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Guzzini M, Lupariello D, Argento G, Arioli L, Ferretti A. Vascular and Bone Regeneration of the Donor Site After Corticoperiosteal Flap From the Medial Femoral Condyle. Hand (N Y) 2022; 17:366-372. [PMID: 32686510 PMCID: PMC8984706 DOI: 10.1177/1558944720930299] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The aim of this study was to evaluate the morbidity and regeneration of descending genicular artery and bone on the donor site, the medial condyle of the femur, after harvesting the corticoperiosteal flap and to report the clinical, functional, and radiographic outcomes of the treatment of atrophic nonunions of upper limb with corticoperiosteal vascularized flap at 5-year follow-up. Methods: From January 2011 to January 2018, 36 patients (average age of 45.8 years) were enrolled and evaluated with clinical and radiographic follow-up (average time of 66 months). In 20 patients, magnetic resonance angiography was also performed preoperatively and postoperatively to investigate the fate of the descending genicular artery after harvesting the corticoperiosteal flap. Results: Radiographic evaluation demonstrated a success rate of 94.4% (average time of bone healing of 5.2 months). At the recipient site, clinical evaluation showed excellent results in 75% to 80% of cases, and at the donor site, no statistical differences were found between before and after surgery clinical condition. In all patients who underwent magnetic resonance imaging, images showed a complete recovery of the blood supply of the medial femoral condyle. Conclusions: Medial condyle corticoperiosteal flap represents a valid choice for the treatment of upper limb nonunions. This technique brings a very low morbidity on the donor site, with complete restoration of blood supply and bone tissue. The limit of this flap is its low mechanical support, which suggests performing this technique especially for the treatment of upper limb nonunions.
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Affiliation(s)
- Matteo Guzzini
- S. Andrea Hospital, University of Rome
“La Sapienza”, Rome, Italy
| | | | - Giuseppe Argento
- S. Andrea Hospital, University of Rome
“La Sapienza”, Rome, Italy
| | - Leopoldo Arioli
- S. Andrea Hospital, University of Rome
“La Sapienza”, Rome, Italy,Leopoldo Arioli, Unit of Orthopedics and
Traumatology, S. Andrea Hospital, University of Rome “La Sapienza”, Via di
Grottarossa, 1035-1039, 00189 Rome, Italy.
| | - Andrea Ferretti
- S. Andrea Hospital, University of Rome
“La Sapienza”, Rome, Italy
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Landscheidt K, Lauer H, Goertz O, Hernekamp JF. [Successful Scaphoid Reconstruction through a renewed free vascularized medial Femoral Condyle Graft]. HANDCHIR MIKROCHIR P 2021; 54:82-86. [PMID: 34706378 DOI: 10.1055/a-1548-6738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Politikou O, Wirth S, Giesen T, Guggenberger R, Giovanoli P, Calcagni M. Corticoperiosteal medial femoral condyle flap for recalcitrant nonunion in ankle and foot: Outcomes and radiological evaluation of donor site morbidity. Foot Ankle Surg 2020; 26:918-923. [PMID: 32067885 DOI: 10.1016/j.fas.2019.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/11/2019] [Accepted: 12/29/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the effectiveness and safety of free corticoperiosteal medial femoral condyle (MFC) flap for ankle, hindfoot and midfoot reconstruction in patients with recalcitrant nonunion. METHODS Patients who underwent ankle and foot reconstruction using the MFC flap at our clinic were recruited for assessment of the union rate, time to union and functional outcome. Furthermore, a clinical and radiological examination of the donor knee was performed using both computed tomography and magnetic resonance imaging. RESULTS Thirteen patients with a mean follow-up time of 2.5 years were included; 10 of them had a previously failed ankle and foot arthrodesis. Union was achieved in 11 patients in an average time of 10 months after MFC flap surgery. Donor site morbidity was minor with no radiological evidence for soft tissue or bone complication. CONCLUSION MFC flaps are a useful and safe reconstructive tool and may be considered after failed ankle and foot arthrodesis.
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Affiliation(s)
- Olga Politikou
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
| | - Stephan Wirth
- Division Foot and Ankle Surgery, Orthopaedics Department, University Hospital Balgrist, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Thomas Giesen
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
| | - Roman Guggenberger
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
| | - Pietro Giovanoli
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
| | - Maurizio Calcagni
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
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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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Soldado F, Barrera‐Ochoa S, Bergua‐Domingo JM, Domenech P, Corona PS, Knorr J. Bone nonunion management in children with a vascularized tibial periosteal graft. Microsurgery 2020; 40:760-765. [DOI: 10.1002/micr.30655] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 03/20/2020] [Accepted: 09/03/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Francisco Soldado
- International Pediatric Upper Extremity and Microsurgery Institute Barcelona Childrens HM Nens‐HM Hospitales Barcelona Spain
- UCA Unit‐Vithas San José Vitoria Spain
| | | | - Josep Maria Bergua‐Domingo
- International Pediatric Upper Extremity and Microsurgery Institute Barcelona Childrens HM Nens‐HM Hospitales Barcelona Spain
- UCA Unit‐Vithas San José Vitoria Spain
| | - Pedro Domenech
- International Pediatric Upper Extremity and Microsurgery Institute Barcelona Childrens HM Nens‐HM Hospitales Barcelona Spain
- UCA Unit‐Vithas San José Vitoria Spain
| | - Pablo Salvador Corona
- International Pediatric Upper Extremity and Microsurgery Institute Barcelona Childrens HM Nens‐HM Hospitales Barcelona Spain
- UCA Unit‐Vithas San José Vitoria Spain
| | - Jorge Knorr
- International Pediatric Upper Extremity and Microsurgery Institute Barcelona Childrens HM Nens‐HM Hospitales Barcelona Spain
- UCA Unit‐Vithas San José Vitoria Spain
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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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9
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Intraoperative anatomy of the vascular supply to the medial femoral condyle. J Plast Reconstr Aesthet Surg 2019; 72:1503-1508. [DOI: 10.1016/j.bjps.2019.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 05/15/2019] [Indexed: 11/18/2022]
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10
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Struckmann VF, Rusignuolo G, Harhaus L, Trinler U, Bickert B, Kneser U, Kremer T. Donor site morbidity of vascularized bone grafts from the medial femoral condyle for osseous revascularization. Microsurgery 2019; 40:104-109. [PMID: 31077458 DOI: 10.1002/micr.30468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 04/14/2019] [Accepted: 04/26/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND Vascularized bone grafts from the medial femoral condyle (MFC) are used to gain surgical revascularization of osseous defects. To date objective data regarding the donor site morbidity are limited. This study aims to evaluate the donor site associated outcome after MFC flap harvest. PATIENTS AND METHODS From 2008 to 2016, 22 patients who underwent MFC bone flap harvest for osseous revascularization of 9 talus, 8 scaphoids, 2 metacarpals, 1 phalanx, 1 pilon tibiale, and 1 distal femur were included. Outcome analysis was performed for the whole cohort as well as for two subgroups (recipient site upper [group A] and lower extremity [group B]) by the lower extremity functional scale (LEFS), the OAK-score of the Swiss Orthopedic Society and the visual analog scale (VAS). Additionally, a 3D gait analysis was performed for four patients. RESULTS The mean flap size was 1 × 1 × 3 cm. No flap loss was observed. One minor surgical revision was performed due to donor site hematoma. Mean follow-up was 35.8 (12-98) months. Mean LEFS-score was 74.9 ± 9.5 (A: 74.3 ± 7.9; B: 75.6 ± 11.2, p > .05) and OAK-score was 92.8 ± 9.4 (A: 93.2 ± 5.8; B: 92.4 ± 12.3, p > .05). At follow-up examination, pain at rest was stated with 0.1 ± 0.2 (A: 0.1 ± 0.3; B 0 ± 0, p > .05) and with activity 0.6 ± 1.4 (A: 1.2 ± 1.8; B: 0 ± 0, p > .05) on VAS. The 3-D gait analysis showed normative walking patterns. CONCLUSION After MFC flap harvest knee function and gait pattern were almost unimpaired. Donor site morbidity can be considered as being of minor concern in the decision-making for this microvascular procedure.
