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Scampa M, Mégevand V, Martineau J, Schaefer DJ, Kalbermatten DF, Oranges CM. Medial Femoral Condyle Free Flap: A Systematic Review and Proportional Meta-analysis of Applications and Surgical Outcomes. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5708. [PMID: 38596574 PMCID: PMC11000773 DOI: 10.1097/gox.0000000000005708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/12/2024] [Indexed: 04/11/2024]
Abstract
Background Recalcitrant bone nonunion and osseous defect treatment is challenging and often requires vascularized bone transfer. The medial femoral condyle flap has become an increasingly popular option for reconstruction. The study aims at reviewing its different applications and synthesizing its surgical outcomes. Method A systematic review including all studies assessing surgical outcomes of free medial femoral condyle flap for bone reconstruction in adults was conducted on January 31, 2023. Flap failure and postoperative complications were synthesized with a proportional meta-analysis. Results Forty articles describing bony reconstruction in the head and neck, upper limb, and lower limb areas were selected. Indications ranged from bony nonunion and bone defects to avascular bone necrosis. Multiple flaps were raised as either pure periosteal, cortico-periosteal, cortico-cancellous-periosteal, or cortico-chondro-periosteal. A minority of composite flaps were reported. Overall failure rate was 1% [95% confidence interval (CI), 0.00-0.08] in head & neck applications, 4% in the lower limb (95% CI, 0.00-0.16), 2% in the upper limb (95% CI, 0.00-0.06), and 1% in articles analyzing various locations simultaneously (95% CI, 0.00-0.04). Overall donor site complication rate was 4% (95% CI, 0.01-0.06). Major reported complications were: femoral fractures (n = 3), superficial femoral artery injury (n = 1), medial collateral ligament injury (n = 1), and septic shock due to pace-maker colonization (n = 1). Conclusion The medial femoral condyle flap is a versatile option for bone reconstruction with high success rates and low donor site morbidity.
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Affiliation(s)
- Matteo Scampa
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, Geneva, Switzerland
| | - Vladimir Mégevand
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, Geneva, Switzerland
- Department of Plastic surgery, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, United Kingdom
| | - Jérôme Martineau
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, Geneva, Switzerland
| | - Dirk J. Schaefer
- Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery, Basel University Hospital, Basel, Switzerland
| | - Daniel F. Kalbermatten
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, Geneva, Switzerland
| | - Carlo M. Oranges
- From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Geneva University Hospitals, Geneva University, Geneva, Switzerland
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Pei Y, Zhu L, Xu Q, Wang J, Sun Y, Wang G. Clinical report of microsurgical treatment of Kohler's disease. Sci Rep 2024; 14:6341. [PMID: 38491143 PMCID: PMC10943104 DOI: 10.1038/s41598-024-57088-w] [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: 04/28/2023] [Accepted: 03/14/2024] [Indexed: 03/18/2024] Open
Abstract
The conservative treatment for Kohler's disease will take several months, but some patients still have flatfoot and persistent pain. From October 2013 to July 2015, 3 children with Kohler's disease underwent navicular decompression and micro-circulation reconstruction surgery in our hospital. All the patients have received conservative treatment for more than 3 months and the effect was poor. X-ray showed the bone density of navicular increased significantly. All patients were followed up over 1 year. The 3 patients recovered well. VAS score decreased from 7.0 to 2.6 at 1 month after the operation. The pain symptom disappeared completely on 3 months after surgery. The density of navicular bone recovered to normal. Navicular decompression and micro-circulation reconstruction surgery may quickly improve the ischemic status of navicular bone, alleviate pain symptom and enable patients to resume normal activity as soon as possible.
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Affiliation(s)
- Yantao Pei
- Department of Orthopedics, Department of Hand Surgery, Foot and Ankle Surgery, Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Lei Zhu
- Department of Orthopedics, Department of Hand Surgery, Foot and Ankle Surgery, Qilu Hospital of Shandong University, Jinan, 250012, China.
| | - Qingjia Xu
- Department of Orthopedics, Department of Hand Surgery, Foot and Ankle Surgery, Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Juntao Wang
- Department of Orthopedics, Department of Hand Surgery, Foot and Ankle Surgery, Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Yuliang Sun
- Department of Orthopedics, Department of Hand Surgery, Foot and Ankle Surgery, Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Gang Wang
- Department of Orthopedics, Department of Hand Surgery, Foot and Ankle Surgery, Qilu Hospital of Shandong University, Jinan, 250012, China
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Kaiser D, Levin LS. Medial Femoral Condyle Free Flap for Persistent Osseous Nonunion of the First Metatarsophalangeal Joint: A Preliminary Report of a New Surgical Indication for the Medial Femoral Condyle Free Flap. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231191135. [PMID: 37654572 PMCID: PMC10467191 DOI: 10.1177/24730114231191135] [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: 09/02/2023] Open
Abstract
Background Recalcitrant or persistent nonunions of the metatarsophalangeal (MTP) joint occur following failed MTP surgery for MTP fusion, failed MTP prosthesis, for hallux rigidus or due to infection and erosion. A deficient soft tissue envelope and compromised vascular supply of tissues in this region compound further attempts to salvage the great toe and preserve function. The medial femoral condyle (MFC) free flap provides vascularized corticocancellous bone and periosteum and has been successfully used for a variety of complex hindfoot and ankle pathologies. We present an additional indication with a small cohort study demonstrating its use in persistent nonunions of the first MTP joint. Methods A retrospective review was completed of all MFC flaps used for revision of failed first MTP joint fusion from January 2019 to November 2022. Demographic information, comorbidities, as well as clinical and radiologic follow-up was obtained from the patient charts. Results Three patients were included with MTP nonunion and an average of 7.5 (range, 5-11) failed prior surgeries. Mean age at index surgery was 50 (range, 46-57) years. An osseous union was achieved in all patients after 82 (range, 75-88) days. Hardware removal was possible after 81 (range, 55-98) days. Mean follow-up was 17 (range, 5-31) months. We note a 100% flap success rate without returns to the operating room. The lengths of the bone flaps were 2 to 4 cm, the volumes were 8 to 12 cm3. Fixation was performed with 1 intramedullary K-wire. The recipient vessel in all patients was the dorsalis pedis artery or a tributary thereof. All arterial anastomoses were performed under the operating microscope. Conclusion The MFC free flap is a reasonable option for salvage of complex recalcitrant or persistent nonunions of the first MTP joint. More prospective long-term studies with functional outcomes are necessary to confirm these findings. Level of Evidence Level IV, retrospective case series.
