Free Medial Femoral Condyle Flap for Reconstruction of Scaphoid Nonunion: A Systematic Review

Proximal Olecranon Free Flap for Cystic Scaphoid Nonunion: An Anatomical Feasibility Study

BACKGROUND

The treatment of scaphoid nonunion is challenging, with one approach aiming to provide vascularized bone to encourage union. While the iliac crest and medial femoral condyle are well-described donor sites for osseous flaps, they require violation of a separate limb and confer particular donor site morbidities. We investigate the viability of using a proximal olecranon osseous free flap in the setting of scaphoid nonunion.

METHODS

Ten proximal olecranon free flaps were harvested in cadaveric specimens, and the length of the pedicle, diameter of the pedicle, number of perforators and quality of bone graft harvested were recorded. Furthermore, a volar approach to the scaphoid was performed, and the shortest distance from the scaphoid to the radial artery noted, to determine whether utilization of the olecranon free flap was possible without grafting.

RESULTS

The posterior ulnar recurrent artery [PURA] was present in all specimens. The median pedicle length from take-off of the PURA to the olecranon flap was 65 (62.2-71.0) mm. The number of visible periosteal perforators varied between 1 and 2 per specimen. The median diameter of the main perforator before dividing into subperiosteal branches was 2 (2.1-2.5) mm. The quality of the bone graft harvested was mainly assessed as good (n = 5) or moderate (n = 4). The mean shortest distance from scaphoid to radial artery was 10 mm.

CONCLUSIONS

The olecranon free flap is a suitable alternative source of vascularized bone for scaphoid nonunion.

Vascularized Bone Reconstruction for Recalcitrant Clavicular Nonunion: A Systematic Review of the Literature

PURPOSE

Clavicular nonunion is an uncommon complication with a significant impact on quality of life and can be difficult to manage. In recalcitrant cases, or situations unfavorable for take of nonvascularized grafts, vascularized osseous reconstruction may be utilized. Several donor sites for such flaps have been described, with each associated with unique benefits and drawbacks.

METHODS

A systematic review utilizing MEDLINE and Embase databases was performed for cases of vascularized bone reconstruction for clavicle nonunion.

RESULTS

Twenty-six papers met inclusion, comprising 67 patients. Mean age was 43.1 years, across 32 male and 35 female patients. Mean period of nonunion was 43.2 months in the fibular group, 42.0 months in the medial femoral condyle (MFC), and 12 months in the rib flap group. Patients had undergone a mean of 2.67 prior operations at the time of vascularized osseous flap; a proportion of patients had undergone prior locoregional radiotherapy (9/26) or been complicated by infection (12/22). Radiological union was achieved in 95.2% (20/21) of fibular flaps, 95.6% (25/27) of MFC flaps, and 66.7% (2/3) of rib flaps. Mean time to union was 10.6 months for the fibular group, 7.8 months for the MFCs, and 4.0 months for the rib flaps. Complications occurred in 55.6% (20/36) of patients having fibular flaps, 26.1% (6/23) of MFC flaps, and 50% (2/4) of rib flaps.

CONCLUSIONS

All osseous flaps yielded similar and consistent rates of union when used to reconstruct defects of the clavicle. Higher complication rates, particularly donor site morbidity, were noted with fibula and rib flaps when compared to the MFC.

Surgical Treatment of Scaphoid Fractures: Recommendations for Management

Background: Several operative treatments exist for scaphoid fractures, varying by approach (e.g., ercutaneous, volar, or dorsal), implant type (e.g., screw or Kirschner wire), and bone raft choice (e.g., none, nonvascularized, or vascularized). Many previous systematic eviews and meta-analyses have investigated outcomes following different surgicalÚpproaches, the use of vascularized versus nonvascularized bone graft for scaphoidßracture nonunions, and treatment for specific fracture patterns. However, given the advancements n scaphoid fracture treatment in recent years, there is a need for updated treatment recommendations hat would be beneficial to hand surgeons. Purpose: We present a comprehensive review of the operative treatment of scaphoid fractures based on recent literature and propose a unified treatment algorithm for managing these fractures. Methods: The English-language literature was searched from 2002 to 2023 for high evidence level (e.g., randomized trials), review, and meta-analysis articles with the following search terms: "scaphoid, "u8220"scaphoid" AND "nonunion, " and "scaphoid" AND "malunion. " Each article was creened by the authors to determine the scaphoid fracture scenario addressed and ubsequent treatment recommendations. The findings from article reviews were then rganized by scaphoid fracture types in this manuscript. Results: A total of 95 pertinent articles were ultimately selected and used as the basis for reviewing different scaphoid fracture scenarios. A treatment algorithm was then proposed based on literature review. Conclusion: This summary of the recent literature can guide hand surgeons in addressing scaphoidßractures. Future research in scaphoid fracture treatment, particularly for nonunions, would be most beneficial n the form of systematic review, meta-analysis, or multicenter prospective randomized clinical trials. Level of Evidence: IV.