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Affiliation(s)
- Victoria Franziska Struckmann
- BG Trauma Center Ludwigshafen, Department of Hand, Plastic und Reconstructive Surgery, Burn Care Center, Hand and Plastic Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Giuseppe Rusignuolo
- BG Trauma Center Ludwigshafen, Department of Hand, Plastic und Reconstructive Surgery, Burn Care Center, Hand and Plastic Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Leila Harhaus
- BG Trauma Center Ludwigshafen, Department of Hand, Plastic und Reconstructive Surgery, Burn Care Center, Hand and Plastic Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Ursula Trinler
- BG Trauma Center Ludwigshafen, Laboratory for Clinical Movement Analysis, Ludwigshafen, Germany
| | - Berthold Bickert
- BG Trauma Center Ludwigshafen, Department of Hand, Plastic und Reconstructive Surgery, Burn Care Center, Hand and Plastic Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Ulrich Kneser
- BG Trauma Center Ludwigshafen, Department of Hand, Plastic und Reconstructive Surgery, Burn Care Center, Hand and Plastic Surgery, University of Heidelberg, Ludwigshafen, Germany
| | - Thomas Kremer
- BG Trauma Center Ludwigshafen, Department of Hand, Plastic und Reconstructive Surgery, Burn Care Center, Hand and Plastic Surgery, University of Heidelberg, Ludwigshafen, Germany.,Department of Plastic and Hand Surgery, Leipzig, Germany
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Hirtler L, Lübbers A, Rath C. Vascular coverage of the anterior knee region - an anatomical study. J Anat 2019; 235:289-298. [PMID: 31070789 PMCID: PMC6637446 DOI: 10.1111/joa.13004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2019] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Lena Hirtler
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Anke Lübbers
- Department of Surgery, Malteser Hospital St Franziskus-Hospital, Flensburg, Germany
| | - Claus Rath
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
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Xu Q, Zheng X, Li Y, Zhu L, Ding Z. Anatomical Study of the Descending Genicular Artery Chimeric Flaps. J INVEST SURG 2019; 33:422-427. [PMID: 30884993 DOI: 10.1080/08941939.2018.1532541] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Qingjia Xu
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Xuefeng Zheng
- Anatomical Institute of Minimally Invasive Surgery, Southern Medical University, Guangzhou, China
| | - Yang Li
- Anatomical Institute of Minimally Invasive Surgery, Southern Medical University, Guangzhou, China
| | - Lei Zhu
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Zihai Ding
- Anatomical Institute of Minimally Invasive Surgery, Southern Medical University, Guangzhou, China
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Izquierdo Ò, Aparicio P, Domínguez E, Castellanos J. Lunate Reconstruction Using Osteochondral Vascularized Graft in Kienböck's Disease. J Hand Microsurg 2018; 10:146-149. [PMID: 30483022 DOI: 10.1055/s-0038-1630144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 01/04/2018] [Indexed: 10/17/2022] Open
Abstract
There is a general consensus that the pathogenesis for Kienböck's disease remains uncertain, though it is probably related to nonphysiologic stress transmission across the lunate, acting in concert with one of several possible vascular abnormalities. Most surgical treatments focus on mechanical aspects rather than real physiopathology, but in the recent years several articles have shown the utility of vascularized grafts in the treatment of Kienböck's disease, especially in its early stages. The authors present a case of a successfully reconstruction of a IIIA stage Kienböck's disease with an osteochondral vascularized graft from medial femoral condyle.
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Affiliation(s)
- Òscar Izquierdo
- Upper Limb and Microsurgery Unit, Orthopaedics Department, Parc Sanitari Sant Joan de Déu de Sant Boi de Llobregat, Barcelona
| | - Pilar Aparicio
- Upper Limb and Microsurgery Unit, Orthopaedics Department, Parc Sanitari Sant Joan de Déu de Sant Boi de Llobregat, Barcelona
| | - Enric Domínguez
- Upper Limb and Microsurgery Unit, Orthopaedics Department, Parc Sanitari Sant Joan de Déu de Sant Boi de Llobregat, Barcelona
| | - Juan Castellanos
- Upper Limb and Microsurgery Unit, Orthopaedics Department, Parc Sanitari Sant Joan de Déu de Sant Boi de Llobregat, Barcelona
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14
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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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SILVA GUSTAVOBERSANI, VELLOSA MATHEUSTEOTONIO, CHO ALVAROBAIK, COSTA RAQUELBERNARDELLIIAMAGUCHIDA, CAMARGO OLAVOPIRESDE, MATTAR JÚNIOR RAMES. MEDIAL FEMORAL CONDYLE CORTICOPERIOSTEAL FLAP: ANATOMIC STUDY. ACTA ORTOPEDICA BRASILEIRA 2018; 26:179-182. [PMID: 30038542 PMCID: PMC6053957 DOI: 10.1590/1413-785220182603190661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Objective The medial femoral condyle corticoperiosteal flap is irrigated by the descending genicular artery, and when this is absent, by the superior medial genicular artery. The descending genicular artery divides into the muscular, saphenous, and osteoarticular branches. The objective of this study was to describe the variables involved in the dissection of the medial femoral condyle flap. Methods Thirty thighs from 20 cadavers were dissected and the following variables were recorded: age, height, weight, thigh length, presence of the descending genicular artery, whether the saphenous branch originated from the descending genicular artery, the length of the branches originating from the descending genicular artery, and the diameter of the descending genicular artery and the vena comitans. Results The descending genicular artery was present in 93.3% of the specimens (28/30). The saphenous branch originated from this artery in 76.7% of the dissections (23/70). The mean distance between the origin of the descending genicular artery and the knee joint was 13.4 cm (±١.4), the mean length of the descending genicular artery was 7.5 cm (±1.5), the mean diameter of the descending genicular artery was 1.9 mm (±٠.3), and the mean diameter of the vena comitans was 1.7 mm (±٠.3). Conclusion The vascularized medial femoral condyle is a versatile option for reconstruction of musculoskeletal injuries. It allows transference of bone associated with muscle and skin, which are each nourished by independent branches. Level of Evidence IV; Case series.
