In the region of the knee joint, descriptions of flaps based on the superior lateral genicular artery and descending genicular artery are quite frequent. In contrast, information regarding other popliteal branches is scarce or non‐existent. The aim of this study was to provide a concise and complete overview on the extent and variability of the perforator angiosomes of the femoral and popliteal arteries in the anterior knee region. Twenty lower extremities were dissected, the respective perforators identified and perfused with dye. All resulting angiosomes were marked and documented. A total of 84 angiosomes were identified in all specimens, with an average of 4.2 (3–6) angiosomes per specimen. The average size of the angiosomes was 97.04 ± 72.30 cm² (8.61–360.41 cm²), their source vessels had an average diameter of 1.42 ± 0.54 mm (0.60–3.25 mm). The complex and highly variable distribution of perforator angiosomes of the anterior knee region and especially of its less frequently investigated distal part was demonstrated. Based on these results, the planning of existing perforator flaps in this region and the development of flaps including the inferior medial or inferior lateral genicular arteries may be facilitated.

Long Term Follow Up of a Vascularized Osteocutaneous Free Flap for Reconstruction in Charcot Neuroarthropathy: A Case Report

Vascularized osteocutaneous free flaps have seen increasing use in foot and ankle surgery for the repair of bony defects secondary to chronic nonunion, osteomyelitis, and fractures. One example is the Medial Femoral Condyle (MFC) Flap. The utility of the MFC flap for the repair of a bony defect in a diabetic patient, however, has yet to be explored. We report the long-term results of a case describing the use of an MFC flap to reconstruct an osseous defect resulting from first metatarsophalangeal joint resection in a diabetic patient.

Wrist arthrodesis with the medial femoral condyle flap: Outcomes of vascularized bone grafting for osteomyelitis

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.

The Chimeric Myo-Osseous Medial Femoral Condyle Flap for Tibial Nonunion: A Case Report

Objective: The descending genicular artery provides the dominant pedicle for the medial femoral condyle and medial femoral trochlear free flaps. Variations of the flap include using a skin paddle for monitoring, a vastus medialis muscle component, and the medial superior geniculate artery for the pedicle. We present a case of a 49-year-old man with a distal tibial fracture from a motor vehicle accident complicated by chronic osteomyelitis, poor soft tissue envelope, and tibial nonunion. Methods: The composite lower extremity defect was reconstructed with a chimeric myo-osseous variant of the medial femoral condyle free flap since no perforator was available to the skin and there was a large amount of dead space. Results: At 9 months postoperatively, there was successful tibial union, adequate coverage of the defect, and a return to unassisted ambulation. Conclusions: The chimeric myo-osseous variant of the medial femoral condyle free flap adds to the versatility of this flap and has application in reconstructing defects of bone that also require soft tissue coverage.

The Periosteal Medial Femoral Condyle Free Flap: A New Option for Soft Tissue Reconstruction of the Distal Lower Extremity

BACKGROUND

Small (<30 cm) soft tissue defects of the distal leg, foot, and ankle pose a complicated issue with regard to wound healing. Multiple flaps have been proposed for reconstruction of these wounds with varying levels of success. The medial femoral condyle flap is a free bone flap supplied by the descending geniculate artery. It is currently used in the treatment of fracture nonunion, infected bone defects, avascular necrosis, and osteoradionecrosis. This study proposes the use of the periosteal portion of the medial femoral condyle (PMFC) flap for soft tissue reconstruction of the distal leg, foot, and ankle.

METHODS

We performed a single-center, retrospective series of 6 patients with distal leg, foot, and ankle wounds. All patients underwent reconstruction using the PMFC flap.

RESULTS

Of the 6 patients, 5 had chronic wounds. There were no incidences of flap loss. Five patients healed without complication, four of which had undergone immediate skin grafting, whereas one had concomitant skin paddle reconstruction. The remaining patient required a second surgery with a rotation flap for recurrent osteomyelitis and wound infection 2 months after the initial surgery. Mean operative time decreased after a 2-case learning curve.

CONCLUSIONS

Small wounds of the distal extremity can be difficult to treat, with many requiring free or rotational flap coverage. We propose novel use of the PMFC flap for reconstruction of small soft tissue defects of the distal leg, foot, and ankle. In our series, we demonstrated no donor site morbidity, with excellent cosmetic and functional outcomes.

The Medial Femoral Condyle Corticoperiosteal Free Flap for Frontal Sinus Reconstruction

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

The medial femoral trochlea flap with a monitor skin island-Report of two cases

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.

Surgical Revascularization-An Innovative Approach to the Treatment of Talar Osteonecrosis Dissecans Stages II and III

Talar osteonecrosis dissecans is caused by osseous malperfusion, leading to destruction of the talar bone. The current reference standard for advanced stages lacking arthrosis is core decompression, followed by autologous cancellous bone grafting. However, talar revascularization has not been observed in a subset of patients after this procedure. Microsurgical vascularized bone grafting can improve outcomes by the induction of angiogenesis. We present the 1-year follow-up data from 3 patients with talar osteonecrosis dissecans, who had undergone free vascularized medial femoral condyle autotransplantation. The patients were evaluated preoperatively and 3, 6, and 12 months postoperatively. The active range of motion, pain (visual analog scale [VAS]), and American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and lower extremity functional scale were used. Osteonecrosis dissecans stage II was seen in patient 1 (aged 27 years) and stage III in patients 2 (aged 18 years) and 3 (aged 41 years). Preoperative pain of the ankle was recorded as VAS score of 3 by patients 1 and 2 and VAS score of 6 by patient 3. At 12 months postoperatively, patients 1 and 2 recorded a VAS score of 2 and patient 3, a VAS score of 0. All patients showed improvement in the lower extremity functional scale and American Orthopaedic Foot and Ankle Society scale scores. After 6 and 12 months, magnetic resonance imaging showed a well-vascularized femoral condyle incorporated into the talus in all the patients. Autotransplantation of vascularized bone grafts from the medial femoral condyle is a promising technique for surgical revascularization of talar osteonecrosis dissecans stage II and III.