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Roger de Oña I, Garcia Villanueva A, Garcia Lopez JI, Garcia de Lucas F. Versatility of the medial corticoperiosteal flap: from recalcitrant non-unions up to large bony defects. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05351-0. [PMID: 38772929 DOI: 10.1007/s00402-024-05351-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 04/25/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Reconstructive microsurgery techniques using vascularized bone grafts have revolutionized the treatment of complex cases associated with recalcitrant non-unions or osteomyelitis. The medial femoral corticoperiosteal flap (MFCP flap) has emerged as a valuable option in bone reconstruction. Its clinical applications have been extended over the years considering this flap from non-unions with minimal bone lost, up to large intercalary defects of the upper and lower extremities. This article aims to present the clinical applications and outcomes of the MFCP flap in various reconstructive scenarios. METHODS Seventy-nine patients with persistent non-union and bone defects of the upper and lower limb were evaluated from June 2008 to October 2020. All of them were reconstructed with a corticoperiosteal flap from the medial femoral condyle in our hospital. Previous procedures, bone gap and type of flap used were recorded. Postoperative functional status was assessed with time of bone healing, complications and clinical final outcome. RESULTS Radiological evidence of bone union was observed at 4.09 months (range 2-9). Healing rate was 97% with periosteal corticocancellous flaps (PCC flaps) and 93% with corticoperiosteal flaps (CP flaps). Average follow-up was 14.5 months (range 5-28). There were no significant donor site complications. CONCLUSIONS The MFCP flap offers a versatile and reliable option for bone reconstruction. Its ability to provide vascularized bone tissue with low morbidity enhances the healing process and improves outcomes. The MFCP flap has been increasing its applications and it serves as a valuable option in the treatment of recalcitrant non-unions or bony defects irrespective of site and size up to 5 cm in the upper and lower extremities.
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Affiliation(s)
- Ignacio Roger de Oña
- Microsurgery Unit, Department of Orthopaedic Surgery, FREMAP Hospital Madrid, Carretera de Pozuelo 61, Majadahonda, 28222, Madrid, Spain
| | - Andrea Garcia Villanueva
- Microsurgery Unit, Department of Orthopaedic Surgery, FREMAP Hospital Madrid, Carretera de Pozuelo 61, Majadahonda, 28222, Madrid, Spain.
| | - Jose Ignacio Garcia Lopez
- Upper Limb Unit, Department of Orthopaedic Surgery, FREMAP Hospital Madrid, Carretera de Pozuelo 61, Majadahonda, 28222, Madrid, Spain
| | - Fernando Garcia de Lucas
- Upper Limb Unit, Department of Orthopaedic Surgery, FREMAP Hospital Madrid, Carretera de Pozuelo 61, Majadahonda, 28222, Madrid, Spain
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2
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Karunaratne YG, Romeo PB. Vascularized Reconstruction of Recalcitrant Clavicular Nonunion with the Medial Femoral Condyle Free Flap: A Systematic Review of the Literature. J Hand Microsurg 2024; 16:100016. [PMID: 38854380 PMCID: PMC11127545 DOI: 10.1055/s-0043-1760767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
Recalcitrant clavicular nonunion is an uncommon but challenging problem. Vascularized bone reconstruction is not first-line therapy due to complexity and donor morbidity, though it has utility in select cases. A systematic review of Embase and Medline databases was undertaken for cases of medial femoral condyle reconstruction for clavicle nonunion. Ten studies met inclusion, encompassing 26 patients. Mean age was 38.9 years. Ten patients were male and 16 female. Mean time of nonunion was 37.79 months prior to intervention; mean time to union following medial femoral condyle flap was 7.60 months. Two patients did not achieve union. Of the 11 patients who previously had at least one failed fixation with bone graft, considered the current "gold standard", 9 patients (81.81%) went on to achieve union, while 2 patients (18.19%) did not. There were six reported complications in five patients. Medial femoral condyle flap is a valuable option in recalcitrant clavicle nonunion.
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Affiliation(s)
- Yasiru Gehan Karunaratne
- Department of Plastic and Reconstructive Surgery, Bankstown-Lidcombe Hospital, Sydney, NSW, Australia
| | - Pascalino Bruno Romeo
- Department of Plastic and Reconstructive Surgery, Nepean Hospital, Sydney, NSW, Australia
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El Sewify O, Abi-Rafeh J, Legler J, Karimi S, Baradaran A, Efanov JI. Clinical, Radiologic, and Functional Outcomes following Bone Grafting for Metacarpal Non-Unions: A Systematic Review. J Clin Med 2024; 13:1148. [PMID: 38398461 PMCID: PMC10889921 DOI: 10.3390/jcm13041148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
Objectives: Metacarpal non-unions are complex hand defects that can lead to severe hand impairment. Treatment may require the use of artificial or autologous bone grafts. This systematic review aims to describe the outcomes of bone grafting following metacarpal non-union in an attempt to establish an optimal therapeutic protocol for this complication. Methods: A systematic review was conducted in adherence with PRISMA guidelines. Data collection and analysis were performed in duplicate and confirmed by a third investigator. Our primary outcomes focused on radiological time to bone fusion and rates of non-union. Additionally, functional outcomes and complications were analyzed as means of central tendency. Results: Eighteen studies were included in the systematic review, accounting for a total of 47 patients. The average follow-up time was 12.4 months. Fourteen studies analyzed radiological outcomes, with atrophic non-union representing the most common type. The time to bone fusion, assessed radiologically, following bone graft was an average of 6.9 months (n = 14), with a 100% rate of union in 42 patients. Regarding patient-reported pain improvement, 76% of patients experienced pain relief. Moreover, all patients reported a complete subjective return to baseline hand function. Adverse events, limited to hematoma and seroma, were seen in three patients, representing a complication rate of 11.8% in the examined population. Conclusions: Metacarpal non-union can be treated successfully via vascularized and non-vascularized bone grafting. Based on the available evidence, bone grafts demonstrate favorable union rates, post-operative pain reduction, hand function recovery, earlier bone fusion times, and minimal complications in the context of metacarpal non-union management.
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Affiliation(s)
- Omar El Sewify
- Faculty of Medicine, Laval University, Quebec, QC G1V0A6, Canada
| | - Jad Abi-Rafeh
- Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, McGill University, Montreal, QC H3G2M1, Canada
| | - Jack Legler
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G2M1, Canada
| | - Shayan Karimi
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3G2M1, Canada
| | - Aslan Baradaran
- Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, McGill University, Montreal, QC H3G2M1, Canada
| | - Johnny I. Efanov
- Plastic and Reconstructive Surgery, Department of Surgery, Centre hospitalier de l’Universite de Montreal (CHUM), Montreal, QC H2X3E4, Canada
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Higgins JP. Vascularized Medial Femoral Condyle Flap Reconstruction for Osseous Defects of the Hand and Wrist. Hand Clin 2024; 40:151-159. [PMID: 37979987 DOI: 10.1016/j.hcl.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Vascularized bone flaps from the descending genicular artery system are versatile and effective for the use of recalcitrant nonunions from the tubular bones of the hand to the long bones of the upper extremity. Familiarity with the vascular pedicle, various techniques of harvest and inset, and skin paddle harvest and application are essential for the reconstructive surgeon.
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Affiliation(s)
- James P Higgins
- Curtis National Hand Center, MedStar Union Memorial Hospital, 3333 North Calvert Street, Johnston Professional Building, Mezzanine Level, Baltimore, MD 21218, USA.