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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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Guzzini M, Lanzetti RM, Perugia D, Lupariello D, Vadalà A, Guidi M, Civitenga C, Ferretti A. The treatment of long bones nonunions of upper limb with microsurgical cortico-periosteal free flap. Injury 2017; 48 Suppl 3:S66-S70. [PMID: 29025613 DOI: 10.1016/s0020-1383(17)30661-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE Medial condyle corticoperiosteal flap is an emerging option for the treatment of upper limb non-infected nonunions. The hypothesis of our study is that corticoperiosteal flap could be an effective and safe procedure for the treatment of upper limb non-infected nonunions, evaluating radiographic and clinical outcome. METHODS We enrolled 14 patients who underwent vascularized medial femoral condyle corticoperiosteal free flaps from January 2011 to December 2014. All patients were clinically evaluated (VAS, DASH) before surgery and at 6 and 12 months post surgery. The radiographic evaluation was performed every 30 days until the complete healing and at 12-month follow-up. We also recorded the range of motion pre and post surgery at the donor site. RESULTS All nonunion sites healed primarily at an average time period of 5.2 months ±1. Preoperative DASH score was 70 ± 15.6; at 6 month follow-up was 21.51 ± 10.63; at 12 month follow-up 18.0 ± 9.9. Preoperative VAS was 7.05 ± 2; at 6-month follow-up was 2.1 ± 2; at 12-month follow-up was 1.8 ± 1.16. Statistical analysis showed a significant difference (p <0.001) about the preoperative and the postoperative VAS and DASH evaluation both at 6 and 12-month follow-up, but we did not record any statistical difference between the 6-month and 12-month follow-up. At the donor site, the mean VAS score was 2 ± 2.1 at seven days post operatively. All patients restore the full ROM at 7 days post surgery. CONCLUSIONS Vascularized medial condyle corticoperiosteal free flap represents an effective and safe procedure for the treatment of upper limb nonunions.
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Affiliation(s)
- Matteo Guzzini
- Unit of Orthopedics and Traumatology, S. Andrea Hospital, "La Sapienza" University, Rome, Italy; Corresponding author at: Unit of Orthopedics and Traumatology, S. Andrea Hospital, Via grottarossa 1053, 00100, Rome, Italy
| | - Riccardo Maria Lanzetti
- Unit of Orthopedics and Traumatology, S. Andrea Hospital, "La Sapienza" University, Rome, Italy; Corresponding author at: Unit of Orthopedics and Traumatology, S. Andrea Hospital, Via grottarossa 1053, 00100, Rome, Italy
| | - Dario Perugia
- Unit of Orthopedics and Traumatology, S. Andrea Hospital, "La Sapienza" University, Rome, Italy; Corresponding author at: Unit of Orthopedics and Traumatology, S. Andrea Hospital, Via grottarossa 1053, 00100, Rome, Italy
| | - Domenico Lupariello
- Unit of Orthopedics and Traumatology, S. Andrea Hospital, "La Sapienza" University, Rome, Italy; Corresponding author at: Unit of Orthopedics and Traumatology, S. Andrea Hospital, Via grottarossa 1053, 00100, Rome, Italy..
| | - Antonio Vadalà
- Unit of Orthopedics and Traumatology, S. Andrea Hospital, "La Sapienza" University, Rome, Italy; Corresponding author at: Unit of Orthopedics and Traumatology, S. Andrea Hospital, Via grottarossa 1053, 00100, Rome, Italy
| | - Marco Guidi
- Unit of Orthopedics and Traumatology, S. Andrea Hospital, "La Sapienza" University, Rome, Italy; Corresponding author at: Unit of Orthopedics and Traumatology, S. Andrea Hospital, Via grottarossa 1053, 00100, Rome, Italy
| | - Carolina Civitenga
- Unit of Orthopedics and Traumatology, S. Andrea Hospital, "La Sapienza" University, Rome, Italy; Corresponding author at: Unit of Orthopedics and Traumatology, S. Andrea Hospital, Via grottarossa 1053, 00100, Rome, Italy
| | - Andrea Ferretti
- Unit of Orthopedics and Traumatology, S. Andrea Hospital, "La Sapienza" University, Rome, Italy; Corresponding author at: Unit of Orthopedics and Traumatology, S. Andrea Hospital, Via grottarossa 1053, 00100, Rome, Italy
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Huang YC, Loh CYY, Lin CH, Lin YT, Hsu CC. Intraflap anastomoses for separated bone and cutaneous pedicle vascular anomaly in a chimeric medial femoral condyle flap. Microsurgery 2017; 37:954-955. [PMID: 28892203 DOI: 10.1002/micr.30224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 07/19/2017] [Accepted: 08/18/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Yi-Chun Huang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Charles Yuen Yung Loh
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Hung Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Te Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chung-Chen Hsu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
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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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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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Hao C, Wang Y, Shao L, Liu J, Chen L, Zhao Z. Local Injection of Bone Mesenchymal Stem Cells and Fibrin Glue Promotes the Repair of Bone Atrophic Nonunion In Vivo. Adv Ther 2016; 33:824-33. [PMID: 27098172 DOI: 10.1007/s12325-016-0329-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION This study aimed to evaluate the efficacy of local injection of bone mesenchymal stem cells (BMSCs) and fibrin glue in the treatment of atrophic nonunion in an animal model. METHODS Thirty-six male Lewis rats were randomly assigned into three groups: Group A (control group), Group B (atrophic nonunion group), and Group C (experimental group). All the rats underwent femoral osteotomy of the right hind limb, and stabilized with a custom-designed external fixator. Atrophic nonunion of the rats in Group B and C was induced by cauterization of the periosteum and bone marrow removal, and repaired by injection of fibrin glue and BMSCs-seeded fibrin glue, respectively. The surgically treated femurs were assessed by radiographic and histological analysis, and biomechanical test. RESULTS During the follow-up period, the external fixator maintained correct placement and all the femurs retained normal positioning. Eight weeks postoperatively, atrophic nonunion was detected in Group B, with the presence of fibrous connective tissue in the osteotomy gap. The femurs in Group C demonstrated complete bony bridging of the osteotomy gap, with the formation of plenty of woven bone. CONCLUSION The repair of bone atrophic nonunion can be promoted through local injection of BMSCs and fibrin glue.