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Affiliation(s)
- Dominik Kaiser
- Orthopaedic Department, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - L. Scott Levin
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Division of Plastic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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4
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Patel NK, Tipps JA, Bartlett SP, Kovach SJ, Levin LS, Mendenhall SD. Expanding Indications of the Medial Femoral Condyle Free Flap: Systematic Review in Head and Neck Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4925. [PMID: 37035122 PMCID: PMC10079347 DOI: 10.1097/gox.0000000000004925] [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: 01/03/2023] [Accepted: 02/14/2023] [Indexed: 04/11/2023]
Abstract
The medial femoral condyle free flap serves as an attractive reconstructive option for small- to intermediate-sized bony defects. It is commonly applied in the extremities with limited reports in the head and neck. Methods A systematic review of the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results Seventeen articles met inclusion criteria, yielding 166 cases for analysis, with a majority of the cohort from a single study (n = 107; 64.4%). However, all included studies represented novel reconstructive sites and surgical indications. Flap components were described in 157 cases; periosteum was used only in four cases (2.5%), whereas all others are composed of cortical bone combined with periosteum, cancellous bone, and/or cartilage (97.5%). Additionally, a skin island was used in 43 cases (25.9%). Flap measurements were reported in 51 cases, averaging 4.5 ± 2.7 cm in length. Seven cases listed skin island dimensions, averaging 20.2 ± 12.8 cm2. The descending genicular artery was the primary pedicle employed (n = 162; 97.6%), while the superior medial genicular was used in the descending genicular artery's absence (n = 4; 2.4%). Descending genicular artery pedicle length from 15 reporting cases averaged 6.4 ± 1.2 cm. Successful reconstructions totaled 160 cases (96.4%). Recipient complications were seen in 16 cases (9.6%) with six constituting flap failures (3.6%). Donor site complications were minimal (n = 6; 3.6%); however, this included one major complication of femoral shaft fracture. Conclusion The medial femoral condyle free flap is an effective reconstructive option for the head and neck due to its versatile nature, low complication profile at both recipient and donor site, ease of harvest, and two-team approach.
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Affiliation(s)
- Niki K. Patel
- From the Division of Plastic, Reconstructive, and Oral Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pa
| | - John A. Tipps
- From the Division of Plastic, Reconstructive, and Oral Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Scott P. Bartlett
- From the Division of Plastic, Reconstructive, and Oral Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Stephen J. Kovach
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
- Division of Plastic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - L. Scott Levin
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Shaun D. Mendenhall
- From the Division of Plastic, Reconstructive, and Oral Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
- Division of Orthopaedic Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pa
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5
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Levin LS. From replantation to transplantation: The evolution of orthoplastic extremity reconstruction. J Orthop Res 2022. [PMID: 36413095 DOI: 10.1002/jor.25488] [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: 08/16/2022] [Revised: 10/20/2022] [Accepted: 11/15/2022] [Indexed: 11/23/2022]
Abstract
For more than six decades, the use of the operating microscope for extremity surgery has led to remarkable advances in the management of orthopedic trauma, tumors, infections, and congenital differences. The microsurgical reconstructive ladder ascends from basic microsurgical procedures such as a digital artery or nerve repair to more complex procedures such as autologous tissue transplantation. Functional muscle transfers, toe-to-hand transfers, and recently vascularized composite allotransplantation are the highest rungs on this ladder that help restore extremity function. The development of the orthoplastic approach over the last three decades simultaneously integrates the principles and practices of both orthopedic surgery and plastic surgery for optimal care and salvage of extremities. Clinical, anatomic, and basic science research in reconstructive microsurgery has resulted in significant improvements in extremity salvage, reconstruction, and restoration.
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Affiliation(s)
- L Scott Levin
- Department of Orthopaedic Surgery, Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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6
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Windhofer CM, Orthner E, Bürger HK. Vascularized osteochondral free flaps from the femoral trochlea as versatile procedure for reconstruction of osteochondral lesions of the talus. Foot Ankle Surg 2022; 28:935-943. [PMID: 35065852 DOI: 10.1016/j.fas.2022.01.002] [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: 08/27/2021] [Revised: 12/10/2021] [Accepted: 01/08/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Osteochondral lesions of the talus (OLT) are defects affecting the articular cartilage as well as the subchondral bone, on the lateral shoulder possibly associated with trauma. This study presents the results of reconstructing OLT using vascularized osteochondral flaps from the femoral trochlea. METHODS We treated 19 patients with osteochondral talar shoulder defects, using osteochondral flaps from the medial (MFT) or lateral (LFT) femoral trochlea. Functional outcome was evaluated by clinical investigation, visual analogue scale (VAS, 0-10), American Orthopaedic Foot and Ankle Society-Ankle and Hindfoot Scale (AOFAS, 0-100) and The Foot and Ankle Disability Index (FADI, 0-104). Radiographic postoperative follow-up was done by anterior-posterior and lateral X-rays and union of the transferred osteochondral flaps was documented by CT scans. RESULTS The osteochondral flaps fused in all of the 19 cases. After a median follow-up of 45.5 months, the patients showed an average FADI of 94.9 and AOFAS-Ankle and Hindfoot Scale of 91.2. All of them were walking free and normal. Subjective median satisfaction was 1.3 in a scale from 1 to 5. CONCLUSION Vascularized transfer of osteochondral flaps from the femoral trochlea is a reliable treatment option for symptomatic OLT of the medial and lateral talar edge. LEVEL OF CLINICAL EVIDENCE Therapeutic IV.