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Özdemir A, Odabaşı E, Eravsar E, Safalı S, Acar MA. Treatment of recalcitrant femur nonunion with pedicled corticoperiosteal medial femoral condyle flap. Sci Rep 2023; 13:20326. [PMID: 37990029 PMCID: PMC10663536 DOI: 10.1038/s41598-023-47432-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 11/14/2023] [Indexed: 11/23/2023] Open
Abstract
Periosteal or osteoperiosteal medial femoral condyle (MFC) flaps may be good options for atrophic nonunion. The aim of this study was to evaluate the effectiveness and safety of pedicled MFC flap in the treatment of recalcitrant femur nonunion without bone defect. Thirteen patients (11 male and 2 female), who suffered recalcitrant femur nonunion and were treated with pedicled osteoperiosteal MFC flap between January 2014 and April 2018, were included in this study. Patient files were reviewed retrospectively. Atrophic or recalcitrant 2/3 distal femoral nonunion were the indications for this clinical procedure. Demographics and operative data, flap size, visual analog scale (VAS) score, time to union, and complications were evaluated. A total of 13 patients underwent femur nonunion treatment with MFC flap after an average of 3.4 previous surgical procedures. The median age was 34 (Q1: 32.5, Q3:43) years old. The mean flap size was 4.3 × 6.4 cm, all nonunions healed in a median 5 months (Q1: 4.5, Q3: 6). There were an intraoperative knee medial collateral ligament injury in a patient, hematoma in a patient, and seroma in two patients. The median length of the follow-up was 40 months (Q1: 30, Q3: 47). There wasn't any additional complication in long-term follow-up. Functional outcomes were satisfactory. The median preoperative VAS score was 7 (Q1: 6, Q3: 9.5), decreasing to 1 (Q1: 0, Q3: 1) at the 6-month follow-up, and further reducing to 0 (Q1: 0, Q3: 1) at the 24-month follow-up. The nonunion period ranged from 6 to 18 months. The pedicled MFC flap is a good option for recalcitrant femur nonunion where larger vascularized flaps are not warranted. It is easy to harvest, does not require microvascular anastomosis, is effective, and offers minimal donor site morbidity.
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Affiliation(s)
- Ali Özdemir
- Department of Orthopaedics and Traumatology and Hand Surgery Konya, Selcuk University, Konya, Turkey.
| | - Egemen Odabaşı
- Department of Orthopaedics and Traumatology, Konya Beyhekim Training and Research Hospital, Konya, Turkey
| | - Ebubekir Eravsar
- Department of Orthopaedics and Traumatology, Konya City Hospital, Konya, Turkey
| | - Selim Safalı
- Department of Orthopaedics and Traumatology and Hand Surgery Konya, Selcuk University, Konya, Turkey
| | - Mehmet Ali Acar
- Department of Orthopaedics and Traumatology and Hand Surgery Konya, Selcuk University, Konya, Turkey
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Tee R, Harvey JN, Tham SK, Ek ET. Medial Femoral Condyle Corticoperiosteal Flap for Failed Total Wrist Fusions. J Wrist Surg 2023; 12:288-294. [PMID: 37564622 PMCID: PMC10411124 DOI: 10.1055/s-0043-1760737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 12/03/2022] [Indexed: 01/22/2023]
Abstract
Background Recalcitrant nonunion following total wrist arthrodesis is a rare but challenging problem. Most commonly, in the setting of failed fusion after multiple attempts of refixation and cancellous bone grafting, the underlying cause for the failure is invariably multifactorial and is often associated with a range of host issues in addition to poor local soft-tissue and bony vascularity. The vascularized medial femoral condyle corticoperiosteal (MFC-CP) flap has been shown to be a viable option in a variety of similar settings, which provides vascularity and rich osteogenic progenitor cells to a nonunion site, with relatively low morbidity. While its utility has been described for many other anatomical locations throughout the body, its use for the treatment of failed total wrist fusions has not been previously described in detail in the literature. Methods In this article, we outline in detail the surgical technique for MFC-CP flap for the management of recalcitrant aseptic nonunions following failed total wrist arthrodesis. We discuss indications and contraindications, pearls and pitfalls, and potential complications of this technique. Results Two illustrative cases are presented of patients with recalcitrant nonunions following multiple failed total wrist fusions. Conclusion When all avenues have been exhausted, a free vascularized corticoperiosteal flap from the MFC is a sound alternative solution to achieve union, especially when biological healing has been compromised. We have been able to achieve good clinical outcomes and reliable fusion in this difficult patient population.
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Affiliation(s)
- Richard Tee
- Division of Hand Surgery, Department of Orthopaedic Surgery, Dandenong Hospital, Monash Health, Melbourne, Victoria, Australia
| | - Jason N. Harvey
- Division of Hand Surgery, Department of Orthopaedic Surgery, Dandenong Hospital, Monash Health, Melbourne, Victoria, Australia
- Orthosport Victoria, Richmond, Melbourne, Victoria, Australia
| | - Stephen K. Tham
- Division of Hand Surgery, Department of Orthopaedic Surgery, Dandenong Hospital, Monash Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash Medical Centre, Monash University, Melbourne, Victoria, Australia
- Victorian Hand Surgery Associates, Fitzroy, Melbourne, Victoria, Australia
| | - Eugene T. Ek
- Division of Hand Surgery, Department of Orthopaedic Surgery, Dandenong Hospital, Monash Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash Medical Centre, Monash University, Melbourne, Victoria, Australia
- Melbourne Orthopaedic Group, Windsor, Melbourne, Victoria, Australia
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Hoftiezer YAJ, Posada Alvarez C, Werenski JO, Schreuder HWB, Eberlin KR, Lee SG, Lozano-Calderón SA. Salvage of a Fractured Proximal Ulnar Osteoarticular Allograft Using a Medial Femoral Condyle Free Flap: A Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00024. [PMID: 37531445 DOI: 10.2106/jbjs.cc.22.00796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
CASE We present the case of a 47-year-old paraplegic woman who underwent resection of an intermediate-grade chondrosarcoma in the proximal ulna, which was initially reconstructed with an osteoarticular allograft. However, after more than 25 years without complications, she sustained an intra-articular fracture of the allograft, which was then successfully treated using a vascularized medial femoral condyle (MFC) flap and anterolateral thigh flap. The patient has subsequently recovered her baseline elbow function, has no pain, and can use her wheelchair without restrictions. CONCLUSION Free MFC flaps are viable options to salvage osteoarticular allografts that are affected by intra-articular fractures.
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Affiliation(s)
- Yannick Albert J Hoftiezer
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Department of Plastic, Reconstructive and Hand Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolina Posada Alvarez
- Department of Orthopaedics, University Medical Center Groningen/University of Groningen, Groningen, the Netherlands
| | - Joseph O Werenski
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - H W B Schreuder
- Department of Orthopaedic Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Sang-Gil Lee
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Santiago A Lozano-Calderón
- Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Sliepen J, Hoekstra H, Onsea J, Bessems L, Depypere M, Noppe N, Herteleer M, Sermon A, Nijs S, Vranckx JJ, Metsemakers WJ. Treatment and outcome of fracture-related infection of the clavicle. Injury 2023; 54:110910. [PMID: 37421837 DOI: 10.1016/j.injury.2023.110910] [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: 02/15/2023] [Revised: 05/16/2023] [Accepted: 06/18/2023] [Indexed: 07/10/2023]
Abstract
INTRODUCTION The number of operatively treated clavicle fractures has increased over the past decades. Consequently, this has led to an increase in secondary procedures required to treat complications such as fracture-related infection (FRI). The primary objective of this study was to assess the clinical and functional outcome of patients treated for FRI of the clavicle. The secondary objectives were to evaluate the healthcare costs and propose a standardized protocol for the surgical management of this complication. METHODS All patients with a clavicle fracture who underwent open reduction and internal fixation (ORIF) between 1 January 2015 and 1 March 2022 were retrospectively evaluated. This study included patients with an FRI who were diagnosed and treated according to the recommendations of a multidisciplinary team at the University Hospitals Leuven, Belgium. RESULTS We evaluated 626 patients with 630 clavicle fractures who underwent ORIF. In total, 28 patients were diagnosed with an FRI. Of these, eight (29%) underwent definitive implant removal, five (18%) underwent debridement, antimicrobial treatment and implant retention, and fourteen patients (50%) had their implant exchanged in either a single-stage procedure, a two-stage procedure or after multiple revisions. One patient (3.6%) underwent resection of the clavicle. Twelve patients (43%) underwent autologous bone grafting (tricortical iliac crest bone graft (n = 6), free vascularized fibular graft (n = 5), cancellous bone graft (n = 1)) to reconstruct the bone defect. The median follow-up was 32.3 (P25-P75: 23.9-51.1) months. Two patients (7.1%) experienced a recurrence of infection. The functional outcome was satisfactory, with 26 out of 28 patients (93%) having full range of motion. The median healthcare cost was € 11.506 (P25-P75: € 7.953-23.798) per patient. CONCLUSION FRI is a serious complication that can occur after the surgical treatment of clavicle fractures. In our opinion, when treated adequately using a multidisciplinary patient-specific approach, the outcome of patients with an FRI of the clavicle is good. The median healthcare costs of these patients are up to 3.5 times higher compared to non-infected operatively treated clavicle fractures. Although not studied individually, we consider factors such as the size of the bone defect, condition of the soft tissue, and patient demand important when it comes to guiding our surgical decision making in cases of osseous defects.