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Guzzini M, Calderaro C, Guidi M, Civitenga C, Ferri G, Ferretti A. Treatment of a Femur Nonunion with Microsurgical Corticoperiosteal Pedicled Flap from the Medial Femoral Condyle. Case Rep Orthop 2016; 2016:5125861. [PMID: 27064589 PMCID: PMC4811065 DOI: 10.1155/2016/5125861] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 02/24/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction. The vascularized corticoperiosteal flap is harvested from the medial femoral condyle and it is nourished by the articular branch of the descending genicular artery and the superomedial genicular artery. This flap is usually harvested as a free flap for the reconstruction of bone defects at forearm, distal radius, carpus, hand, and recently at lower limb too. Case Report. A 50-year-old Caucasian man referred to our department for hypertrophic nonunion of the distal femur, refractory to the conservative treatments. The first surgical choice was the revision of the nail and the bone reconstruction with a corticoperiosteal pedicled flap from the medial femoral condyle. We considered union to have occurred 3.5 months after surgery when radiographs showed bridging of at least three of the four bony cortices and clinically the patient was able to walk with full weight bearing without any pain. At the last follow-up (25 months), the patient was completely satisfied with the procedure. Discussion. The corticoperiosteal flap allows a faster healing of fractures with a minimal morbidity at the donor site. We suggest that the corticoperiosteal pedicled flap graft is a reliable and effective treatment for distal femur nonunion.
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Affiliation(s)
- Matteo Guzzini
- Department of Orthopaedic and Traumatology, Sant' Andrea Hospital, Faculty of Medicine and Psychology, “Sapienza” University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Cosma Calderaro
- Department of Orthopaedic and Traumatology, Sant' Andrea Hospital, Faculty of Medicine and Psychology, “Sapienza” University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Marco Guidi
- Department of Orthopaedic and Traumatology, Sant' Andrea Hospital, Faculty of Medicine and Psychology, “Sapienza” University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Carolina Civitenga
- Department of Orthopaedic and Traumatology, Sant' Andrea Hospital, Faculty of Medicine and Psychology, “Sapienza” University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Germano Ferri
- Department of Orthopaedic and Traumatology, Sant' Andrea Hospital, Faculty of Medicine and Psychology, “Sapienza” University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Andrea Ferretti
- Department of Orthopaedic and Traumatology, Sant' Andrea Hospital, Faculty of Medicine and Psychology, “Sapienza” University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
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Diaz-Gallardo P, Knörr J, Vega-Encina I, Corona PS, Barrera-Ochoa S, Rodriguez-Baeza A, Mascarenhas VV, Soldado F. Free vascularized tibial periosteal graft with monitoring skin island for limb reconstruction: Anatomical study and case report. Microsurgery 2015; 37:248-251. [DOI: 10.1002/micr.30011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 10/01/2015] [Accepted: 11/10/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Paula Diaz-Gallardo
- Pediatric Orthopedics, Hospital Sant Joan De Deu, Universitat De Barcelona; Barcelona Spain
| | - Jorge Knörr
- Pediatric Orthopedics, Hospital Sant Joan De Deu, Universitat De Barcelona; Barcelona Spain
| | - I. Vega-Encina
- Hospital Vithas San José & Hospital Universitario De Álava; Vitoria Spain
| | - Pablo S. Corona
- Orthopedic Surgery Department; Hospital Universitari Vall D'hebron; Barcelona Spain
| | - Sergi Barrera-Ochoa
- Orthopedic Surgery Department; Hospital Universitari Vall D'hebron; Barcelona Spain
| | - Alfonso Rodriguez-Baeza
- Human Anatomy and Embryology Department, Faculty of Medicine; Universitat Autònoma De Barcelona; Barcelona Spain
| | | | - Francisco Soldado
- Pediatric Hand Surgery and Microsurgery; Hospital Sant Joan De Deu, Universitat De Barcelona; Barcelona Spain
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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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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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Schoenleber SJ, Hutson JJ. Treatment of hypertrophic distal tibia nonunion and early malunion with callus distraction. Foot Ankle Int 2015; 36:400-7. [PMID: 25358806 DOI: 10.1177/1071100714558509] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hypertrophic nonunions and early malunions of pilon and distal tibia fractures result in complex, challenging to treat deformities. Callus distraction histiogenesis is an option for their management, allowing for the simultaneous correction of multiplanar deformity and limb length discrepancy. METHODS A single-surgeon, retrospective case series was performed. Eight patients (6 males and 2 females) who were treated with callus distraction from 1991 to 2011 were reviewed. Six of 8 patients had varus deformities (range, 8-19 degrees) and 2 patients had valgus deformities (both 16 degrees) of the distal tibia metaphysis. Six of 8 had apex anterior deformities (range, 2-21 degrees) and 2 had apex posterior deformity (range, 9-20 degrees). An Ilizarov fixator or Taylor Spatial Frame (Smith & Nephew, Memphis, TN) was used to distract the nonunion or early malunion to correct alignment and shortening. Preoperative and postoperative radiographic outcomes, limb alignment, and ankle-hindfoot scores were reviewed. RESULTS Union was achieved in all patients at a mean of 5.8 months (range, 4.1-7.6 months). The 3 patients treated with an Ilizarov-type fixator had deformity correction to within 5 degrees of neutral in 1 plane and to within 10 degrees in the other plane. All 5 patients treated with a Taylor Spatial Frame had correction to within 5 degrees of neutral alignment in both coronal and sagittal planes. There were 2 complications requiring reoperation and 1 persistent limb length discrepancy (2 cm) after treatment. Median AOFAS ankle-hindfoot score was 82.5 (range, 53-90) at an average follow-up of 30.4 months (range, 8-92). CONCLUSIONS Callus distraction histiogenesis was a minimally invasive technique that can successfully treat patients with hypertrophic nonunion and early malunion of the distal tibia. We believe the application of a computer-assisted 6-axis frame to correct the deformity improved the correction of these multiplanar deformities. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
| | - James Jackson Hutson
- Department of Orthopaedics, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
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Caterson EJ, Singh M, Turko A, Weaver MJ, Talbot S. The medial femoral condyle free osteocutaneous flap for osteomyelitis in pilon fractures. Injury 2015; 46:414-8. [PMID: 25464984 DOI: 10.1016/j.injury.2014.11.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 11/08/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND High energy tibial plafond (pilon) fractures are known to have a high rate of complication, particularly wound dehiscence and infection. Wound infection, requiring debridement of both soft tissue and bone can be especially challenging to reconstruct due to the combination of high load-bearing requirements within a thin soft tissue envelope. METHOD We present a case of a pilon fracture with a post-operative complication of wound dehiscence and infection necessitating bone debridement, ultimately resulting in chronic osteomyelitis. We used a medial femoral osteocutaneous free flap to provide vascularised structure to the defect. Included is a comprehensive literature review for the use of the MFC osteocutaneous free flaps in lower extremities. RESULTS This flap provided restoration of the medial column of the ankle. The use of vascularised bone resulted in rapid post-operative bony union. The vascularised bone flap was press fit into the defect ruling out the potential for further hardware related infections. We report follow up of over one year. CONCLUSION The MFC free osteocutaneous flap is a good option for small bone and soft tissue defects of lower extremities, especially in setting of chronic osteomyelitis. It can be custom fabricated and either fixated or press fit into a chronic pilon fracture cavity to obliterate dead space with vascularised bone. LEVEL OF EVIDENCE Level IV, retrospective case study.