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Affiliation(s)
- Christian M Windhofer
- Trauma Department, AUVA Unfallkrankenhaus, Salzburg, Dr. Franz-Rehrl-Platz 5, A-5010 Salzburg, Austria; Ludwig-Boltzmann-Institute for Experimental and Clinical Traumatology in AUVA Trauma Research Center, Donaueschingenstrasse 13, A-1200 Wien, Austria.
| | - Ernst Orthner
- Fußzentrum Wels, Vogelweiderstraße 3b, A-4600 Wels, Austria.
| | - Heinz K Bürger
- Privat Hospital Maria Hilf, Radetzkystrasse 35, A-9020 Klagenfurt, Austria.
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7
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Rodriguez JR, Chan JKK, Huang RW, Chen SH, Lin CH, Lin YT, Lin CH, Hsu CC. Free Medial Femoral Condyle Flap for Phalangeal and Metacarpal Bone Reconstruction. J Plast Reconstr Aesthet Surg 2022. [DOI: 10.1016/j.bjps.2022.08.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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8
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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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9
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Sherman AE, Mehta MP, Nayak R, Mutawakkil MY, Ko JH, Patel MS, Kadakia AR. Biologic Augmentation of Tibiotalocalcaneal Arthrodesis With Allogeneic Bone Block Is Associated With High Rates of Fusion. Foot Ankle Int 2022; 43:353-362. [PMID: 34677103 DOI: 10.1177/10711007211041336] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The orthopaedic conditions and systemic comorbidities that occur in patients who require bone block tibiotalocalcaneal (TTC) arthrodesis have made this procedure associated with a higher-than-normal risk of nonunion, graft collapse, hardware failure, and amputation. Here, we present a novel approach to bone block TTC arthrodesis using adjunctive osteoinductive agents and a prolonged course of protected weightbearing to assess if we could improve on historical outcomes. We also evaluated the efficacy of a vascularized medial femoral condyle (MFC) free flap to augment TTC arthrodesis. METHODS Fourteen adult patients underwent bone block TTC arthrodesis biologically augmented with fresh-frozen femoral head allograft, bone marrow aspirate concentrate, and demineralized bone matrix cortical fibers. Three patients with soft tissue defects underwent vascularized reconstruction with an MFC free flap. Radiographic union, the Foot Function Index (FFI), and PROMIS pain interference (PI), and physical function (PF) scores were assessed at follow-up. RESULTS TTC fusion was documented on plain radiograph in 13 of 14 patients (92.9%) and CT in 10 of 11 patients (90.9%). Mean time to fusion was 183.2 ± 83.2 days. One patient (7.1%) experienced nonunion and persistent infection requiring amputation. Patients who underwent vascularized bone grafting had significantly shorter time to fusion (112.3 ± 31.7 days vs 204.4 ± 82.7 days, P = .05). Patient-reported outcomes revealed mild to moderate pain and dysfunction after 1 year (mean FFI = 41.0% ± 23.1%, PROMIS PI = 58.3 ± 1.8, PROMIS PF = 39.0 ± 2.2). CONCLUSION In this relatively small series, the biologic augmentation of bone block TTC arthrodesis with osteoinductive agents and protective weightbearing resulted in excellent rates of fusion, modest pain, and preserved function of the lower extremity in almost all those treated. Osseous healing appears to be enhanced and accelerated with application of an MFC flap. We believe that this approach offers a viable salvage option for these challenging clinical problems. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Alain E Sherman
- Department of Orthopaedic Surgery, Northwestern Medicine Feinberg School of Medicine, Chicago, IL, USA
| | - Mitesh P Mehta
- Department of Orthopaedic Surgery, Northwestern Medicine Feinberg School of Medicine, Chicago, IL, USA
| | - Rusheel Nayak
- Department of Orthopaedic Surgery, Northwestern Medicine Feinberg School of Medicine, Chicago, IL, USA
| | - Muhammad Y Mutawakkil
- Department of Orthopaedic Surgery, Northwestern Medicine Feinberg School of Medicine, Chicago, IL, USA
| | - Jason H Ko
- Department of Orthopaedic Surgery, Northwestern Medicine Feinberg School of Medicine, Chicago, IL, USA.,Department of Surgery (Plastic Surgery), Northwestern Medicine Feinberg School of Medicine, Chicago, IL, USA
| | - Milap S Patel
- Department of Orthopaedic Surgery, Northwestern Medicine Feinberg School of Medicine, Chicago, IL, USA
| | - Anish R Kadakia
- Department of Orthopaedic Surgery, Northwestern Medicine Feinberg School of Medicine, Chicago, IL, USA
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10
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Addressing common orthopaedic calamities with microsurgical solutions. Injury 2021; 52:3561-3572. [PMID: 34030865 DOI: 10.1016/j.injury.2021.05.003] [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: 04/13/2021] [Accepted: 05/04/2021] [Indexed: 02/02/2023]
Abstract
Reconstructive microsurgery has been an essential aspect of orthopaedic surgery and extremity reconstruction since the introduction of the operating microscope in the mid-20th century. The reconstructive ladder ranges from simple healing by secondary intention to complex procedures such as free tissue transfer and vascularized composite allotransplantation. As orthopaedic surgery has evolved over the past 60 years, so too have the reconstructive microsurgical skills that are often needed to address common orthopaedic surgery problems. In this article, we will discuss a variety of complex orthopaedic surgery scenarios ranging from trauma to infection to tumor resection as well as the spectrum of microsurgical solutions that can aid in their management.