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Affiliation(s)
- Jonathan Sliepen
- University Medical Center Groningen, Department of Trauma Surgery, University of Groningen, 9713 GZ Groningen, The Netherlands; University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium
| | - Harm Hoekstra
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - Jolien Onsea
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - Laura Bessems
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - Melissa Depypere
- University Hospitals Leuven, Department of Laboratory Medicine, 3000 Leuven, Belgium
| | - Nathalie Noppe
- University Hospitals Leuven, Department of Radiology, 3000 Leuven, Belgium
| | - Michiel Herteleer
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - An Sermon
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - Stefaan Nijs
- University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Jan J Vranckx
- University Hospitals Leuven, Department of Plastic and Reconstructive Surgery, 3000 Leuven, Belgium
| | - Willem-Jan Metsemakers
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium.
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di Summa PG, Sapino G, Wagner D, Maruccia M, Guillier D, Burger H. Combined Free Flaps for Optimal Orthoplastic Lower Limb Reconstruction: A Retrospective Series. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050859. [PMID: 37241091 DOI: 10.3390/medicina59050859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/10/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: Open fracture of the lower limb can lead to substantial bone and soft tissue damage, resulting in a challenging reconstructive scenarios, especially in presence of bone or periosteal loss, with a relevant risk of non-union. This work analyzes outcomes of using a double approach for orthoplastic reconstruction, adopting the free medial condyle flap to solve the bone defects, associated to a second free flap for specific soft tissue coverage. Indications, outcomes and reconstructive rationales are discussed. Materials and Methods: A retrospective investigation was performed on patients who underwent complex two-flap microsurgical reconstruction from January 2018 to January 2022. Inclusion criteria in this study were the use of a free femoral condyle periostal/bone flap together with a second skin-only flap. Only distal third lower limb reconstructions were included in order to help equalize our findings. Out of the total number of patients, only patients with complete pre- and post-operative follow-up (minimum 6 months) data were included in the study. Results: Seven patients were included in the study, with a total of 14 free flaps. The average age was 49. Among comorbidities, four patients were smokers and none suffered from diabetes. Etiology of the defect was acute trauma in four cases and septic non-union in three cases. No major complications occurred, and all flaps healed uneventfully with complete bone union. Conclusions: Combining a bone periosteal FMC to a second skin free flap for tailored defect coverage allowed achievement of bone union in all patients, despite the lack of initial bone vascularization or chronic infection. FMC is confirmed to be a versatile flap for small-to-medium bone defects, especially considering its use as a periosteal-only flap, with minimal donor site morbidity. Choosing a second flap for coverage allows for a higher inset freedom and tailored reconstruction, finally enhancing orthoplastic success.
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Affiliation(s)
- Pietro G di Summa
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland
| | - Gianluca Sapino
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland
| | - Daniel Wagner
- Department of Orthopedic Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland
| | - Michele Maruccia
- Department of Plastic Surgery and Reconstructive Surgery, University Hospital of Bari, 70100 Bari, Italy
| | - David Guillier
- Department of Plastic Reconstructive and Hand Surgery, Department of Oral and Maxillofacial Surgery-University Hospital, 21231 Dijon, France
| | - Heinz Burger
- Privat Clinic Maria Hilf, 9010 Klagenfurt, Austria
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Guidi M, Guzzini M, Civitenga C, Lanzetti RM, Kim BS, Besmens IS, Riegger M, Lucchina S, Calcagni M, Perugia D. Multifactorial Analysis of Treatment of Long-Bone Nonunion with Vascularized and Nonvascularized Bone Grafts. J Hand Microsurg 2023; 15:106-115. [PMID: 37020609 PMCID: PMC10070005 DOI: 10.1055/s-0042-1748783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Introduction The purpose of the study was to evaluate the results of treatment of the nonunion of long bones using nonvascularized iliac crest grafts (ICGs) or vascularized bone grafts (VBGs), such as medial femoral condyle corticoperiosteal flaps (MFCFs) and fibula flaps (FFs). Although some studies have examined the results of these techniques, there are no reports that compare these treatments and perform a multifactorial analysis. Methods The study retrospectively examined 28 patients comprising 9 women and 19 men with an average age of 49.8 years (range: 16-72 years) who were treated for nonunion of long bones between April 2007 and November 2018. The patients were divided into two cohorts: group A had 17 patients treated with VBGs (9 patients treated with MFCF and 8 with FF), while group B had 11 patients treated with ICG. The following parameters were analyzed: radiographic patterns of nonunion, trauma energy, fracture exposure, associated fractures, previous surgeries, diabetes, smoking, age, and donor-site morbidity. Results VBGs improved the healing rate (HR) by 9.42 times more than the nonvascularized grafts. Treatment with VBGs showed a 25% decrease in healing time. Diabetes increased the infection rate by 4.25 times. Upper limbs showed 70% lower infection rate. Smoking among VBG patients was associated with a 75% decrease in the HR, and diabetes was associated with an 80% decrease. Conclusion This study reports the highest success rates in VBGs. The MFCFs seem to allow better clinical and radiological outcomes with less donor-site morbidity than FFs.
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Affiliation(s)
- Marco Guidi
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Matteo Guzzini
- Department of Orthopedics and Traumatology, S. Andrea Hospital, University of Rome “La Sapienza,” Rome, Italy
| | - Carolina Civitenga
- Department of Orthopedics and Traumatology, S. Andrea Hospital, University of Rome “La Sapienza,” Rome, Italy
| | | | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Inga Swantje Besmens
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Martin Riegger
- Department of Orthopedics and Traumatology, Lugano's Regional Hospital, Viganello, Switzerland
| | - Stefano Lucchina
- Hand Surgery Unit, Locarno Hand Center, Locarno's Regional Hospital, Locarno, Switzerland
| | - Maurizio Calcagni
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Dario Perugia
- Department of Orthopedics and Traumatology, S. Andrea Hospital, University of Rome “La Sapienza,” Rome, Italy
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Mechanical strain induces ex vivo expansion of periosteum. PLoS One 2022; 17:e0279519. [PMID: 36584151 PMCID: PMC9803115 DOI: 10.1371/journal.pone.0279519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/02/2022] [Indexed: 12/31/2022] Open
Abstract
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.
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Guzzini M, Arioli L, Mori F, Ferretti A. Is it really necessary to perform venous anastomosis in vascularized corticoperiosteal bone flap? A randomized prospective 4-year follow-up study. Injury 2022; 53:2859-2864. [PMID: 35753816 DOI: 10.1016/j.injury.2022.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Matteo Guzzini
- "Sapienza" University of Rome, Unit of Orthopedics and Traumatology, S. Andrea University Hospital, Via Grottarossa, 1035, 00186, Rome, Italy
| | - Leopoldo Arioli
- "Sapienza" University of Rome, Unit of Orthopedics and Traumatology, S. Andrea University Hospital, Via Grottarossa, 1035, 00186, Rome, Italy.
