Évaluation des séquelles du site donneur du lambeau libre de fibula. À propos de 42 cas consécutifs

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

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

Osteocutaneous flaps for head and neck reconstruction: A focused evaluation of donor site morbidity and patient reported outcome measures in different reconstruction options

With significant improvements in success rates for free flap reconstruction of the head and neck, attention has turned to donor site morbidity associated with osteocutaneous free flaps. In this review, we address the morbidity associated with harvest of the four most commonly used osteocutaneous flaps; the free fibula flap, the scapula flap, the iliac crest flap and the radial forearm flap. A comprehensive literature search was performed to identify articles relevant to donor site morbidity for these flaps. We assessed morbidity in terms of incidence of delayed healing, chronic pain, aesthetic outcomes, site specific complications and patient satisfaction/quality of life. Weighted means were calculated when sufficient studies were available for review. The radial forearm and free fibula flaps are associated with high rates of delayed healing of approximately 20% compared to the scapular (<10%) and iliac flaps (5%). The radial forearm flap has higher rates of chronic pain (16.7%) and dissatisfaction with scar appearance (33%). For the majority of these patients harvest of one of these four osteocutaneous does not limit daily function at long-term follow-up. The scapular osteocutaneous flap is associated with the lowest relative morbidity and should be strongly considered when the recipient defect allows. The radial forearm is associated with higher morbidity in terms of scarring, fractures, chronic pain and wrist function and should not be considered as first choice when other flap options are available.

Donor site morbidity after vascularized fibula free flap: gait analysis during prolonged walk conditions

The aim of this study was to determine the effect of vascularized fibula free flap (VFFF) harvest on gait variables during the six-minute walk test (6MWT). Eleven patients who had undergone VFFF harvest and 11 healthy peers participated in this case-control study. The main evaluation consisted of the collection of gait variables using the GAITRite system during three periods of the 6MWT: beginning (0-1min), middle (2:30-3:30min), and end (5-6min). The 6MWT was significantly shorter in the VFFF group than in the reference group (-31%, P<0.001). Most gait variables differed significantly between the groups for each period (P-value range 0.04-0.0004), including toe in/out on the operated side (P-value range 0.005-0.01). The increase in toe in/out on the operated side suggests a functional modification caused by an imbalance of the agonist-antagonist muscles. On comparison of the different periods, gait velocity decreased between the beginning and middle periods and increased between the middle and end periods in both groups. However, a significantly lower velocity between the beginning and end periods was found only for the VFFF group (P=0.026), suggesting an alteration in physical management. In conclusion, these results suggest that VFFF harvesting could alter gait and joint integrity.

Pediatric Microvascular Reconstruction: A Report from the Microvascular Committee

BACKGROUND: Free tissue transfer is an integral part of modern head and neck surgery in the adult population. Its use in the pediatric population has not been well described. Recently, there has been an increase in the application of these techniques in the pediatric population. The morbidity of free tissue transfer in small pediatric patients and its effect on growth has not been well described.

OBJECTIVE: To evaluate the utility of microvascular reconstruction techniques in the pediatric population.

STUDY DESIGN: A consensus study was performed by the microvascular committee of the American Academy of Otolaryngology-Head and Neck Surgery. Thirty active microvascular surgeons reviewed their databases to find patients less than 21 years of age who underwent free tissue transfer.

RESULTS: 49 free tissue transfers performed between 1999 and 2005. The mean age was 12.1 years (age range, 3–21). The types of flaps transferred were radial forearm (10), fibula (21), rectus abdominus (7), scapula (1), latissimus dorsi (3), groin (1), gracillus (4), and jejunum (2). Morbidity at the donor site was relatively minimal. Five patients developed wound breakdown. One of these required return to the operating room. Morbidity at the reconstructed site was also rare. Patients were followed for an average of 49 months (range, 1–131 months), and no problems were noted with growth at the donor or recipient sites.

CONCLUSIONS: Free flaps in the pediatric population have morbidity and survival similar to those in the adult population.

SIGNIFICANCE: While indications differ from those in the adult population, these techniques are viable and valuable and should be considered in the pediatric reconstructive paradigm.