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Abstract
BACKGROUND The use of free flaps from the medial femoral condyle has grown in popularity and is now a workhorse in the reconstruction of skeletal defects. The utility of this technique has not yet been described for the pediatric patient population. The authors present their series of pediatric patients who underwent surgery using a medial femoral condyle free flap or a variant thereof in skeletal reconstruction and demonstrate the efficacy of this technique in this population. METHODS A multi-institutional retrospective review of patients aged 18 years or younger who required a medial femoral condyle flap for skeletal reconstruction was undertaken. Operative technique, radiographs, and clinical outcomes were recorded. A novel technique (Innocenti) was used to avoid the distal femoral physis in which a Kirschner wire was placed under fluoroscopic guidance just proximal to the growth plate. RESULTS Thirteen patients met inclusion criteria, with an average age of 14.7 years (range, 7 to 18 years) and mean follow-up of 28 months (range, 3 to 120 months). Six were skeletally immature at the time of medial femoral condyle harvest, with the last patient having organic bone disease, putting her at risk for pathologic fracture. All 13 patients achieved bony union, and no patients suffered pathologic fractures or physeal injuries; no patients developed length discrepancies. CONCLUSIONS The authors present the first series of corticocancellous medial femoral condyle free flaps in the pediatric population along with a novel technique to avoid injury to the physis in skeletally immature patients. This technique is effective for a variety of skeletal defects or nonunions and is safe for growing patients without causing physeal arrest or growth disturbance. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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12
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Abstract
In order to address complex extremity injuries, the orthoplastic approach uses plastic, orthopedic, and microsurgical techniques and includes other disciplines to optimize limb salvage. This collaboration, if created early in treatment, allows for more expedient and individualized solutions to a variety of extremity injuries resulting in decreased hospital stay, fewer complications, and improved functional outcomes. The orthoplastic approach does not merely avoid amputation, but also improves patient function and quality of life in the short and long term.
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13
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Politikou O, Wirth S, Giesen T, Guggenberger R, Giovanoli P, Calcagni M. Corticoperiosteal medial femoral condyle flap for recalcitrant nonunion in ankle and foot: Outcomes and radiological evaluation of donor site morbidity. Foot Ankle Surg 2020; 26:918-923. [PMID: 32067885 DOI: 10.1016/j.fas.2019.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/11/2019] [Accepted: 12/29/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the effectiveness and safety of free corticoperiosteal medial femoral condyle (MFC) flap for ankle, hindfoot and midfoot reconstruction in patients with recalcitrant nonunion. METHODS Patients who underwent ankle and foot reconstruction using the MFC flap at our clinic were recruited for assessment of the union rate, time to union and functional outcome. Furthermore, a clinical and radiological examination of the donor knee was performed using both computed tomography and magnetic resonance imaging. RESULTS Thirteen patients with a mean follow-up time of 2.5 years were included; 10 of them had a previously failed ankle and foot arthrodesis. Union was achieved in 11 patients in an average time of 10 months after MFC flap surgery. Donor site morbidity was minor with no radiological evidence for soft tissue or bone complication. CONCLUSION MFC flaps are a useful and safe reconstructive tool and may be considered after failed ankle and foot arthrodesis.
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Affiliation(s)
- Olga Politikou
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
| | - Stephan Wirth
- Division Foot and Ankle Surgery, Orthopaedics Department, University Hospital Balgrist, Forchstrasse 340, 8008 Zurich, Switzerland.
| | - Thomas Giesen
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
| | - Roman Guggenberger
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
| | - Pietro Giovanoli
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
| | - Maurizio Calcagni
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
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14
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Treatment of traumatic losses of substance in the foot. ANN CHIR PLAST ESTH 2020; 65:549-569. [PMID: 32753248 DOI: 10.1016/j.anplas.2020.06.010] [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: 06/19/2020] [Accepted: 06/26/2020] [Indexed: 11/22/2022]
Abstract
Treatment of traumatic loss of bone and tissue substance in the foot necessitates special consideration of the anatomy and physiology of the segment. The causes of foot trauma are multiple and in many cases violent, leading to progressive tissue deterioration that may require multi-phased debridement. The therapeutic objective is to reconstruct a functional foot permitting painless pushing off, walking and footwear use by restoring a stable bone framework, with resistant covering satisfactorily adjusted to the different zones of the foot. While coverage of the back of the foot must be fine, coverage of the plantar zones will be padded. The reconstructive surgeon shall be particularly attentive to plantar sensitivity. To take up the surgical challenge, it is of paramount importance to fully master a wide-ranging therapeutic arsenal ranging from conventional grafts to composite free flaps in view of proposing the solution most suited to the type, size and location of the loss of substance, all the while striving to generate as few sequelae as possible at the donor site. In order for reconstruction to be successful, multidisciplinary collaboration between plastic surgeons, orthopedists and physician is highly recommended.