| | - Fabiana Mori
- "Università degli studi di Padova", Unit of Orthopedics and Traumatology, University Hospital of Padua, Via Nicolò Giustiniani, 1, 35128 Padua, Italy
| | - Andrea Ferretti
- "Sapienza" University of Rome, Unit of Orthopedics and Traumatology, S. Andrea University Hospital, Via Grottarossa, 1035, 00186, Rome, Italy
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13
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Talwar A, Bai J, Wester JR, Attar S, Peabody TD, Ko JH. Vascularized Medial Femoral Condyle Periosteal Flaps With Allograft Bone for Distal Radius Giant Cell Tumors: A Case Report. JBJS Case Connect 2022; 12:01709767-202209000-00033. [PMID: 36049023 DOI: 10.2106/jbjs.cc.21.00652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Abhinav Talwar
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jennifer Bai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - James R Wester
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Samer Attar
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Terrance D Peabody
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jason H Ko
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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14
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Golin AP, Zhang Z, Ratanshi I, McInnes CW. Acute Thumb Reconstruction With Medial Femoral Condyle and Radial Forearm Free Flaps: A Case Report. Hand (N Y) 2022; 18:NP1-NP6. [PMID: 35668636 PMCID: PMC10152520 DOI: 10.1177/15589447221096705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Andrew P Golin
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Zach Zhang
- Division of Plastic Surgery, University of British Columbia, Vancouver, Canada
| | - Imran Ratanshi
- Division of Plastic Surgery, University of British Columbia, Vancouver, Canada.,Royal Columbian Hospital, Fraser Health Authority, British Columbia, Canada
| | - Colin W McInnes
- Division of Plastic Surgery, University of British Columbia, Vancouver, Canada.,Royal Columbian Hospital, Fraser Health Authority, British Columbia, Canada
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15
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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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16
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DeKeyser GJ, Bailey TL, Higgins TF, Tyser AR. Treatment of Recalcitrant Femoral Shaft Nonunion With Medial Femoral Condyle Pedicled Autograft: Technical Trick. J Orthop Trauma 2022; 36:e80. [PMID: 34050083 DOI: 10.1097/bot.0000000000002186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Graham J DeKeyser
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
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17
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Vascularized Bone Grafts in Orthopaedic Surgery: A Review of Options and Indications. J Am Acad Orthop Surg 2022; 30:60-69. [PMID: 34932501 DOI: 10.5435/jaaos-d-20-01200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 10/31/2021] [Indexed: 02/01/2023] Open
Abstract
Vascularized bone grafts have demonstrated increased perfusion, structural integrity, and ability to achieve good outcomes in challenging clinical situations when compared with nonvascularized grafts. These grafts may be pedicled or free, and bring perfused, viable bone into areas of impaired healing. Although numerous grafts have been described, a few grafts have demonstrated particular usefulness and versatility. Pedicled grafts from the distal radius, medial femoral condyle, ribs, and fibula have improved outcomes in challenging situations without the need for microsurgery. Free grafts from the fibula and medial femoral condyle/trochlea, although they require microsurgical anastomosis, can be transferred to virtually any site in the body and have expanding indications. The capacity of these grafts to achieve favorable outcomes in difficult cases make them a powerful tool for orthopaedic surgeons to have in their armamentarium.
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18
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Christen T, Krähenbühl SM, Müller CT, Durand S. Periosteal medial femoral condyle free flap for metacarpal nonunion. Microsurgery 2021; 42:226-230. [PMID: 34636060 PMCID: PMC9292408 DOI: 10.1002/micr.30826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/07/2021] [Accepted: 09/28/2021] [Indexed: 11/12/2022]
Abstract
Background Metacarpal nonunion is a rare condition. The osteogenic capacity of periosteal free flap was investigated in five patients with metacarpal nonunion and impaired bone vascularization. Patients and methods Surgery was performed between 64 and 499 days after the initial bone osteosynthesis. The average age was 27.6 (range 16–32) years. Nonunion was caused by excessive periosteal removal in two patients, extensive open trauma in three. Four nonunions were diaphyseal, one metaphyseal. A periosteal medial femoral condyle free flap was raised on the descending genicular artery for four patients, the superomedial genicular artery for one. After osteosynthesis with a plate, the flap was wrapped around the metacarpal, overlapping the bone proximally and distally. The recipient vessel were the dorsal branch of the radial artery and a vena comitans in the anatomical snuffbox in four patients, at the base of the first webspace in one. Results The flap size ranged from 5 × 3.5 cm to 8 × 4 cm. No postoperative complication occurred. Radiological bone union was achieved 3 to 8 months after surgery. One patient had a full range of motion, one a slight extension lag of the proximal interphalangeal joint, two moderate joint stiffness of the proximal interphalangeal or metacarpophalangeal joint (one requiring plate removal and extensor tenolysis), one severe stiffness that allowed using a hook grip which was the aim of the surgery. Conclusion In case of metacarpal nonunion with impaired bone vascularization, the periosteal medial femoral condyle free flap provides an effective and biomimetic approach to bone healing.
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Affiliation(s)
- Thierry Christen
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Swenn M Krähenbühl
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Camillo T Müller
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Sébastien Durand
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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19
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"Use of pedicled corticoperiosteal flap in resistant cases of distal femur non-union: Our learning experience". J Plast Reconstr Aesthet Surg 2021; 75:621-628. [PMID: 34732336 DOI: 10.1016/j.bjps.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 06/04/2021] [Accepted: 09/19/2021] [Indexed: 11/22/2022]
Abstract
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.
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20
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Neuwirth M, Ziegler T, Benedikt S, Winter R, Kamolz LP, Schintler M, Rab M, Mueller-Eggenberger M, Mischitz M, Palle W, Hoenck K, Schoellnast H, Janek E, Borenich A, Buerger H. Donor site morbidity after the harvest of microvascular flaps from the medial and lateral femoral condyle region: Objective, radiologic, and patient-reported outcome of a multi-center trial. J Plast Reconstr Aesthet Surg 2021; 75:160-172. [PMID: 34635456 DOI: 10.1016/j.bjps.2021.08.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 06/27/2021] [Accepted: 08/26/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND With the experience-based hypothesis of low donor site morbidity (DSM) for free flaps from the distal femur, this cohort study aimed to evaluate the DSM according to objective and reproducible criteria. METHODS One hundred and fifty-six patients who had a flap harvest from either the medial or lateral femoral condyle region between 2005 and 2017 were included. A retrospective chart review was performed for all patients. In total, 97 patients were available for a follow-up examination. Outcomes were assessed according to objective (Knee Society Score; Larson Knee Score; OAK Score; 0-100 points), patient-reported (IKDC Score; KOOS Score; 0-100 points), and radiologic criteria (Kellgren and Lawrence Score; MRI Osteoarthritis Knee Score). RESULTS The median follow-up time was 1,529 days (range: 248-4,810). The mean Knee Society Score (94.8 ± 10.1), Larson Knee Score (94.5 ± 10.1), and OAK Score (95.5 ± 6.6) showed nearly unimpaired knee function. The overall patient-reported DSM was low (IKDC Score: 86.7 ± 17.4; KOOS Score: 89.3 ± 17.1). Osteochondral (OC) flaps had a significantly higher DSM, regardless of the donor site. Bone flaps did not show any relevant radiologic morbidity in the Kellgren and Lawrence Score. Besides the procedure-associated cartilage lesions at the OC donor sites, MRI Osteoarthritis Knee Score did not show any significant presence of further knee pathologies in the bilateral MRI Scans. The obvious cartilage lesions did not have a relevant impact on the knee function of most patients. CONCLUSION The DSM for bone and soft-tissue flaps from the femoral condyle region is negligible. OC flaps are associated with a significantly higher DSM, although a clinically relevant impact on knee function was not evident in the majority of patients.
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Affiliation(s)
- Maximilian Neuwirth
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria; Departement of Plastic, Aesthetic and Reconstructive Surgery, General Hospital Klagenfurt am Woerthersee, Feschnigstraße 11, Klagenfurt 9020, Austria.
| | - Thomas Ziegler
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
| | - Stefan Benedikt
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
| | - Raimund Winter
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
| | - Lars P Kamolz
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
| | - Michael Schintler
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria
| | - Matthias Rab
- Departement of Plastic, Aesthetic and Reconstructive Surgery, General Hospital Klagenfurt am Woerthersee, Feschnigstraße 11, Klagenfurt 9020, Austria
| | - Michael Mueller-Eggenberger
- Departement of Plastic, Aesthetic and Reconstructive Surgery, General Hospital Klagenfurt am Woerthersee, Feschnigstraße 11, Klagenfurt 9020, Austria
| | - Madeleine Mischitz
- Departement of Plastic, Aesthetic and Reconstructive Surgery, General Hospital Klagenfurt am Woerthersee, Feschnigstraße 11, Klagenfurt 9020, Austria
| | - Wolfgang Palle
- Department of Trauma Surgery, Hospital Friesach, Austria
| | - Karina Hoenck
- Department of Trauma Surgery, Hospital Friesach, Austria
| | - Helmut Schoellnast
- Division of General Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Elmar Janek
- Division of General Radiology, Department of Radiology, Medical University of Graz, Austria
| | - Andrea Borenich
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Austria
| | - Heinz Buerger
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Austria; Departement of Plastic, Aesthetic and Reconstructive Surgery, General Hospital Klagenfurt am Woerthersee, Feschnigstraße 11, Klagenfurt 9020, Austria; Division of Hand and Microsurgery, Private Hospital Maria Hilf, Austria
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21
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Singh K, Huang TCT, Meaike JD, Mills AM, Nathan JM, Lettieri SC, Arce K, Moran SL. The Medial Femoral Condyle Free Flap for Reconstruction of Recalcitrant Defects in the Head and Neck. Ann Plast Surg 2021; 87:291-297. [PMID: 34397517 DOI: 10.1097/sap.0000000000002736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Small recalcitrant defects of the mandible and maxilla may be secondary to tumor, trauma, infection, and congenital origin. Vascularized bone grafting has been shown to effectively manage these defects; however, donor sites are limited. The vascularized medial femoral condyle (MFC) provides adequate cortical cancellous bone with the option of a skin island, consistent anatomy, and minimal donor site morbidity. This article outlines the use of the MFC flap for maxillomandibular reconstruction. METHODS A retrospective chart review of patients who required segmental maxillomandibular reconstruction with the MFC flap was conducted. A total of 9 patients (5 men and 5 women) with an average age of 45.3 years were identified. The etiology of the defects, flap sizes, and postoperative outcomes were recorded. RESULTS Three patients had osteoradionecrosis of the neomandible after irradiation of the free fibula reconstruction, 3 patients had defects after cancer extirpation (1 mandible, 2 maxillary), 1 patient had a maxillary defect from trauma, and 2 patients had a residual cleft palate defect. All defects failed initial treatment with nonvascularized bone grafts. The average dimensions of the MFC flaps were 1.2 × 2.5 × 4 cm. Two of 9 flaps included a skin island. Eight flaps survived completely, but 1 patient suffered from flap failure requiring debridement and resulted in an oroantral fistula. Four patients received endosseous dental implants. Average time to union was 6.7 months, and average time to implant was 6.75 months. The average follow-up time was 24.9 months. CONCLUSIONS The MFC flap is useful in the reconstruction of small segmental maxillomandibular defects and for the salvage of a neomandible after osteoradionecrosis. The MFC flap provides a reliable platform for endosseous dental implants and serves as an alternative source of vascularized bone reconstruction in the head and neck.