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Affiliation(s)
- Edward J Caterson
- Divison of Plastic Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA.
| | - Mansher Singh
- Divison of Plastic Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Arthur Turko
- Divison of Orthopedics Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Michael J Weaver
- Divison of Orthopedics Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Simon Talbot
- Divison of Plastic Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA
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Soldado F, Knörr J, Haddad S, Corona PS, Barrera‐Ochoa S, Collado D, Mascarenhas VV, Gauzy JS. Vascularized tibial periosteal graft in complex cases of bone nonunion in children. Microsurgery 2014; 35:239-43. [DOI: 10.1002/micr.22342] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/28/2014] [Accepted: 10/03/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Francisco Soldado
- Department of Pediatric Upper Extremity Surgery and Microsurgery, Hospital Sant Joan de DeuUniversitat de Barcelona Spain
| | - Jorge Knörr
- Pediatric Orthopedic Surgery DepartmentHôpital des Enfants, CHU Toulouse France
| | - Sleiman Haddad
- Orthopaedic Surgery DepartmentHospital Universitari Vall d'HebronBarcelona Spain
| | - Pablo S. Corona
- Orthopaedic Surgery DepartmentHospital Universitari Vall d'HebronBarcelona Spain
| | - Sergi Barrera‐Ochoa
- Orthopaedic Surgery DepartmentHospital Universitari Vall d'HebronBarcelona Spain
| | - Diego Collado
- Orthopaedic Surgery DepartmentHospital Universitari Vall d'HebronBarcelona Spain
| | | | - Jerome Sales Gauzy
- Pediatric Orthopedic Surgery DepartmentHôpital des Enfants, CHU Toulouse France
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Mattiassich G, Marcovici LL, Dorninger L, Kerschhagl M, Buerger H, Kroepfl A, Larcher L. Reconstruction with vascularized medial femoral condyle flaps in hindfoot and ankle defects: a report of two cases. Microsurgery 2014; 34:576-81. [PMID: 24942331 DOI: 10.1002/micr.22286] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 05/29/2014] [Accepted: 06/05/2014] [Indexed: 11/11/2022]
Abstract
In this article, we report using free vascularized medial femoral condyle (MFC) flaps for reconstruction of bone defects and nonunion of the hindfoot and ankle in two patients. One patient had an open calcaneal fracture and hindfoot bone defect with impaired gait due to Achilles tendon functional loss. The second patient had nonunion with a chondral defect of the talus after a fall. Following uneventful recoveries, good objective and subjective results were achieved in terms of pain reduction and improved gait in both patients. No further operative intervention was needed during a 3-year follow-up period. The versatility of the corticoperiosteal graft from the MFC makes it an important reconstructive tool for addressing several major surgical problems of bony nonunion in the extremities, including posttraumatic reconstruction of hindfoot and ankle disorders.
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Affiliation(s)
- Georg Mattiassich
- Trauma Center Unfallkrankenhaus Linz, University Teaching Hospital of the Paracelsus Medical University Salzburg, Linz, Austria
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Al-Jabri T, Mannan A, Giannoudis P. The use of the free vascularised bone graft for nonunion of the scaphoid: a systematic review. J Orthop Surg Res 2014; 9:21. [PMID: 24690301 PMCID: PMC3976175 DOI: 10.1186/1749-799x-9-21] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 03/12/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fractures of the scaphoid are well known to be problematic especially when complicated by avascular necrosis, nonunion and carpal collapse. Fixation techniques have involved nonvascularised bone grafting; however, in the presence of avascular necrosis, generally poor union rates (47%) occur as identified by a meta-analysis performed by Merrell et al. The introduction of pedicled vascularised bone grafts showed further improvement; however, in the presence of carpal collapse, union rates as low as 50% have been reported by Chang et al. amongst others using the 1,2-intercompartmental supraretinacular artery pedicled graft. The difficulty lies in having a short pedicle with limited manoeuvrability to correct a humpback deformity and insert into the scaphoid cavity. Prior trauma to the soft tissues or distal radius may prohibit the use of pedicled grafts. The aim of this systematic review is to examine the published evidence for the use of free vascularised bone grafts in cases of scaphoid nonunion. METHODS A systematic review was performed with the following defined search strategy on MEDLINE and Google Scholar: ((scaphoid nonunion) OR scaphoid pseudarthrosis) AND bone graft. Articles were reviewed and data compiled into tables for analysis. Statistical analysis was performed with determination of descriptive statistics, and differences between the groups were calculated using categorical variables and chi-square test. A p value of 0.05 or less was considered to be statistically significant. RESULTS Two hundred and sixty-three articles were identified with a total of 12 articles meeting the inclusion criteria. Two hundred and forty-five cases of scaphoid nonunion were identified through the articles included in this systematic review. Fifty-six patients underwent free vascularised bone grafts from the medial femoral condyle with a 100% union rate and correction of humpback deformity, and 188 patients underwent free vascularised bone grafting from the iliac crest with an 87.7% union rate. The difference between the two similar groups was statistically significant (p = 0.006). CONCLUSIONS The promising data suggests that the medial femoral condylar free graft based on the descending genicular vessels can be considered in cases of proximal pole avascular necrosis and humpback deformity or in situations where other flaps are precluded or deemed unlikely to cause union.
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Affiliation(s)
- Talal Al-Jabri
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK.
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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: 19] [Impact Index Per Article: 1.7] [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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Bürger HK, Windhofer C, Gaggl AJ, Higgins JP. Vascularized medial femoral trochlea osteocartilaginous flap reconstruction of proximal pole scaphoid nonunions. J Hand Surg Am 2013; 38:690-700. [PMID: 23474156 DOI: 10.1016/j.jhsa.2013.01.036] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 01/16/2013] [Accepted: 01/17/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE The descending geniculate artery's branching pattern includes periosteal vessels supplying the cartilage-bearing trochlea of the medial patellofemoral joint. Previous cadaveric studies described anatomic similarities between the greater curvature of the proximal scaphoid and the convex surface of the medial femoral trochlea (MFT). We describe the technique and report our first 16 consecutive cases of vascularized osteocartilaginous arthroplasty for chronic scaphoid proximal pole nonunions using the MFT, with a minimum of 6 months of follow-up. METHODS Chart reviews of 16 consecutive cases of osteocartilaginous MFT flap transfers for scaphoid reconstruction were performed at 2 institutions. Follow-up data were recorded at a minimum of 6 months, with an average of 14 months (range, 6-72 mo). Patient age and sex, duration of nonunion, number of previous surgical procedures, surgical technique, achievement of osseous union, preoperative and postoperative scapholunate angles, preoperative and postoperative range of motion, and pain relief were recorded. RESULTS Computed tomography imaging confirmed healing in 15 of 16 reconstructed scaphoids. Mean patient age was 30 years (range, 18-47 y). The average number of previous surgical procedures was 1 (range, 0-3). All patients experienced some wrist pain improvement (12/16 complete relief, 4/16 incomplete relief). Wrist range of motion at follow-up averaged 46° extension (range, 28° to 80°) and 44° flexion (range, 10° to 80°), which was similar to preoperative measurements (average 46° extension and 43° flexion). Scapholunate relationship remained unchanged with average scapholunate angles of 52° before surgery and 49° after surgery. CONCLUSIONS Osteochondral vascularized MFT flaps provide a reliable means of achieving resolution of difficult proximal pole scaphoid nonunions. These flaps allow resection of the proximal portion of the unhealed scaphoid and reconstruction with an anatomically analogous convex segment of cartilage-bearing bone. This technique provides the advantages of vascularized bone and ease of fixation. Early follow-up demonstrates a high rate of union with acceptable motion and pain relief. CLINICAL RELEVANCE Early follow-up suggests that the vascularized MFT osteocartilaginous flap is a valuable tool for treating challenging proximal pole scaphoid nonunions.