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15
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Saad A, Jimenez ML, Rogero RG, Saad S, Nakashian MN, Winters BS. Medial Femoral Condyle Periosteal Free Flap for the Treatment of Talus Avascular Necrosis. Foot Ankle Int 2020; 41:728-734. [PMID: 32326752 DOI: 10.1177/1071100720917158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In patients with avascular necrosis (AVN) of the talus in the precollapse stage unresponsive to conservative measures, joint preservation should be considered. Good results have previously been reported for vascularized bone grafting. The medial femoral condyle (MFC) free flap has recently been introduced, which consists of corticoperiosteal bone. We present a novel surgical technique using a periosteal-only MFC (pMFC) free flap in the treatment of talus AVN. METHODS We retrospectively reviewed all pMFC free flaps performed from 2016 to 2018 in the precollapse stage of talus AVN. Surgical management included an ankle arthroscopy, talus core decompression, and ipsilateral pMFC free flap to the talus. Foot and Ankle Ability Measure (FAAM)-Activities of Daily Living (ADL) and visual analog scale (VAS) pain scores were evaluated, and pre- and postoperative imaging studies were assessed by a musculoskeletal-trained radiologist for all patients. Six pMFC free flaps in 5 patients were included in this case series. AVN etiology included idiopathic, posttraumatic, and sepsis-related treatment. All patients were female with an average age of 44.2 (range, 37-67) years. Average postoperative follow-up was 16.9 (range, 6-28) months. RESULTS Pre- to postoperative FAAM-ADL, ADL single assessment numeric evaluation, and VAS scores showed statistically significant improvement (P < .039). No reoperations or flap complications were observed. There was 1 minor complication, which included postoperative paresthesias at the pMFC harvest site. Postoperative x-rays showed no subsequent collapse, and magnetic resonance imaging (MRI) illustrated progressive improvement of bone marrow edema, decreased surrounding areas of AVN, and decreased joint effusion when compared to preoperative MRI. CONCLUSION The pMFC free flap is a novel modification of a previously described technique, which appears to have similar results compared to the traditional MFC free flap. It was safe and effective in the short term with excellent clinical and radiographic outcomes. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Adam Saad
- The Institute for Advanced Reconstruction, Egg Harbor Township, NJ, USA
| | - Megan L Jimenez
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Ryan G Rogero
- Rothman Orthopaedic Institute, Philadelphia, PA, USA.,Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Sherif Saad
- Atlantic Medical Imaging, Egg Harbor Township, NJ, USA
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Stranix JT, Piper ML, Azoury SC, Kozak G, Ben-Amotz O, Wapner KL, Levin LS. Medial Femoral Condyle Free Flap Reconstruction of Complex Foot and Ankle Pathology. FOOT & ANKLE ORTHOPAEDICS 2019; 4:2473011419884269. [PMID: 35097345 PMCID: PMC8697073 DOI: 10.1177/2473011419884269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Complex hindfoot pathology may benefit from vascularized bone flap reconstruction rather than traditional bone grafting techniques. Medial femoral condyle (MFC) flaps provide vascularized periosteum, skin, and corticocancellous bone. Methods: A retrospective, single-institution cohort study of consecutive MFC flaps performed for complicated hindfoot reconstruction between 2013 and 2019 was reviewed. Radiologic follow-up assessed osseous union and clinical outcomes were evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score. Thirty MFC flaps were performed in 28 patients for complex hindfoot pathology. Twenty-seven flaps had adequate clinical and radiographic follow-up (mean 15.8 months). Results: The majority presented with avascular necrosis (83%) and failed prior operations (67%, mean 3.1). Most hindfoot procedures involved arthrodesis (n = 24, 80%); tibiotalocalcaneal (n = 11) and talonavicular (n = 7) most frequently. Mean osseous flap volume was 10.3 cm3 (range 1.7-18.4 cm3); one flap required takeback for venous congestion but no total flap losses occurred. Primary osseous union was initially achieved in 20 patients (74%, mean 217 days). Six flaps developed interface nonunion; 5 underwent revision arthrodesis and ultimately achieved union in 24/27 flaps (89%, mean 271 days). Risk factors for nonunion were body mass index (BMI) >30 ( P = .017) and prior arthrodesis ( P = .042). Mean AOFAS hindfoot scores increased significantly from 52.3 preoperatively to 70.7 postoperatively ( P < .001). Subscore analysis demonstrated significant improvement in postoperative pain scores from 14.2 to 27.3 out of 40 ( P < .001). Conclusion: The MFC free flap provided vascularized bone for complicated foot and ankle reconstruction with relatively low donor site morbidity, promising osseous union results, and improved functional outcomes. Level of Evidence: Level IV, retrospective case series.
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Affiliation(s)
- John T. Stranix
- Department of Plastic Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Merisa L. Piper
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Said C. Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Geoffrey Kozak
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Oded Ben-Amotz
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Keith L. Wapner
- Department of Orthopedic Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - L. Scott Levin
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
- Department of Orthopedic Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
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Long Term Follow Up of a Vascularized Osteocutaneous Free Flap for Reconstruction in Charcot Neuroarthropathy: A Case Report. Ann Plast Surg 2018; 82:180-183. [PMID: 30557182 DOI: 10.1097/sap.0000000000001670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Vascularized osteocutaneous free flaps have seen increasing use in foot and ankle surgery for the repair of bony defects secondary to chronic nonunion, osteomyelitis, and fractures. One example is the Medial Femoral Condyle (MFC) Flap. The utility of the MFC flap for the repair of a bony defect in a diabetic patient, however, has yet to be explored. We report the long-term results of a case describing the use of an MFC flap to reconstruct an osseous defect resulting from first metatarsophalangeal joint resection in a diabetic patient.
