Vascularized ulnar periosteal pedicled flap for forearm nonunion in children

Lateral Humeral Pure Periosteal Flap for Nonunion of Humerus Pathologic Fracture in an Elderly Patient: A Case Report

Pathological fractures associate a complex tumoral microenvironment that can culminate in a complex bone nonunion. Surgical treatment with vascularized periosteal flaps has resulted into an excellent option in children because of their angiogenic and osteogenic properties; nonetheless, it has been scarcely reported in the adult. We present a case report that challenges the classical concept of not using pure periosteal flaps in the adult, widening surgical options for nonunion. A 67-year-old male patient diagnosed with multiple myeloma presented nonunion after pathological fracture in the left humerus. He was treated with a pedicled lateral humeral pure periosteal flap based in the posterior collateral radial vessels. It measured a 6 cm × 4 cm and was pedicled proximally, wrapping it around the nonunion site after compression plate osteosynthesis. Post operatory was uneventful and the patient was followed 9 months after surgery. Periosteal callus and bony bridges were formed 4 months after surgery. This case avoids the need of a free flap such as the Sakai, with conservation of the advantages of the cambium layer such as demonstrated in children.

Vascularized Deep Femoral Periosteal Flap: Anatomical Study and Clinical Application in Congenital Pseudarthrosis of the Tibia in Two Cases

BACKGROUND

Vascularized periosteal transplants have proven to be highly effective and rapid in promoting bone healing in biologically complex nonunions in children, with several reported donor sites. This study aimed to assess the feasibility of harvesting a vascularized diaphyseal femoral periosteal flap (VDFPF) from cadavers and evaluate its clinical application in two cases of bilateral congenital pseudarthrosis of the tibia.

METHODS

This study investigated the periosteal branches of the deep femoral vessels (DFV) supplying the femoral diaphysis in 19 previously latex-injected cadavers. The femur was divided into four segments. The distance from the midpoint of the inguinal ligament to the origin of the DFV and the number of periosteal branches were recorded. The vascularized diaphyseal femoral periosteal flap (VDFPF) was used to treat one side in two patients with bilateral congenital pseudarthrosis of the tibia (aged 14 and 2 years).

RESULTS

The DFV's origin was located at a mean of 4.2 cm (range 2.8-8.5 cm) distal to the midpoint of the inguinal ligament. In 15 cases, the DFV coursed adjacent to the second and third quarters of the femoral shaft, providing a mean number of 5 (range 4-8) periosteal branches, allowing for the harvesting of a new pure vascularized periosteal flap. Healing of congenital pseudarthrosis of the tibia occurred within 3 months in both patients, with no donor or recipient site complications at the final follow-up of 13 months.

CONCLUSIONS

The VDFPF may be an effective periosteal transplant and a viable alternative to other large free periosteal transplants used in children for treating complex non-unions, especially when tibial and fibular donors are not available. Bone union was fast compared to other techniques used to treat these challenging cases.

Vascularized Periosteal Grafts for Bone Union in Children: A Systematic Review

BACKGROUND

The periosteum is the main organ responsible for bone regeneration. Vascularized Periosteal Grafts (VPG) have demonstrated exceptional efficacy and speed in facilitating bone union among children with challenging bone healing conditions. Despite their promising results, the overall impact of these interventions has yet to be comprehensively evaluated through systematic review. This systematic review aimed to provide comprehensive insights into bone union outcomes and complications related to the use of VPG in children.

MATERIALS AND METHODS

MEDLINE/PubMed, Embase, Web of Science, Clinicaltrials.gov, and Cochrane Library were searched from database inception to September 2023 and screened for relevant studies. Data were collected regarding patient demographics, disease, treatment, anatomical location, graft used, donor and receptor vessels, skin paddle monitoring, follow-up duration, time to union, consolidation, and complications. The correlation between age and bone union was assessed using Pearson and Spearman correlation coefficients, as appropriate. Study quality was assessed using the Methodological Index for Non-randomized Studies Criteria.

RESULTS

A total of 15 studies involving 135 patients were included. All the studies were classified as Level 4 evidence. The mean MINORS score was 5.1 ± 1. The aim of the VPG was nonunion treatment in 90 patients (67%), nonunion prevention in 35 patients (26%), and bone union acceleration in 10 patients (7%). The origin of the bone union problem was traumatic in 59 cases (44%), congenital pseudoarthrosis of the tibia or fibula in 48 patients (35%), oncologic in 23 patients (17%), and infectious in 5 patients (4%). Nine different sources of periosteal flaps were used to enhance bone union. Bone union rate was 96% with a mean time of 4.2 months (range 1-18 months). Spearman test showed a non-statistically significant negative correlation between age and bone union time (r = -0.3, p = 0.759).

CONCLUSIONS

VPGs are a safe and reliable treatment for promoting bone union, especially in the context of complex pediatric bone-healing challenges.

Microsurgery in pediatric upper limb reconstructions: An overview

The use of microsurgery has spread during the last decades, making resolvable many complex defects considered hitherto inapproachable. Although the small vessel diameter in children was initially considered a technical limitation, the increase in microsurgical expertise over the past three decades allowed us to manage many pediatric conditions by means of free tissue transfers. Pediatric microsurgery has been shown to be feasible, gaining a prominent place in the treatment of children affected by limb malformations, tumors, nerve injuries, and post-traumatic defects. The aim of this current concepts review is to describe the more frequent pediatric upper limb conditions in which the use of microsurgical reconstructions should be considered in the range of treatment options.