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Anatomical Variations of the Saphenous and Descending Genicular Artery Perforators. Plast Reconstr Surg 2013; 131:363e-372e. [DOI: 10.1097/prs.0b013e31827c7067] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Since the advent of the operating microscope by Julius Jacobson in 1960, reconstructive microsurgery has become an integral part of extremity reconstruction and orthopaedics. During World War I, with the influx of severe extremity trauma Harold Gillies introduced the concept of the reconstructive ladder for wound closure. The concept of the reconstructive ladder goes from simple to complex means of attaining wound closure. Over the last half century microsurgery has continued to evolve and progress. We now have a microsurgical reconstructive ladder. The microsurgical reconstruction ladder is based upon the early work on revascularization and replantation extending through the procedures that are described in this article.
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Affiliation(s)
- Scott M Tintle
- University of Pennsylvania, Philadelphia, PA, United States
| | - L Scott Levin
- University of Pennsylvania, Philadelphia, PA, United States.
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Papanna MC, Al-Hadithy N, Somanchi BV, Sewell MD, Robinson PM, Khan SA, Wilkes RA. The use of bone morphogenic protein-7 (OP-1) in the management of resistant non-unions in the upper and lower limb. Injury 2012; 43:1135-40. [PMID: 22465515 DOI: 10.1016/j.injury.2012.03.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 01/19/2012] [Accepted: 03/04/2012] [Indexed: 02/02/2023]
Abstract
The aim of the present study was to investigate the safety and efficacy of local implantation of BMP-7 for the treatment of resistant non-unions in the upper and lower limb. Fifty-two patients (30 males, mean age 52.8 years; range 20-81) were treated with local BMP-7 implantation in a bovine bone-derived collagen paste with or without revision of fixation. Thirty-six patients had closed injuries, ten had open injuries and six had infected non-unions. Patients had undergone a mean of 2 (1-5) operations prior to implantation of BMP-7. Clinical and radiological union was achieved in 94% at a mean time of 5.6 months (3-19). Two patients with subtrochanteric femoral fractures failed to achieve union secondary to inadequate fracture stabilisation, persistent unfavourable biological environment and systemic co-morbidities. One patient developed synostosis attributed to the BMP-7 application. This study demonstrates BMP-7 implanted in a bovine-derived collagen paste is an effective adjunctive treatment for resistant non-unions in the upper and lower limb.
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Affiliation(s)
- M C Papanna
- Dept of Orthopaedics and Limb Reconstruction, Salford Royal Hospital, Salford, UK; Doncaster Royal Infirmary, Doncaster DN2 5LT, UK.
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Holm J, Vangelisti G, Remmers J. Use of the medial femoral condyle vascularized bone flap in traumatic avascular necrosis of the navicular: a case report. J Foot Ankle Surg 2012; 51:494-500. [PMID: 22726653 DOI: 10.1053/j.jfas.2012.04.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Indexed: 02/03/2023]
Abstract
The medial femoral condyle vascularized bone flap has a high success rate in published literature regarding its use in nonunions and avascular necrosis of the upper and lower extremities. It is reported to have minimal donor site morbidity and the ability to provide structural support and torsional strength to load-bearing areas. The flap has found particular success in the treatment of scaphoid nonunions. The tarsal navicular, similar to the scaphoid, is largely articular cancellous bone with little surface area for vascular inflow. These anatomic features make the navicular prone to nonunion and avascular necrosis in traumatic scenarios. We describe a case of nonunion and avascular necrosis of the tarsal navicular occurring as sequelae of a high-impact midfoot injury sustained in an automobile accident. After an initial attempt at open reduction and internal fixation with midfoot bridge plating, subsidence and nonunion resulted. An attempt at arthrodesis of the talonavicular and naviculocuneiform joints was then undertaken. This too failed, leading to the development of additional collapse and avascular necrosis. The site was treated with a medial femoral condyle vascularized bone flap. In this single case, the patient returned to pain-free ambulation and reported excellent outcomes and functional capacity. Although we present a successful case, a larger case series is necessary to establish the use of this flap as a reliable option for the treatment of nonunion and avascular necrosis of the tarsal navicular.
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Affiliation(s)
- Janson Holm
- Legacy Health/Kaiser Permanente Podiatric Surgical Residency, Portland, OR, USA
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Metaphyseal locking compression plate as an external fixator for the distal tibia. INTERNATIONAL ORTHOPAEDICS 2012; 36:1923-7. [PMID: 22648557 PMCID: PMC3427449 DOI: 10.1007/s00264-012-1585-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 05/15/2012] [Indexed: 11/01/2022]
Abstract
PURPOSE Recently we coined the term supercutaneous plating using a locking compression plate (LCP) as an external fixator. The use of this technique in peri-articular areas is facilitated by the development of anatomical plates with various screw sizes. The purpose of this report is to describe our results using the metaphyseal locking plate (LCP) as an external fixator in the treatment of infected post-traumatic problems of the distal tibia. METHODS Between August 2008 and January 2012 a total of seven patients underwent external plating ("supercutaneous plating") of the distal tibia using a metaphyseal locking plate. Average age was 43 years (range 20-79). Six out of seven patients had a documented infection at the time of external plate application. All patients in this cohort were followed prospectively at regular intervals by the senior author (PK). RESULTS The plate was in situ for an average of 17.5 weeks (range 6-60). There were no clinically significant pin site infections. In four patients the plate was kept in place until there was complete consolidation. In three patients the external plate was exchanged for formal internal fixation once the infection had subsided. At the latest follow-up (average 12.8 months, range 4-31), all patients were fully weight bearing with a fully healed tibia. All patients were infection-free with well-healed wounds. CONCLUSION Infection of the distal tibia after treatment of traumatic and post-traumatic problems is a challenging problem. It is common practice that after initial debridement and hardware removal, temporary bony stabilisation is provided by external fixation. Most external frames for the lower leg are bulky and cumbersome, causing significant problems for the patient. To circumvent these issues, we have successfully used an anatomically-contoured metaphyseal locking compression plate as external fixator in a series of seven patients for acute or post-traumatic problems of the tibia.