Vascularized Reconstruction of Recalcitrant Clavicular Nonunion with the Medial Femoral Condyle Free Flap: A Systematic Review of the Literature

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.

Free vascularized bone graft from the lateral epicondylar region of the humerus for treatment of scaphoid nonunion

BACKGROUND

Free vascularized bone grafting (FVBG) has become one of the essential methods for treating scaphoid nonunion complicated by avascular necrosis. However, commonly used bone graft, including the medial femoral condyle bone graft and iliac crest bone graft, still present challenges such as a high rate of donor site complications and variations of vascular pedicle. In this study, we have introduced a novel bone graft-the lateral humeral condyle bone graft with the posterior branch of the radial collateral artery (PBRCA) as the vascular pedicle-as an alternative option, with the aim of overcoming some of the limitations of previously described FVBG procedures.

METHODS

Nine patients who had a nonunion of the scaphoid that had been present for an average of 16.8 months (range 9-35 months) were managed with use of a free vascularized bone graft obtained from the lateral humeral epicondylar region. Avascularity of the scaphoid, as assessed on preoperative magnetic resonance imaging and intraoperative bone marrow puncture test. Postoperatively, regular X-ray and CT scans examinations were conducted to assess the progress of fracture healing. Active motion of the wrist, and grip strength recovery were measured periodically. Wrist pain was graded using the Visual Analogue Scale (VAS), while wrist joint functionality was evaluated using the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) questionnaire and the Patient-Rated Wrist Evaluation (PRWE) scale. The elbow functional outcome was evaluated by the Mayo Elbow Performance Score (MEPS).

RESULTS

All of nine lateral humeral epicondylar bone grafts were successfully harvested. The blood supply of the graft during surgery was excellent in six cases and good in three cases. The size of the bone grafts ranges from 1.0 cm × 0.5 cm × 0.5 cm to 2.0 cm × 1.0 cm × 0.5 cm. The average vascular pedicle length was 3.4 cm (range 2.0-6.0 cm). There were no early complications in either the donor or recipient areas after surgery. Union was successfully achieved in all nine patients, with an average time to union of 14.3 weeks (range 11-20 weeks) after surgery. The average follow-up period was 31.2 months (range 26-40 months). At the final follow-up, the average palmar flexion, dorsal extension, radial deviation, and ulnar deviation angles of the injured wrist joint were 56.1° (range 45°-70°), 56.1° (range 40°-80°), 10.6° (range 5°-20°), and 22.2° (range 15°-35°), respectively, which reached 79.0%, 82.1%, 59.4%, and 72.8% of the average activity of the contralateral normal side. The average grip strength of the injured side was 35.2 kg (range 22-51 kg), which was equivalent to 81.3% of the average grip strength of the contralateral side. The average VAS score for wrist joint pain was 1.0 point (range 0-2 points); the Quick-DASH score was 9.2 points (range 6-18 points); and the PRWE score was 13.1 points (range 9-16 points), the Mayo Elbow Performance Index was 100 points (range 100-100 points). One patient reported a feeling of friction during movement but no pain. One patient reported numbness in the donor site. One patient complained of pain when applying force to the scar in the donor area. During the follow-up period, these complications showed improvement without any treatment.

CONCLUSION

The FVBG technique has been considered an effective method for treating scaphoid nonunion with avascular necrosis. Compared to traditional FVBG, the lateral humeral epicondylar bone graft exhibits a higher union rate, fewer complications, and easier accessibility, making it a favorable choice.