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Affiliation(s)
- Kuldeep Singh
- From the Division of Plastic Surgery, Department of Surgery
| | - Tony C T Huang
- From the Division of Plastic Surgery, Department of Surgery
| | - Jesse D Meaike
- From the Division of Plastic Surgery, Department of Surgery
| | - Andrew M Mills
- From the Division of Plastic Surgery, Department of Surgery
| | - John M Nathan
- Section of Head and Neck Oncologic Surgery and Reconstruction, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - Kevin Arce
- Section of Head and Neck Oncologic Surgery and Reconstruction, Division of Oral and Maxillofacial Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Steven L Moran
- From the Division of Plastic Surgery, Department of Surgery
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22
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Willemot L, Stewart D, Lawson R. Reconstruction of an infected midshaft radius and ulna nonunion using a free vascularized fibula and medial femoral condyle flap. Microsurgery 2021; 41:666-670. [PMID: 33932250 DOI: 10.1002/micr.30750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/16/2021] [Accepted: 04/23/2021] [Indexed: 11/07/2022]
Abstract
Conventional grafts do not perform well in the treatment of large diaphyseal bone defects. Forearm nonunions are especially challenging due to complex biomechanical and kinematic demands. Free bone flaps may yield more predictable bony restoration in these cases, while keeping morbidity acceptable to the patient. We aim to illustrate one combination of flaps which can be used in these conditions. This article reports on a 23 year old patient with an 8 cm diaphyseal nonunion of the radius and a similar 7 cm defect of the ulna after infection of fracture fixation hardware. The radius was treated with a free fibular flap (FFF) and the ulna with a medial femoral condyle (MFC) flap in a staged procedure after initial debridement. The patient was followed up for 6 months without significant complications. Both flaps healed within 3 months, yet the MFC demonstrated faster bony incorporation. We attributed this to the spongious nature of the MFC flap compared to the thick cortical FFF. This case report hopes to illustrate one type of flap combination for extensive forearm bone defects. The selection and approach minimizes donor site morbidity to a single limb and possibly hastens bony union of the forearm.
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Affiliation(s)
- Laurent Willemot
- Department of Orthopedic Surgery, Ghent University Hospital, Ghent, Belgium.,Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, Australia
| | - David Stewart
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, Australia
| | - Richard Lawson
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, Australia
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23
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Suganuma S, Tada K, Yamauchi D, Takagawa S, Yasutake H, Shimanuki K, Tsuchiya H. Reconstruction using a free vascularised medial femoral condyle corticoperiosteal flap for osteomyelitis of the juxta-articular distal radius: A case report and literature review. Trauma Case Rep 2021; 32:100408. [PMID: 33665305 PMCID: PMC7905069 DOI: 10.1016/j.tcr.2021.100408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2021] [Indexed: 11/17/2022] Open
Abstract
Osteomyelitis of the epiphysis after a distal radius fracture is uncommon. If not adequately and promptly treated, the detrimental effects on wrist function can be devastating. However, management of septic bone defects of the epiphysis is significantly challenging. We report the case of a patient with juxta-articular distal radius osteomyelitis successfully treated with a free vascularised corticoperiosteal flap from the medial femoral condyle (MFC corticoperiosteal flap). A 46-year-old right-handed man fell on the grass from a height of 2 m during a demolition. He was diagnosed with a right distal radius and ulnar styloid process fracture. He underwent open reduction and internal fixation. However, he developed a deep infection, resulting in postoperative osteomyelitis. Therefore, thorough debridement was performed and an external fixator was applied. Antibiotics were administered according to the culture results. He underwent reconstruction for bone defect using an MFC corticoperiosteal flap 28 days after re-operation. The patient could resume work without limitations 4 months after the reconstruction. The infection subsided completely, and radiographs confirmed bone union at 5 months after the reconstruction. His wrist range of motion was 40° in dorsal flexion (uninjured side 70°), 50° in palmar flexion (75°), 80° in supination (90°), and 90° in pronation (90°). There was no donor site complication. The patient has reported no pain for 1 year since the injury. The use of the MFC corticoperiosteal flap for reconstruction of the juxta-articular distal radius osteomyelitis decreased the time required for bone union, enabled local antibiotic delivery to control infection, and helped preserve wrist function.
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Affiliation(s)
- Seigo Suganuma
- Department of Orthopaedic Surgery, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Kaoru Tada
- Department of Orthopaedic Surgery, Kanazawa University Hospital, Kanazawa, Japan
| | - Daisuke Yamauchi
- Department of Orthopaedic Surgery, Fukui-ken Saiseikai Hospital, Fukui, Japan
| | - Shingo Takagawa
- Department of Orthopaedic Surgery, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Hidetoshi Yasutake
- Department of Orthopaedic Surgery, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Keito Shimanuki
- Department of Orthopaedic Surgery, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Kanazawa University Hospital, Kanazawa, Japan
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24
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Vascularized bone grafts for post-traumatic defects in the upper extremity. Arch Plast Surg 2021; 48:84-90. [PMID: 33503750 PMCID: PMC7861969 DOI: 10.5999/aps.2020.00969] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/29/2020] [Indexed: 11/26/2022] Open
Abstract
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.
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Alolabi N, Lovy AJ, Shin AY, Bishop AT. Medial femoral trochlea flap reconstruction: Clinical outcomes and perspectives. J Plast Reconstr Aesthet Surg 2020; 74:1991-1998. [PMID: 33455866 DOI: 10.1016/j.bjps.2020.12.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/10/2020] [Accepted: 12/19/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We report our experience with use of the medial femoral trochlea (MFT) osteochondral flap for carpal applications. METHODS Outcomes of all patients treated with MFT flaps were reviewed. Healing, range of motion, grip strength, carpal alignment, pain, and complication data were collected. RESULTS MFT flaps were performed on seven patients with a mean age of 26.1 (range, 17-42) years. Indications included scaphoid proximal pole nonunion (n = 3), Kienböck's disease (n = 3), and Preiser's disease (n = 1). The mean follow-up was 32.3 (range, 5-70) months. Union was achieved in five patients at a mean of 12 (range 6-22) weeks. All five patients had increased grip strength and absence of pain at follow-up. There were two failures due to graft resorption. CONCLUSIONS The MFT osteochondral flap is a technically challenging yet powerful tool to replace the loss of both carpal articular cartilage and adjacent bone.