Long-term donor-site morbidity after vascularized free fibula flap harvesting: Clinical and gait analysis

The aim of this study was to determine the clinical morbidity and changes in gait temporal spatial parameters after harvesting of a vascularized free fibula flap. This study included 11 patients (mean age: 52 ± 17 years) and 11 healthy controls (mean age: 50 ± 14 years). The patients were assessed between 5 and 104 months post surgery. The study consisted of a subjective functional evaluation with two validated clinical scores (Kitaoka Score and Point Evaluation System (PES) score), clinical and neurological examination of the legs, and evaluation of gait temporal spatial parameters while walking at a comfortable speed. The mean functional Kitaoka score was 78/100, and the mean PES score of 12.18 was considered average. At the time of the review, five patients had sensory disorders, two had toe deformities, and eight had pain at the donor site. The gait analysis showed that the patient's comfortable walking speed was significantly lower in comparison to that of the controls, and that stride length and cadence were reduced. In addition, most of the gait-specific parameters were significantly different. The donor leg displayed greater variability during walking. To reduce the risk of falling, this study revealed that the patients' gait pattern had changed as they took a more cautious approach during walking. Early rehabilitation is expected to help improve and/or restore the physical abilities of patients after harvesting of the vascularized free fibula flap.

Reconstruction of mandibular defects

Defects requiring reconstruction in the mandible are commonly encountered and may result from resection of benign or malignant lesions, trauma, or osteoradionecrosis. Mandibular defects can be classified according to location and extent, as well as involvement of mucosa, skin, and tongue. Vascularized bone flaps, in general, provide the best functional and aesthetic outcome, with the fibula flap remaining the gold standard for mandible reconstruction. In this review, we discuss classification and approach to reconstruction of mandibular defects. We also elaborate upon four commonly used free osteocutaneous flaps, inclusive of fibula, iliac crest, scapula, and radial forearm. Finally, we discuss indications and use of osseointegrated implants as well as recent advances in mandibular reconstruction.

Free fibula donor-site morbidity: clinical and biomechanical analysis

The aim of this study was the quantitative assessment of donor-site morbidity after fibula harvest. Ten patients were identified with a unilateral fibula harvesting and healthy contralateral side. The average follow-up time was 32.3 months. The study design included standardized questionnaire; morbidity point-evaluation system; orthopedic-biomechanical evaluation, including true ankle motion, clinical-functional American Orthopedic Foot and Ankle Society (AOFAS) hindfoot score, pedobarography, measurement of maximal voluntary isometric strength, and radiologic examination using an ankle osteoarthritis grading. Average donor-side morbidity score was low, with 2.6 points (range, 0 to 13). Average AOFAS hindfoot score was good, with 87.3 points (range, 74 to 100). Pedobarography showed significant decrease of the big toe pushup force. Isometric strength measurement showed significant reduction of the peroneus longus muscle. Discrete to mild medial ankle osteoarthritis was found in 70% of the cases. The overall donor-side morbidity was low, but an eversion torque deficit could initiate or support a progressive functional ankle instability and in long-term cause or accelerate a ligamentous secondary ankle osteoarthritis.

Long bone reconstruction with vascularized bone grafts

The vascularized fibula may be used for long bone reconstruction reliably and successfully. Since its description by Taylor, the fibula flap has evolved to solve a myriad of long bone reconstructive dilemmas. The flap is used routinely for non-unions, postoncologic resections, and congenital defects. It provides faster and more reliable union than nonvascularized grafts. When constructed in a double-barrel configuration, it offers the ability to bear weight. The vascularized fibula can be used to maintain growth by virtue of transferring the physis. The vascularized fibula is thus both the workhorse and thoroughbred in long bone construction.

Complete rehabilitation of the mandible following segmental resection

Segmental resection of the mandible leads to significant patient morbidity. Loss of mandibular support to the teeth, tongue and lip causes dysfunctional mastication, swallowing, speech, airway protection and oral competence. Patients also suffer disfigurement following segmental mandibulectomy because the mandible is an important aesthetic landmark. The degrees to which dysfunction and disfigurement occur depend both on the location of the mandibular segment removed and the amount of surrounding soft tissue excised. Between January 1985 and December 2004, 780 fibula osteoseptocutaneous flaps have been used for head and neck reconstruction at the Chang Gung Memorial Hospital, Taiwan. The fibula flap has proven to be the bony flap of choice because it has a lengthy bicortical segment of bone available, a reasonably long vascular pedicle, large diameter vessels, good bone quality, and is easily contoured with multiple osteotomies. The flap can be harvested while ablation is being performed. In addition, a reliable, mobile, thin skin component can always be included to address the soft tissue reconstructive requirements. A chimeric design employing a portion of the soleus muscle can provide further reconstructive options. Ideally complete rehabilitation of the mandible involves placement of titanium osseointegrated implants, which allow dental restoration. Primary placement of implants is preferred in patients without cancer. Selection of candidates to receive osseointegrated implants is paramount. The temporomandibular joint remains a challenge to reconstruct adequately.