Evolution of free flap reconstruction in the upper extremity: perspective from a tertiary plastic and reconstructive institution

Soft tissue reconstruction of the upper extremity requires consideration of wound bed status, varied anatomic composition, future function and tissue match, whether in thickness, pliability or involvement of other tissue components. Of the options available, microvascular free tissue flaps allow maximal customizability with the avoidance of long-term donor site morbidity. Free tissue transfers have evolved, given increased surgical proficiency, from direct vessel-based flaps to septocutaneous vessel-based flaps, to musculocutaneous perforator flaps, and most recently to free-style free flaps. With increases in technical complexity come limitless alternatives. We documented the progression of free flap upper extremity reconstruction in recreating form and function of the upper extremity. The foundations laid should allow surgeons the freedom and versatility to choose the most faithful restoration of the defect and produce the best functional and aesthetic results.

Non-vascularised corticocancellous (tricortical) iliac bone graft longer than 3 cm for non-union after failed surgical treatment

PURPOSE

We hypothesised that traditional iliac tricortical bone grafts (no vascularised) still have a reasonable role in promoting satisfactory bony healing in non-union defects of certain sizes. Here, we report the clinical/radiological outcomes through a retrospective case series.

METHODS

We screened 74 patients with definitive non-union in the long bones of the upper extremities who visited the outpatient department from 2008 to 2018. Among these patients, 25 who met our inclusion/exclusion criteria were investigated.

RESULTS

The mean age was 51.92 years, and there were 12, 9, 1, and 3 lesions of the radius, ulna, clavicle, and humerus, respectively. The tools for primary fixations were plate and intramedullary nails in 24 and 1 patients, respectively. Six patients presented with atrophic non-union. The mean period from a previous surgery was 6.84 months. The mean defective bone sizes were 1.81 and 3.50 cm pre-debridement and post-debridement, respectively. All devices had locking plates longer than the previous plate, and the graft was concurrently fixed by screws in three patients. At a mean of 15.92 weeks after the revision surgery, all patients experienced union. At the final follow-up, the clinical outcomes were satisfactory. No significant differences in clinical outcomes were found according to the lesion, type of non-union, period from the previous surgery, or harvest length of the iliac bone.

CONCLUSIONS

If the proper indications and some technical aspects are considered, a non-vascularised iliac bone graft longer than 3 cm could still be a reasonable option for treating diaphyseal non-union of the upper extremities.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Correlation between Risk Factors and Healing Times in Long Bone Nonunions Treated with Corticoperiosteal Flap from the Medial Femoral Condyle

BACKGROUND

 The rate of fracture nonunion varies depending on the anatomical site. Numerous procedures have been proposed to treat recalcitrant nonunions. The vascularized medial femoral condyle corticoperiosteal free flap (MFCCFF) is increasingly used in nonunions with small bone loss.The percentage of success of the MFCCFF is high but the factors involved in delayed bone healing or failure of this technique or the contraindications are not described in the literature.This multicentric study aims to identify and report the different factors involved in determining the time of bone healing in the treatment of atrophic nonunion of long bones with the vascularized medial MFCCFF.

METHODS

 All patients who underwent vascularized medial MFCCFF from January 2011 to December 2020 for the treatment of recalcitrant atrophic nonunions of long bones. Patients were reviewed at 2 and 6 weeks, and 3, 6, and 12 months postoperatively and evaluated by physical and radiographic examinations and patient-reported outcome measures.

RESULTS

 The final study population comprised 59 patients with a mean follow-up of 26.2 ± 7.6 months, a rate of bone healing of 94.9% with a mean radiographic bone healing time of 4.1 ± 1.3 months, and low morbidity of the donor site. Diabetes mellitus, a body mass index (BMI) ≥30 kg/m2, and ≥2 previous surgeries on the fracture site were factors predicting timing for bone healing at the multivariate analysis.

CONCLUSION

 This study demonstrates the MFCCFF as an effective and safe procedure for the treatment of the recalcitrant atrophic nonunion of long bones. An association was found between the lengthening of bone healing time and a high BMI, presence of ≥2 previous surgical interventions, and diabetes mellitus, indicating these comorbidities as risk factors (not absolute contraindications) for this microsurgical treatment. So, to our knowledge, the MFCCFF could be the first-choice treatment for atrophic nonunion of long bones.