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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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20
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Hong JP(J, Song S, Suh HSP. Supermicrosurgery: Principles and applications. J Surg Oncol 2018; 118:832-839. [DOI: 10.1002/jso.25243] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 08/23/2018] [Indexed: 12/30/2022]
Affiliation(s)
- Joon Pio (Jp) Hong
- Department of Plastic SurgeryAsan Medical Center, University of Ulsan College of MedicineSeoul Korea
| | - Sinyoung Song
- Department of Plastic SurgeryAsan Medical Center, University of Ulsan College of MedicineSeoul Korea
| | - Hyun Suk Peter Suh
- Department of Plastic SurgeryAsan Medical Center, University of Ulsan College of MedicineSeoul Korea
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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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22
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Feasibility of a bone and soft tissue chimeric anterolateral thigh free flap? Anatomic study and report of two cases for oral cavity reconstruction. J Plast Reconstr Aesthet Surg 2018; 71:729-735. [DOI: 10.1016/j.bjps.2017.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 10/24/2017] [Accepted: 12/05/2017] [Indexed: 11/20/2022]
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23
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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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24
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The medial femoral condyle flap to re-vitalise the femoral head for calcaneal reconstruction. J Plast Reconstr Aesthet Surg 2017; 70:974-976. [PMID: 28359727 DOI: 10.1016/j.bjps.2017.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 03/07/2017] [Indexed: 11/23/2022]
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25
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Medial Femoral Condyle Free Flap for Premaxillary Reconstruction in Median Facial Dysplasia. J Craniofac Surg 2017; 28:e57-e60. [DOI: 10.1097/scs.0000000000003199] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Kazmers NH, Thibaudeau S, Steinberger Z, Scott Levin L. Upper and lower extremity reconstructive applications utilizing free flaps from the medial genicular arterial system: A systematic review. Microsurgery 2016; 38:328-343. [DOI: 10.1002/micr.30138] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 11/10/2016] [Accepted: 12/02/2016] [Indexed: 11/07/2022]
Affiliation(s)
| | - Stephanie Thibaudeau
- Division of Plastic and Reconstructive Surgery; McGill University; Montreal Quebec H3A 14A Canada
| | - Zvi Steinberger
- Department of Orthopaedic Surgery; Penn Medicine University City; Philadelphia Pennsylvania
| | - L. Scott Levin
- Department of Orthopaedic Surgery; Penn Medicine University City; Philadelphia Pennsylvania
- Division of Plastic Surgery; Perelman Center for Advanced Medicine; Philadelphia Pennsylvania
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Bekara F, Herlin C, Somda S, de Runz A, Grolleau JL, Chaput B. Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: What is the safest coverage? A meta-analysis. Microsurgery 2016; 38:109-119. [PMID: 27018650 DOI: 10.1002/micr.30047] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 02/22/2016] [Accepted: 02/25/2016] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Currently, increasingly reconstructive surgeon consider the failure rates of perforator propeller flaps especially in the distal third of the lower leg are too important and prefer to return to the use of free flap at first line option with failure rates frequently lower than 5%. So, we performed a systematic review with meta-analysis comparing free flaps (perforator-based or not) and pedicled-propeller flaps to respond to the question "what is the safest coverage for distal third of the lower limb?" METHODS This review was conducted according to PRISMA criteria. From 1991 to 2015, MEDLINE®, Pubmed central, Embase and Cochrane Library were searched. The pooled estimations were performed by meta-analysis. The homogeneity Q statistic and the I2 index were computed. RESULTS We included 36 articles for free flaps (1,226 flaps) and 19 articles for pedicled-propeller flaps (302 flaps). The overall failure rate was 3.9% [95%CI:2.6-5.3] for free flaps and 2.77% [95%CI:0.0-5.6] for pedicled-propeller flaps (P = 0.36). The complication rates were 19.0% for free flaps and 21.4% for pedicled-propeller flaps (P = 0.37). In more detail, we noted for free flaps versus pedicled-propeller flaps: partial necrosis (2.70 vs. 6.88%, P = 0.001%), wound dehiscence (2.38 vs. 0.26%, P = 0.018), infection (4.45 vs. 1.22%, P = 0.009). The coverage failure rate was 5.24% [95%CI:3.68-6.81] versus 2.99% [95%CI:0.38-5.60] without significant difference (P = 0.016). CONCLUSION In the lower limb the complications are not rare and many teams consider the free flaps to be safer. In this meta-analysis we provide evidence that failure and overall complications rate of perforator propeller flaps are comparable with free flaps. Although, partial necrosis is significantly higher for pedicled-propeller flaps than free flaps, in reality the success of coverage appears similar. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:109-119, 2018.
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Affiliation(s)
- Farid Bekara
- Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, Montpellier, France
| | - Christian Herlin
- Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, Montpellier, France
| | - Serge Somda
- Biostatistic Unit, Institut Universitaire du Cancer Toulouse, Toulouse, France
| | - Antoine de Runz
- Department of Plastic and Reconstructive Surgery, Nancy University Hospital, Nancy, France
| | - Jean Louis Grolleau
- Department of Plastic and Reconstructive Surgery, Rangueil University Hospital, Toulouse, France
| | - Benoit Chaput
- Department of Plastic and Reconstructive Surgery, Rangueil University Hospital, Toulouse, France
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Puente-Alonso C, Higueras-Suñe C, González-Vargas JA, Carrasco-López C. Use of fibula flaps to treat persistent talonavicular nonunion: A report of three cases. Microsurgery 2016; 36:430-434. [PMID: 26991122 DOI: 10.1002/micr.30045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 01/18/2016] [Accepted: 02/24/2016] [Indexed: 11/09/2022]
Abstract
Owing to the limited blood supply in the midfoot, multiple arthrodesis attempts in midfood joints may result in severe osteonecrosis, leading to a difficult scenario for bone reconstruction. This article describes the use of fibula flaps (two free and one pedicled flap) to reconstruct bone defects in three cases of persistent nonunion in midfoot joints. Before admission, all patients (aged 32-56 years old) had undergone multiple arthrodesis attempts (range 3-4) aimed at treating joint diseases associated with flatfoot or Müller-Weiss syndrome. All inserted flaps were stable, and bone fusion was confirmed by X-ray examination at month 4. After the follow-up period (range 1-4 years), all patients showed normal, painless gait. No foot deformities or further complications were observed. Our report suggests that fibula flap transfer may be a good alternative for treating persistent nonunion in midfoot joints involving bone loss, and may prevent the osteonecrosis associated with limited blood supply. © 2016 Wiley Periodicals, Inc. Microsurgery 36:430-434, 2016.