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Cutaneous angiosome territory of the medial femoral condyle osteocutaneous flap. J Hand Surg Am 2012; 37:1033-41. [PMID: 22483181 DOI: 10.1016/j.jhsa.2012.02.033] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 02/21/2012] [Accepted: 02/23/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE The medial femoral condyle flap is used for treatment of nonunions with or without intercalary bone loss. Most reported uses have been without a skin segment, but this flap can provide a skin component supplied by the saphenous artery branch (SAB) of the descending genicular artery (DGA) pedicle. Experience with this flap suggests that an additional distinct, reliable, more-distal, DGA-cutaneous branch can be found at condyle level, capable of supporting skin without using the SAB. This cadaver study evaluated SAB and DGA-cutaneous branch angiosome territories. A clinical case series assesses the DGA-cutaneous branch's clinical utility. METHODS The DGA and SAB were isolated in 12 cadaveric legs, divided, and separately cannulated. Red dye and methylene blue were selectively injected into each vessel manually. Skin perfusion was measured and photographed. RESULTS In all specimens, the DGA was present, originating 14.2 cm proximal to the joint line, and demonstrated a distinct cutaneous branch at condyle level. This vessel provided an average perfusion area of 70 cm(2), centered over the medial knee. The SAB was identified in 11 specimens (92%), with an average perfusion area of 361 cm(2) along the medial aspect of the distal thigh and proximal leg. The DGA communicating branch was present and used for perfusion of the skin paddle in 17 of 20 cases. The SAB was present in 18 of 20 cases, used with DGA-communicating branch in 4 cases, and the sole source of skin perfusion in 1 case. In 2 remaining cases, neither the SAB nor DGA communicating branch was adequate for perfusion of a skin segment. CONCLUSIONS The medial femoral condyle flap can be harvested with a large skin paddle based on the SAB. A smaller skin segment can be harvested using the more distal DGA-communicating branch at condyle level. CLINICAL RELEVANCE Improved understanding of the skin island associated with the DGA's saphenous and cutaneous branches can provide a rapid, reliable method of skin-segment harvest.
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Abstract
With the passage of time, certain hand surgery procedures are anecdotally dubbed "workhorse" techniques. These are procedures that are extremely reliable and have repeatedly demonstrated good results. However, with time, paradigms undergo shifts, and this is as true for hand surgery as any other field. In this article, we will describe the use of three new "workhorse" flaps that we have found to have reliable results in complex hand reconstruction: the pedicled radial forearm fascia flap for dorsal hand reconstruction, the free anterolateral thigh flap for mangled hand reconstruction, and the medial femoral condyle vascularized bone graft for scaphoid fracture nonunion reconstruction.
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Affiliation(s)
- Jeffrey B. Friedrich
- Division of Plastic Surgery, University of Washington, 325 9th Avenue, Box 359796, Seattle, WA 98104 USA
| | | | | | - Paula Galaviz
- Hand Center, Medical College of Wisconsin, Wauwatosa, WI USA
| | - James Chang
- Division of Plastic Surgery, Stanford University, Palo Alto, CA USA
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Katz RD, Parks BG, Higgins JP. The axial stability of the femur after harvest of the medial femoral condyle corticocancellous flap: a biomechanical study of composite femur models. Microsurgery 2012; 32:213-8. [PMID: 22371138 DOI: 10.1002/micr.20986] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 10/28/2011] [Indexed: 11/10/2022]
Abstract
PURPOSE Free bone or periosteal flaps from the medial femoral condyle are being employed for treatment of recalcitrant nonunions. When harvested in a corticocancellous fashion, these flaps have the potential to compromise the stability of the femur. This study is designed to test the axial stability of the femur after harvest of corticocancellous flaps using a standardized composite femur model. METHODS Corticocancellous defects of standardized width and depth (2 cm × 1 cm) were designed with increasing length (3-cm intervals extending from 3 to 24 cm) over the medial femoral condyle of five composite femur models. After harvest of each corticocancellous block, the femur was subjected to an axial force of 9100 N loaded and unloaded over one second using a Mini-Bionix load frame. During the application of force, load and deformation data were collected from the load cell and linear variable differential transducer. To determine changes in stiffness or deformation with increasing flap sizes, analysis of variance with repeated measures was used. If the main effect was found to be significant, a Tukey's test was used to determine differences between specific flap sizes. RESULTS There were no femur fractures in any femurs for any flap size. Deformation during load increased as the size of the flap increased (2.19 mm ± 0.062 mm for the 3-cm flap defect) to (2.33 mm ± 0.113 mm for the 24-cm flap defect). Post-hoc testing of deformation shows a statistically significant difference only between the 3-cm flap defect and the 15-cm flap defect (2.19 vs. 2.30 mm) (P = 0.002). The range of stiffness is between 4,339 and 4,697 N mm(-1) . Stiffness tends to decrease significantly (P < 0.001) with increasing flap size. Harvest of flap sizes greater or equal than 9 cm results in significantly lower stiffness compared to the 3-cm flap. CONCLUSIONS In this composite femur model, when stressed with supraphysiologic forces, the femur retains its axial stability even after harvest of large corticocancellous flaps from its medial aspect. Statistical significance detected in deformation and stiffness may not be clinically relevant if the femur does not fracture after flap harvest. Such was the case in this experiment. The possibility exists of safely harvesting large flaps from this donor site. Corticocancellous flaps from the medial aspect of the femur may serve as an alternative to standard flaps used in medium and large osseous reconstructions. The size of flap that can be safely raised without compromising the stability of the femur has not yet been delineated.
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Affiliation(s)
- Ryan D Katz
- The Curtis National Hand Center, Union Memorial Hospital, 3333 N. Calvert Street, Baltimore, MD 21218, USA.
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Iorio ML, Masden DL, Higgins JP. The limits of medial femoral condyle corticoperiosteal flaps. J Hand Surg Am 2011; 36:1592-6. [PMID: 21872407 DOI: 10.1016/j.jhsa.2011.07.015] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 07/20/2011] [Accepted: 07/22/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE The medial femoral condyle (MFC) vascularized corticoperiosteal flap has been well described for the treatment of nonunion with minimal bone loss. Recent applications of this donor site as a corticocancellous flap for large intercalary defects bring into question the vascular territory of bone supplied by the descending genicular artery (DGA). This study's purpose is to delineate the proximal extent of periosteal blood supply of the medial column of the femur provided by the DGA system. METHODS In 18 cadaveric specimens, the DGA was isolated, measured, and cannulated. Using subtraction techniques of fluoroscopic angiography, the vascular network and proximal-most extent of periosteal perfusion were recorded using radiopaque contrast dye. RESULTS The DGA branched from the superficial femoral artery 14.2 ± 2.4 cm proximal to the joint line of the knee. The length of the vascular pedicle to its attachment onto the periosteum was 7.7 ± 2.2 cm. All specimens demonstrated a filigree of periosteal vessels dominated by a transverse and a longitudinal branch at the level of the condyle. Proximal perfusion was consistently noted by a large, longitudinal medial metaphyseal periosteal artery. The medial metaphyseal periosteal artery demonstrated that the proximal-most perfusion of the DGA was 13.7 ± 1.3 cm proximal to the joint line. Average femur length was 47.1 ± 3.1 cm. The DGA provided perfusion of 29% ± 2% of the total length of the medial femur. CONCLUSIONS The DGA provides a large and reliable region of periosteal perfusion, suggesting that corticocancellous MFC harvest might provide the benefits of vascularized bone for large, intercalary nonunion defects conventionally treated with fibula flaps. CLINICAL RELEVANCE Harvest of MFC osseous flaps extending up to 13.7 cm proximal to the joint line can be perfused from the DGA pedicle. The MFC donor site might, therefore, be a reliable option for vascularized reconstruction of larger bone defects.