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Affiliation(s)
- Noor Alolabi
- Hand, Wrist & Peripheral Nerve Surgery, Division of Plastic & Reconstructive Surgery, Oakville Trafalgar Memorial Hospital, 2525 Old Bronte Road, Suite 560, Oakville, ON, L6M 4J2, Canada
| | - Andrew J Lovy
- Holy Cross Orthopedic Institute, Holy Cross Hospital, 5597 N Dixie Highway, Fort Lauderdale, FL 33334, Florida
| | - Alexander Y Shin
- Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street Southwest, Rochester MN 55905, USA.
| | - Allen T Bishop
- Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street Southwest, Rochester MN 55905, USA
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Guzzini M, Arioli L, Rugiero C, Rossini M, Argento G, Ferretti A. Donorsite defect of medial femoral condyle corticoperiostal flap in the treatment of lower limb infected nonunions. HANDCHIR MIKROCHIR P 2020; 53:376-382. [PMID: 33184802 DOI: 10.1055/a-1240-0181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUNDS Chronic osteomyelitis is a major challenge in orthopaedic surgery; it is the result of open fracture, periprosthetic infection and septic arthritis. Osteomyelitis leads to fracture nonunion. The treatment of bone infection and infected nonunion consists primarily of the complete removal of infected and avascular bone and soft tissue from the surgical site, followed by local and systemic pathogen-specific antibiotic therapy and temporary stabilisation, but may lead to massive skeletal and soft tissue defects. The use of free or pedicled vascularised bone transfers and callus distraction techniques (bone transport) has been recommended for large bone defects. The aim of this study is to evaluate the results of patients affected by infected non-unions of the lower limbs, treated with a corticoperiosteal flap from the medial femoral condyle and to investigate the donor site morbidity of this flap. MATERIALS AND METHODS The patients were 11 males (average age of 45.6 years), who presented a nonunion of the tibial diaphysis in 7 cases and non-union of femoral diaphysis in 4 cases, treated with free or pedicled corticoperiosteal flap. In all patients, surgical debridement was performed before the flap of infected bone and soft tissues that would not contribute to wound healing. Clinical and radiographic evaluations of the recipient site were performed. Preoperative and postoperative X-ray and MRI scans after the 3-year follow-up of the donor site were performed, in order to observe possible bone restoration and any complications. RESULTS The patients reported complete clinical and radiographic bone healing in 90.9 % of cases. As regards donor site, there were no differences between the medial femoral donor condyle compared to the contralateral site, due to complete regeneration of donor site bone. MRI investigation showed complete restoration of the donor site with vascularised bone in all patients. CONCLUSIONS Our results suggest that the use of bone flaps for the treatment of infected non-unions is an effective procedure, that must be performed after accurate debridement of the non-union site. The corticoperiosteal flap seems to have few morbidities on the donor site and a high percentage of successful bone healing.
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Affiliation(s)
- Matteo Guzzini
- Università degli Studi di Roma La Sapienza Ortopedia e Traumatologia
| | - Leopoldo Arioli
- Università degli Studi di Roma La Sapienza Ortopedia e Traumatologia
| | - Clelia Rugiero
- Università degli Studi di Roma La Sapienza Ortopedia e Traumatologia
| | - Marco Rossini
- Università degli Studi di Roma La Sapienza Ortopedia e Traumatologia
| | | | - Andrea Ferretti
- Università degli Studi di Roma La Sapienza Ortopedia e Traumatologia
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Free vascularised medial femoral condyle periosteal flaps in recalcitrant long bone non-union: a systematic review. Arch Orthop Trauma Surg 2020; 140:1619-1631. [PMID: 31974694 DOI: 10.1007/s00402-020-03354-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Indexed: 12/14/2022]
Abstract
INTRODUCTION In adults, treatment of recalcitrant long bone non-union is extremely challenging, with poorly vascularised and atrophic defects unresponsive to standard non-vascularised bone graft treatment. Recent studies have documented the use of free vascularised periosteal flaps to achieve union in refractory long bone fracture non-union, yet its use is not well established. This systematic review aims to assess the evidence for free vascularised periosteal flaps in recalcitrant long bone non-union. MATERIALS AND METHODS The MEDLINE®/PubMed® and Embase databases were searched for the Medical Subject Heading (MeSH) terms periosteal flap/vascularised flap/long bone/non-union/non united fracture in accordance with the PRISMA guidelines. Bibliographies were scrutinised for additional articles. RESULTS Pooled data from 14 studies met the inclusions criteria, comprising 137 cases of non-union, with 117 relating to long bone non-union. Pooled data indicated an overall 99% (116/117) successful union rate. All studies were of mid- to low-level evidence (Level III, IV and V). Only one study directly compared vascularised periosteal flaps to non-vascularised bone grafts, showing union rates of 100% versus 80% and faster time to union (2 versus 5.5 months). CONCLUSIONS Free vascularised periosteal flaps are promising with pooled data showing a 99% success rate in achieving union in refractory long bone non-union. This compares favourably with standard orthopaedic care consisting of revision fixation and non-vascularised bone graft union rates of approximately 80%. However, study design flaws should be addressed by validated outcome measures plus adequate blinding, and further comparative studies with greater patient numbers are required.
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Medial Femoral Condyle Vascularized Bone Graft for Treatment of Midshaft Clavicle Recalcitrant Nonunion With Use of the Transverse Cervical Artery as an Anastomosis. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:JAAOSGlobal-D-19-00049. [PMID: 32656481 PMCID: PMC7322782 DOI: 10.5435/jaaosglobal-d-19-00049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 10/24/2019] [Indexed: 12/01/2022]
Abstract
Vascularized medial femoral condyle bone grafts have been reported to be a reliable treatment for recalcitrant bony nonunions of the extremities. Although clavicle fracture nonunions are rare after treatment with open reduction internal fixation, symptomatic nonunions can be a challenge. The medial femoral condyle vascularized bone graft has been described as a treatment option for clavicle nonunions with the thoracoacromial trunk as the recipient anastomosis site. This case illustrates how the transverse cervical artery and accompanying veins can be used as an anastomosis when the thoracoacromial trunk is inaccessible because of previous surgical- and infection-related scaring. At the final follow-up, the patient had returned to full duty and resumed competitive triathlons. Radiographs demonstrated complete healing of clavicle fracture.
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Zapolsky IJ, Gajewski CR, Webb M, Wapner KL, Levin LS. A Case Report of Bilateral Navicular Osteonecrosis Successfully Treated With Medial Femoral Condyle Vascularized Autografts: A Case Report. JBJS Case Connect 2020; 10:e2000010. [PMID: 32910588 DOI: 10.2106/jbjs.cc.20.00010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
CASE A 17-year-old boy with a history of chronic bilateral navicular osteonecrosis with fragmentation was treated with 6-month staged bilateral open reduction and internal fixation of tarsal navicular with debridement of the necrotic bone and ipsilateral medial femoral condyle vascularized bone grafting. CONCLUSION The patient progressed to full painless weight-bearing on each extremity by 4 months postoperatively with osseous union of both chronic fracture sites and incorporation of vascularized bone grafts. Patient-Reported Outcomes Measurement Information System (PROMIS) scores were improved from preoperative levels at 6 months from each operation. This patient's atypical presentation of a rare disease was successfully treated with the utilization of vascularized bone grafting to salvage the tarsal navicular and preserve the talonavicular joint, enabling return of function and avoidance of early arthrodesis procedure.
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Affiliation(s)
- Ivan J Zapolsky
- 1Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania 2Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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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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Zeman-Kuhnert K, Gaggl A, Brandtner C, Wittig-Draenert A, Bottini G, Wittig J. Donor site morbidity after microvascular medial femoral condylar flap procurement for facial reconstruction. Int J Oral Maxillofac Surg 2020; 49:569-575. [DOI: 10.1016/j.ijom.2019.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 10/03/2019] [Accepted: 11/20/2019] [Indexed: 11/16/2022]
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Guzzini M, Lanzetti RM, Proietti L, Lupariello D, Iorio R, Ferretti A. The role of vascularized flaps in the treatment of proximal pole avascular necrosis in scaphoid non-unions. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:64-68. [PMID: 31821286 PMCID: PMC7233702 DOI: 10.23750/abm.v90i12-s.8367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 07/12/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The purpose of this study is to evaluate the clinical and radiological outcomes of scaphoid non unions surgically treated with bone graft versus medial condyle corticoperiosteal free flaps. MATERIALS AND METHODS 32 patients were divided in 2 groups. Group A (17 patients 12male, 5 females, mean age 35 years old) treated with bone grafts; Group B (15patients 11 male, 4 females, mean age 33 years old) treated with medial condyle cortico periosteal free flap. A radiological follow up was performed about every 30 days after surgery until the complete healing and at 12-month follow-up. The clinical follow up was performed at 6 and 12 months from surgery. Functional assessment was provided by Mayo wrist score and Visual Analogic Scale (VAS). RESULTS The average length of follow up was 12.52 months ± 1.36. In group A 60% of patients healed in 4.4 ± 1months with a reduction of 28.4% of healing times in group B (p<0.05).In Group B all nonunion sites healed primarily at an average time period of 3.2 ± 1 months. Statistical analysis showed a significant difference (p<0.001) about the preoperative and the postoperative VAS and Mayo Wrist Score evaluation in both groups at 6 and 12-month follow-up, moreover we recorded a statistical difference between groups at the 6-month and 12-month follow-up (p<0.05). CONCLUSION The present study showed that the free flaps showed better clinical and radiographic results for the surgical treatment of scaphoid nonunions. In fact, despite the good results of the bone graft, the flaps seems to be preferable in the treatment of these nonunions.