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Affiliation(s)
- Carles Puente-Alonso
- Department of Traumatology and Orthopedic Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Carmen Higueras-Suñe
- Department of Plastic Surgery, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Jose A González-Vargas
- Department of Traumatology and Orthopedic Surgery, Consorci Hospitalari Parc Taulí Sabadell, Sabadell, Spain
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Kodama N, Takemura Y, Shioji S, Imai S. Arthrodesis of the ankle using an anterior sliding tibial graft for osteoarthritis secondary to osteonecrosis of the talus. Bone Joint J 2016; 98-B:359-64. [DOI: 10.1302/0301-620x.98b3.36154] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Aims This retrospective cohort study compared the results of vascularised and non-vascularised anterior sliding tibial grafts for the treatment of osteoarthritis (OA)of the ankle secondary to osteonecrosis of the talus. Patients and Methods We reviewed the clinical and radiological outcomes of 27 patients who underwent arthrodesis with either vascularised or non-vascularised (conventional) grafts, comparing the outcomes (clinical scores, proportion with successful union and time to union) between the two groups. The clinical outcome was assessed using the Mazur and American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores. The mean follow-up was 35 months (24 to 68). Results The mean outcome scores increased significantly in both groups. In the vascularised graft group, the mean Mazur score improved from 36.9 to 74.6 and the mean AOFAS scale improved from 49.6 to 80.1. In the conventional arthrodesis group, the mean Mazur score improved from 35.5 to 65 and the mean AOFAS scale from 49.2 to 67.6. Complete fusion was achieved in 13 patients (76%) in the vascularised group, but only four (40%) in the conventional group. The clinical outcomes and proportion achieving union were significantly better in the vascularised group compared with the conventional arthrodesis group, although time to union was similar in the two groups. Take home message: Vascularised sliding tibial grafts may be used to achieve arthrodesis in patients with OA of the ankle secondary to osteonecrosis of the talus. Cite this article: Bone Joint J 2016;98-B:359–64.
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Affiliation(s)
- N. Kodama
- Shiga University of Medical Science, Seta
Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - Y. Takemura
- Shiga University of Medical Science, Seta
Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - S. Shioji
- Shiga University of Medical Science, Seta
Tsukinowa, Otsu, Shiga, 520-2192, Japan
| | - S. Imai
- Shiga University of Medical Science, Seta
Tsukinowa, Otsu, Shiga, 520-2192, Japan
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Kodama N, Takemura Y, Ueba H, Imai S, Matsusue Y. A new form of surgical treatment for patients with avascular necrosis of the talus and secondary osteoarthritis of the ankle. Bone Joint J 2015; 97-B:802-8. [PMID: 26033060 DOI: 10.1302/0301-620x.97b6.34750] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
A new method of vascularised tibial grafting has been developed for the treatment of avascular necrosis (AVN) of the talus and secondary osteoarthritis (OA) of the ankle. We used 40 cadavers to identify the vascular anatomy of the distal tibia in order to establish how to elevate a vascularised tibial graft safely. Between 2008 and 2012, eight patients (three male, five female, mean age 50 years; 26 to 68) with isolated AVN of the talus and 12 patients (four male, eight female, mean age 58 years; 23 to 76) with secondary OA underwent vascularised bone grafting from the distal tibia either to revascularise the talus or for arthrodesis. The radiological and clinical outcomes were evaluated at a mean follow-up of 31 months (24 to 62). The peri-malleolar arterial arch was confirmed in the cadaveric study. A vascularised bone graft could be elevated safely using the peri-malleolar pedicle. The clinical outcomes for the group with AVN of the talus assessed with the mean Mazur ankle grading scores, improved significantly from 39 points (21 to 48) pre-operatively to 81 points (73 to 90) at the final follow-up (p = 0.01). In all eight revascularisations, bone healing was obtained without progression to talar collapse, and union was established in 11 of 12 vascularised arthrodeses at a mean follow-up of 34 months (24 to 58). MRI showed revascularisation of the talus in all patients. We conclude that a vascularised tibial graft can be used both for revascularisation of the talus and for the arthrodesis of the ankle in patients with OA secondary to AVN of the talus.
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Affiliation(s)
- N Kodama
- Shiga University of Medical Science, Tsukinowa Seta, Otsu, Shiga 520-2192, Japan
| | - Y Takemura
- Shiga University of Medical Science, Tsukinowa Seta, Otsu, Shiga 520-2192, Japan
| | - H Ueba
- Shiga University of Medical Science, Tsukinowa Seta, Otsu, Shiga 520-2192, Japan
| | - S Imai
- Shiga University of Medical Science, Tsukinowa Seta, Otsu, Shiga 520-2192, Japan
| | - Y Matsusue
- Shiga University of Medical Science, Tsukinowa Seta, Otsu, Shiga 520-2192, Japan
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Caterson EJ, Singh M, Turko A, Weaver MJ, Talbot S. The medial femoral condyle free osteocutaneous flap for osteomyelitis in pilon fractures. Injury 2015; 46:414-8. [PMID: 25464984 DOI: 10.1016/j.injury.2014.11.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 11/08/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND High energy tibial plafond (pilon) fractures are known to have a high rate of complication, particularly wound dehiscence and infection. Wound infection, requiring debridement of both soft tissue and bone can be especially challenging to reconstruct due to the combination of high load-bearing requirements within a thin soft tissue envelope. METHOD We present a case of a pilon fracture with a post-operative complication of wound dehiscence and infection necessitating bone debridement, ultimately resulting in chronic osteomyelitis. We used a medial femoral osteocutaneous free flap to provide vascularised structure to the defect. Included is a comprehensive literature review for the use of the MFC osteocutaneous free flaps in lower extremities. RESULTS This flap provided restoration of the medial column of the ankle. The use of vascularised bone resulted in rapid post-operative bony union. The vascularised bone flap was press fit into the defect ruling out the potential for further hardware related infections. We report follow up of over one year. CONCLUSION The MFC free osteocutaneous flap is a good option for small bone and soft tissue defects of lower extremities, especially in setting of chronic osteomyelitis. It can be custom fabricated and either fixated or press fit into a chronic pilon fracture cavity to obliterate dead space with vascularised bone. LEVEL OF EVIDENCE Level IV, retrospective case study.