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Affiliation(s)
- Matthew L Iorio
- The Curtis National Hand Center, Union Memorial Hospital, 3333 North Calvert Street, Mezzanine, Baltimore, MD 21218, USA
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Rodríguez-Vegas J, Delgado-Serrano P. Corticoperiosteal flap in the treatment of nonunions and small bone gaps: Technical details and expanding possibilities. J Plast Reconstr Aesthet Surg 2011; 64:515-27. [DOI: 10.1016/j.bjps.2010.06.035] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 05/21/2010] [Accepted: 06/18/2010] [Indexed: 10/19/2022]
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Yamamoto H, Jones DB, Moran SL, Bishop AT, Shin AY. The arterial anatomy of the medial femoral condyle and its clinical implications. J Hand Surg Eur Vol 2010; 35:569-74. [PMID: 20237188 DOI: 10.1177/1753193410364484] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The success of vascularized bone grafts from the medial femoral condyle in various clinical applications has sparked renewed interest in the microvascular anatomy of this region. This study describes the arterial supply of the distal medial femoral condyle and its implications in harvesting vascularized bone grafts. The location, branching pattern, internal diameter, and distribution of perforators of the descending genicular artery and superior medial genicular artery in 19 fresh cadaveric lower limbs were recorded. The descending genicular artery was present in 89% and the superior medial genicular artery was present in 100% of specimens with average distances proximal to the articular surface of 13.7 cm and 5.2 cm, respectively. The average number of perforating vessels was greatest in the posterior distal quadrant of the condyle. The blood supply of the medial femoral condyle is plentiful and consistent making it a useful source for free vascularized bone grafts.
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Affiliation(s)
- H Yamamoto
- Mayo Clinic, Orthopedic Department, Rochester MN, USA
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The corticoperiosteal medial femoral supracondylar flap: anatomical study for clinical evaluation in mandibular osteoradionecrosis. Surg Radiol Anat 2010; 32:971-7. [PMID: 20373100 DOI: 10.1007/s00276-010-0658-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2009] [Accepted: 03/19/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE An ideal way to treat osteoradionecrosis of the jaws is to transfer an osteogenic, appropriately vascularized flap to the affected site. The corticoperiosteal femoral medial supracondylar flap is being used increasingly in the treatment of complex pseudarthrosis of long bones, but is yet to find robust indications for use in the treatment of osteoradionecrosis of the jaw, the reasons being a lack of anatomical data concerning its vascular supply and the local constraints of its routine harvest. This study presents an anatomical study and literature review to explore its potentials in clinical practice. MATERIALS AND METHODS A total of 25 legs were dissected following vascular injection of colored neopren. The descending genicular artery (DGA) and veins were studied with particular attention paid to anatomical variations found in their branches. Calibers and length of the vessels were recorded. RESULTS Many anatomical variations of the DGA were found and a classification proposed. The mean caliber of the DGA at the origin was 1.9 mm, and for the vein, 1.8 mm. The mean useful length of the pedicle was 7.9 cm. A case is reported. CONCLUSION A clear anatomical knowledge (and, therefore, a sound classification system to grade flap harvesting potential) is the key first step prior to extensive clinical use of this flap. Various anatomical patterns of the pedicle are frequently encountered; branches can be elusive when raising the flap. Vascular imaging is therefore a critical step in identifying types and subtypes before surgery.
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Free-Vascularized Medial Femoral Condyle Bone Transfer in the Treatment of Scaphoid Nonunions. Plast Reconstr Surg 2010; 125:1176-1184. [DOI: 10.1097/prs.0b013e3181d1808c] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Giannoudis PV, Kanakaris NK, Dimitriou R, Gill I, Kolimarala V, Montgomery RJ. The synergistic effect of autograft and BMP-7 in the treatment of atrophic nonunions. Clin Orthop Relat Res 2009; 467:3239-48. [PMID: 19396502 PMCID: PMC2772926 DOI: 10.1007/s11999-009-0846-2] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2008] [Accepted: 04/06/2009] [Indexed: 01/31/2023]
Abstract
UNLABELLED Combining autologous bone graft and recombinant human bone morphogenetic protein-7 (BMP-7) to treat long-bone fracture aseptic atrophic nonunions theoretically could promote bone healing at higher rates than each of these grafting agents separately. We retrospectively reviewed prospectively collected data on patient general characteristics, clinical outcomes, and complications over 3 years to determine the healing rates and the incidence of complications and adverse events of this "graft expansion rationale." There were 45 patients (32 male) with a median age of 43 years (range, 19-76 years). Minimum followup was 12 months (mean, 24.5 months; range, 12-65 months). There were seven humeral, 19 femoral, and 19 tibial nonunions. The median number of prior operations was two (range, 1-7). All fractures united. Clinical and radiographic union occurred within a median of 5 months (range, 3-14 months) and 6 months (range, 4-16 months), respectively. Thirty-nine (87%) patients returned to their preinjury occupation at a mean of 4.2 months (range, 3-6 months). The median visual analog scale pain score was 0.9 (range, 0-2.8; maximum 10), and the median functional score was 86 (range, 67-95; maximum 100) at the final followup. BMP-7 as a bone-stimulating agent combined with conventional autograft resulted in a nonunion healing rate of 100% in these 45 patients. LEVEL OF EVIDENCE Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Peter V. Giannoudis
- Academic Department of Trauma and Orthopaedics, Leeds General Infirmary, Clarendon Wing, Level A, Great George Street, Leeds, LS1 3EX UK
| | - Nikolaos K. Kanakaris
- Academic Department of Trauma and Orthopaedics, Leeds General Infirmary, Clarendon Wing, Level A, Great George Street, Leeds, LS1 3EX UK
| | - Rozalia Dimitriou
- Academic Department of Trauma and Orthopaedics, Leeds General Infirmary, Clarendon Wing, Level A, Great George Street, Leeds, LS1 3EX UK
| | - Ian Gill
- Department of Trauma and Orthopaedics, Middlesbrough General Hospital, Middlesbrough, UK
| | - Vinod Kolimarala
- Department of Trauma and Orthopaedics, Middlesbrough General Hospital, Middlesbrough, UK
| | - Richard J. Montgomery
- Department of Trauma and Orthopaedics, Middlesbrough General Hospital, Middlesbrough, UK
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Rehman KU. Free microvascular transfer of segmental corticocancellous femur for reconstruction of the alveolar ridge. Br J Oral Maxillofac Surg 2009; 47:245. [DOI: 10.1016/j.bjoms.2008.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2008] [Indexed: 10/21/2022]
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