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Ciclamini D, Tos P, Guzzini M, Soldati A, Crosio A, Battiston B. The medial femoral condyle free corticoperiosteal flap versus traditional bone graft for treatment of nonunions of long bones: a retrospective comparative cohort study. Injury 2019; 50 Suppl 5:S54-S58. [PMID: 31711649 DOI: 10.1016/j.injury.2019.10.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Davide Ciclamini
- Orthopaedics and Traumatology II, Surgery of the Hand and Upper Limb, AOU Città della Salute e della Scienza, CTO Hospital, Turin, Italy
| | - Pierluigi Tos
- Microsurgery and Surgery of the Hand, Gaetano Pini Hospital, Milan, Italy
| | - Matteo Guzzini
- Orthopaedics and Traumatology Department, University of Rome "La Sapienza" - AO Sant'Andrea, Rome, Italy
| | - Alessandra Soldati
- Orthopaedics and Traumatology Department, Ospedale del Mare, Naples, Italy
| | - Alessandro Crosio
- Orthopaedics and Traumatology II, Surgery of the Hand and Upper Limb, AOU Città della Salute e della Scienza, CTO Hospital, Turin, Italy
| | - Bruno Battiston
- Orthopaedics and Traumatology II, Surgery of the Hand and Upper Limb, AOU Città della Salute e della Scienza, CTO Hospital, Turin, Italy.
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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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Colony Formation, Migratory, and Differentiation Characteristics of Multipotential Stromal Cells (MSCs) from "Clinically Accessible" Human Periosteum Compared to Donor-Matched Bone Marrow MSCs. Stem Cells Int 2019; 2019:6074245. [PMID: 31871468 PMCID: PMC6906873 DOI: 10.1155/2019/6074245] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 11/01/2019] [Indexed: 02/06/2023] Open
Abstract
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.
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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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Grohmann M, Benedikt S, Vasilyeva A, Bürger H, Forbes A, Schintler MV. An Innovative Application of the Free Vascularized Medial Femoral Condyle Flap in the Prevention of Recurring Neuropathic Ulcer in the Diabetic Foot: A Case Report. J Foot Ankle Surg 2019; 57:1020-1023. [PMID: 29804922 DOI: 10.1053/j.jfas.2018.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Indexed: 02/03/2023]
Abstract
Despite various therapy options, the prophylactic and symptomatic treatment of recurrent ulcerations in the diabetic foot are still challenging. We report the application of a free vascularized medial femoral condyle flap to prevent the recurrence of pressure ulcer in a patient with diabetic foot syndrome. Our patient had type 2 diabetes and presented with pressure ulcers and osteomyelitis of metatarsal heads 2 and 3 after a great toe amputation. We chose to use a medial femoral condyle flap as a damper in the area of the metatarsal heads because of the relatively young age and good vascularity of our patient. We shaped the graft like a ski to distribute the pressure and prevent perforation of the plantar skin. Good results were achieved for wound healing, pain reduction, and improvement of gait. No pressure ulceration had recurred after a 3-year follow-up period. The versatility of the osteomyocutaneous graft from the medial femoral condyle is an important reconstructive tool for addressing major surgical problems. We present the first use of a medial femoral condyle flap in the treatment of a pressure ulcer in a diabetic foot. In selected patients, our method could prevent premature and extended amputations, thereby providing good improvement in patients' quality of life.
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Affiliation(s)
- Martin Grohmann
- Medical Doctor, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Stefan Benedikt
- Medical Doctor, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.
| | - Anna Vasilyeva
- Medical Doctor, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Heinz Bürger
- Medical Doctor, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Abigail Forbes
- Medical Doctor, Plastic Surgery, University of Texas Medical Branch, Galveston, TX
| | - Michael Valentin Schintler
- Professor, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
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Donor-Site Morbidity of Vascularized Bone Flaps from the Distal Femur: A Systematic Review. Plast Reconstr Surg 2019; 142:363e-372e. [PMID: 30148786 DOI: 10.1097/prs.0000000000004691] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Vascularized grafts from the femur, including the medial femoral condyle and medial femoral trochlea, are increasingly being used. It is critical to understand the lower extremity complications from flap harvest. METHODS The authors searched available literature reporting on femoral flaps using PubMed, Embase, Cochrane Database, and Web of Science. After article selection, data were collected regarding demographics, procedure details, outcomes, and complications. The authors classified outcomes as good, fair, or poor based on pain, range-of-motion, sensory changes, subjective reporting, patient-reported outcomes, and other donor-site complications, including the need for additional procedures. RESULTS Two hundred twenty articles were identified. Forty-five met criteria for review, with data available for 283 patients. No patients had range-of-motion deficits beyond 1 year. Two percent of patients (six of 283) required additional donor-site procedures, with one report of a femur fracture after medial femoral condyle harvest. Only one study on 45 medial femoral trochlea patients presented patient-reported outcomes regarding the knee. Few objective data were presented. Twenty-eight articles presented adequate complication data for 252 patients to be rated as good, fair, or poor. Overall, 89 percent had good outcomes without donor-site complications. Of the 176 medial femoral condyle patients with outcomes reported, 92 percent had good outcomes; and 71 percent of the 48 medial femoral trochlea patients had good outcomes reported. CONCLUSIONS Overall, the reported donor-site morbidity from medial femoral condyle and medial femoral trochlea harvest is low. Chronic knee pain and sensory changes are most frequently reported, especially in medial femoral trochlea patients.
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Bezstarosti H, Van Lieshout EMM, Voskamp LW, Kortram K, Obremskey W, McNally MA, Metsemakers WJ, Verhofstad MHJ. Insights into treatment and outcome of fracture-related infection: a systematic literature review. Arch Orthop Trauma Surg 2019; 139:61-72. [PMID: 30343322 PMCID: PMC6342870 DOI: 10.1007/s00402-018-3048-0] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Standardized guidelines for treatment of fracture-related infection (FRI) are lacking. Worldwide many treatment protocols are used with variable success rates. Awareness on the need of standardized, evidence-based guidelines has increased in recent years. This systematic literature review gives an overview of available diagnostic criteria, classifications, treatment protocols, and related outcome measurements for surgically treated FRI patients. METHODS A comprehensive search was performed in all scientific literature since 1990. Studies in English that described surgical patient series for treatment of FRI were included. Data were collected on diagnostic criteria for FRI, classifications used, surgical treatments, follow-up protocols, and overall outcome. A systematic review was performed according to the PRISMA statement. Proportions and weighted means were calculated. RESULTS The search yielded 2051 studies. Ninety-three studies were suitable for inclusion, describing 3701 patients (3711 fractures) with complex FRI. The population consisted predominantly of male patients (77%), with the tibia being the most commonly affected bone (64%), and a mean of three previous operations per patient. Forty-three (46%) studies described FRI at one specific location. Only one study (1%) used a standardized definition for infection. A total of nine different classifications were used to guide treatment protocols, of which Cierny and Mader was used most often (36%). Eighteen (19%) studies used a one-stage, 50 (54%) a two-stage, and seven (8%) a three-stage surgical treatment protocol. Ten studies (11%) used mixed protocols. Antibiotic protocols varied widely between studies. A multidisciplinary approach was mentioned in only 12 (13%) studies. CONCLUSIONS This extensive literature review shows a lack of standardized guidelines with respect to diagnosis and treatment of FRI, which mimics the situation for prosthetic joint infection identified many years ago. Internationally accepted guidelines are urgently required to improve the quality of care for patients suffering from this significant complication.