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Affiliation(s)
- Edward J Caterson
- Divison of Plastic Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA.
| | - Mansher Singh
- Divison of Plastic Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Arthur Turko
- Divison of Orthopedics Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Michael J Weaver
- Divison of Orthopedics Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Simon Talbot
- Divison of Plastic Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA
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Bürger HK, Windhofer C, Gaggl AJ, Higgins JP. Vascularized medial femoral trochlea osteochondral flap reconstruction of advanced Kienböck disease. J Hand Surg Am 2014; 39:1313-22. [PMID: 24855965 DOI: 10.1016/j.jhsa.2014.03.040] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 03/27/2014] [Accepted: 03/27/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To describe the operative technique and report the results of 16 consecutive cases of arthroplasty for advanced Kienböck disease using a vascularized osteochondral graft from the medial femoral trochlea (MFT) with a minimum 12-month follow-up. METHODS Chart reviews of 16 cases of osteochondral MFT flap transfers for lunate reconstruction were performed in 2 institutions. Mean patient age was 35 years (range, 19-51 y). Preoperative Lichtman staging was 2 in 7 patients, 3a in 8 patients, and 3b in 1. Five of 16 patients had undergone a previous procedure for Kienböck disease (3 radial shortening osteotomies, 1 wrist denervation, and 1 distal radius vascularized bone grafting). Ulnar variance recorded at the time of the MFT reconstruction was negative in 8 patients, positive in 6 patients, and neutral in 2 patients. Follow-up data were recorded at a minimum of 12 months (average, 19 mo). Radiographic parameters recorded included preoperative ulnar variance, preoperative and final follow-up radioscaphoid angle, lunate height, lunate diameter, and the Stahl index and Lichtman stage. RESULTS Healing was confirmed in 15 of 16 reconstructed lunates. Lichtman staging remained unchanged in 10 patients, improved in 4 patients from grade 3a and 3b to 2, and worsened in 2 patients from grade 3a to 3b. All but 1 patient experienced improvement in wrist pain (12/16 complete relief; 3/16 incomplete relief). Wrist motion at follow-up averaged 50° extension and 38° flexion, similar to preoperative measurements. Grip strength at follow-up was 85% of the contralateral side. CONCLUSIONS Osteochondral vascularized MFT flaps provided a reliable means of lunate reconstruction in advanced Kienböck disease. This flap allowed resection of the proximal portion of the collapsed lunate and reconstruction with an anatomically analogous convex segment of vascularized cartilage-bearing bone. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Heinz K Bürger
- Privat Hospital Maria Hilf, Klagenfurt, Austria; Trauma Department, Unfallkrankenhaus, Austria; Department of Oral and Maxillofacial Surgery, University Hospital Salzburg, Austria; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Christian Windhofer
- Privat Hospital Maria Hilf, Klagenfurt, Austria; Trauma Department, Unfallkrankenhaus, Austria; Department of Oral and Maxillofacial Surgery, University Hospital Salzburg, Austria; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Alexander J Gaggl
- Privat Hospital Maria Hilf, Klagenfurt, Austria; Trauma Department, Unfallkrankenhaus, Austria; Department of Oral and Maxillofacial Surgery, University Hospital Salzburg, Austria; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - James P Higgins
- Privat Hospital Maria Hilf, Klagenfurt, Austria; Trauma Department, Unfallkrankenhaus, Austria; Department of Oral and Maxillofacial Surgery, University Hospital Salzburg, Austria; Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
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Mattiassich G, Marcovici LL, Dorninger L, Kerschhagl M, Buerger H, Kroepfl A, Larcher L. Reconstruction with vascularized medial femoral condyle flaps in hindfoot and ankle defects: a report of two cases. Microsurgery 2014; 34:576-81. [PMID: 24942331 DOI: 10.1002/micr.22286] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 05/29/2014] [Accepted: 06/05/2014] [Indexed: 11/11/2022]
Abstract
In this article, we report using free vascularized medial femoral condyle (MFC) flaps for reconstruction of bone defects and nonunion of the hindfoot and ankle in two patients. One patient had an open calcaneal fracture and hindfoot bone defect with impaired gait due to Achilles tendon functional loss. The second patient had nonunion with a chondral defect of the talus after a fall. Following uneventful recoveries, good objective and subjective results were achieved in terms of pain reduction and improved gait in both patients. No further operative intervention was needed during a 3-year follow-up period. The versatility of the corticoperiosteal graft from the MFC makes it an important reconstructive tool for addressing several major surgical problems of bony nonunion in the extremities, including posttraumatic reconstruction of hindfoot and ankle disorders.
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Affiliation(s)
- Georg Mattiassich
- Trauma Center Unfallkrankenhaus Linz, University Teaching Hospital of the Paracelsus Medical University Salzburg, Linz, Austria
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