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Affiliation(s)
- H. Bezstarosti
- 000000040459992Xgrid.5645.2Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - E. M. M. Van Lieshout
- 000000040459992Xgrid.5645.2Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - L. W. Voskamp
- 000000040459992Xgrid.5645.2Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - K. Kortram
- 000000040459992Xgrid.5645.2Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - W. Obremskey
- 0000 0001 2264 7217grid.152326.1Vanderbilt University, Nashville, USA
| | - M. A. McNally
- 0000 0001 0440 1440grid.410556.3Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - W J. Metsemakers
- 0000 0004 0626 3338grid.410569.fDepartment of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - M. H. J. Verhofstad
- 000000040459992Xgrid.5645.2Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
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Tsantes AG, Papadopoulos DV, Gelalis ID, Vekris MD, Pakos EE, Korompilias AV. The Efficacy of Vascularized Bone Grafts in the Treatment of Scaphoid Nonunions and Kienbock Disease: A Systematic Review in 917 Patients. J Hand Microsurg 2018; 11:6-13. [PMID: 30911206 DOI: 10.1055/s-0038-1677318] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 10/26/2018] [Indexed: 10/27/2022] Open
Abstract
Background Vascularized bone grafts have become one of the first treatment options for scaphoid nonunions and Kienböck's disease. The aim of this study is to review the current body of the literature regarding the use of four vascularized bone grafts (1,2 ICSRA [1,2 intercompartmental supraretinacular artery] graft, 4+5 ECA [4+5 extracompartmental artery] graft, volar radial graft, and free medial femoral condyle graft) in these pathologies. Patients and Methods A search on MEDLINE and Google Scholar was performed. Exclusion criteria included language other than English, studies with no full text available, case reports, letters, editorials, and review articles. The primary outcomes included consolidation rate of the grafts and time to union regarding scaphoid nonunion, as well as the clinical outcomes (pain, grip strength, range of motion), revascularization of the lunate, and progression of the disease regarding Kienböck's disease. Results A total of 37 articles were included in the study enrolling 917 patients. Regarding scaphoid nonunion, the consolidation rate was 86.3% for the 1,2 ICSRA graft, 93.9% for the volar radial bone graft, and 88.8% for the free medial femoral condyle graft. In patients with Kienböck's disease, progression of the disease was observed in 13% of patients, and grip strength and pain were substantially improved whereas range of motion did not demonstrate statistically significant improvement ( p < 0.05). Conclusion Vascularized bone grafts yield successful outcomes in patients with scaphoid nonunions demonstrating a high union rate. In patients with Kienböck's disease, vascularized grafts lead to revascularization of the lunate in most of the cases with concomitant improvement of the clinical parameters.
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Affiliation(s)
- Andreas G Tsantes
- Department of Orthopedics, University Hospital of Ioannina, Stavros Niarchos Ioannina, Greece
| | | | - Ioannis D Gelalis
- Department of Orthopedics, University Hospital of Ioannina, Stavros Niarchos Ioannina, Greece
| | - Marios D Vekris
- Department of Orthopedics, University Hospital of Ioannina, Stavros Niarchos Ioannina, Greece
| | - Emilios E Pakos
- Department of Orthopedics, University Hospital of Ioannina, Stavros Niarchos Ioannina, Greece
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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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McEwan JK, Tribe HC, Jacobs N, Hancock N, Qureshi AA, Dunlop DG, Oreffo RO. Regenerative medicine in lower limb reconstruction. Regen Med 2018; 13:477-490. [PMID: 29985779 DOI: 10.2217/rme-2018-0011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Bone is a highly specialized connective tissue and has a rare quality as one of the few tissues that can repair without a scar to regain pre-injury structure and function. Despite the excellent healing capacity of bone, tumor, infection, trauma and surgery can lead to significant bone loss requiring skeletal augmentation. Bone loss in the lower limb poses a complex clinical problem, requiring reconstructive techniques to restore form and function. In the past, amputation may have been the only option; however, there is now an array of reconstructive possibilities and cellular therapies available to salvage a limb. In this review, we will evaluate current applications of bone tissue engineering techniques in limb reconstruction and identify potential strategies for future work.
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Affiliation(s)
- Josephine K McEwan
- Bone & Joint Research Group, Centre for Human Development, Stem Cell & Regeneration, Institute of Developmental Sciences, University of Southampton, Tremona Road, Southampton SO16 6YD, UK
| | - Howard C Tribe
- Bone & Joint Research Group, Centre for Human Development, Stem Cell & Regeneration, Institute of Developmental Sciences, University of Southampton, Tremona Road, Southampton SO16 6YD, UK
| | - Neal Jacobs
- Salisbury NHS Foundation Trust, Salisbury, Wiltshire, UK
| | - Nicholas Hancock
- Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
| | - Amir A Qureshi
- Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
| | - Douglas G Dunlop
- Trauma & Orthopaedic Department, University Hospital Southampton, Southampton, UK
| | - Richard Oc Oreffo
- Bone & Joint Research Group, Centre for Human Development, Stem Cell & Regeneration, Institute of Developmental Sciences, University of Southampton, Tremona Road, Southampton SO16 6YD, UK
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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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Mattos D, Ko JH, Iorio ML. Wrist arthrodesis with the medial femoral condyle flap: Outcomes of vascularized bone grafting for osteomyelitis. Microsurgery 2018; 39:32-38. [PMID: 30176071 DOI: 10.1002/micr.30368] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 05/28/2018] [Accepted: 06/20/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND Osteomyelitis of the wrist is rare but destructive. Subsequent bone defects often require vascularized bone for successful healing. Recent literature has pointed to the successful use of the medial femoral condylar (MFC) flap for difficult non-unions, yet it has not been specifically described for wrist fusion. We present our experience with this technique for limited and complete wrist arthrodesis. PATIENTS AND METHODS We reviewed 4 cases of radiocarpal bone loss from osteomyelitis. All cases utilized debridement of nonviable tissues, and at least 6 weeks of intravenous antibiotics, followed by vascularized bone grafting with a MFC flap. The flap was based on the horizontal periosteal branch of the descending geniculate artery, and utilized to directly bridge the bony defects following resection. RESULTS Three patients healed primarily, and 1 patient required secondary cancellous bone grafting to reach union. One patient required revision of the donor site closure. None of the patients had a recurrence of infection or other complications. Average follow up was 8.5 months after reconstruction. Average time to union was 11.5 weeks. Three patients demonstrated full composite fist, and 1 patient had incomplete finger range of motion following several flexor and extensor tendon grafts. CONCLUSIONS These cases illustrate the use of the MFC in wrist arthrodesis after osteomyelitis defects. In all cases, there was complete union in a short time, no recurrence of infection, and low donor-site morbidity.
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Affiliation(s)
- David Mattos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jason H Ko
- Division of Plastic and Reconstructive Surgery, Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Matthew L Iorio
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Division of Plastic and Reconstructive Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colorado
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Abstract
The subtalar joint can be altered in its anatomy and biomechanical behavior. It is important to know how to assess the talar declination angle in order to assess the deformity at the subtalar joint. Consider a straight posterior approach to the subtalar joint and remain liberal in the use of z-shaped Achilles tendon lengthening. A structural bone graft should be used to elevate the talus. Positioning screws should be used to lock the construct.
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Affiliation(s)
- Norman Espinosa
- Institute for Foot and Ankle Reconstruction, Kappelistrasse 7, Zurich 8002, Switzerland.
| | - Elena Vacas
- Institute for Foot and Ankle Reconstruction, Kappelistrasse 7, Zurich 8002, Switzerland
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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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Saad NH, Pontell ME, Winters BS, Daniel J, Saad A. The Periosteal Medial Femoral Condyle Free Flap: A New Option for Soft Tissue Reconstruction of the Distal Lower Extremity. Ann Plast Surg 2018; 79:372-376. [PMID: 28604551 DOI: 10.1097/sap.0000000000001104] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Noah H Saad
- From the *University of Maryland Medical System, Baltimore, MD; †Department of Surgery, Drexel University College of Medicine, Philadelphia, PA; and ‡Rothman Institute of Orthopedics; and §The Plastic Surgery Center, The Institute for Advanced Reconstruction, Egg Harbor, NJ
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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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Morsy M, Sur YJ, Akdag O, Eisa A, El-Gammal TA, Lachman N, Moran SL. Anatomic and high-resolution computed tomographic angiography study of the lateral femoral condyle flap: Implications for surgical dissection. J Plast Reconstr Aesthet Surg 2018; 71:33-43. [DOI: 10.1016/j.bjps.2017.08.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 05/17/2017] [Accepted: 08/06/2017] [Indexed: 11/26/2022]
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