The arterial anatomy of the medial femoral condyle and its clinical implications

Medial Femoral Condyle Periosteal Free Flap for Bone Coverage Following Debridement of Intermediate-Stage Osteoradionecrosis of the Jaw

STUDY DESIGN

Case report. Osteoradionecrosis (ORN) of the jaw is a potentially devastating consequence of head and neck irradiation. The progression of ORN can lead to loss of bone, teeth, soft tissue necrosis, pathologic fracture, and oro-cutaneous fistula. Reconstructive surgery has mostly been reserved for late-stage disease where segmental resections are frequently necessary. Evidence is emerging to support earlier treatment in the form of debridement in combination with soft tissue free flaps for intermediate-stage ORN. The authors present a case of a 76-year-old male with persistent Notani 2 ORN of the mandible, treated with surgical removal of all remaining mandibular teeth, transoral debridement of all necrotic mandibular bone, and bone coverage with a left medial femoral condyle (MFC) periosteal free flap based on the descending genicular artery. Treatment was uneventful both intraoperatively and postoperatively. Since surgery (15 mo) the patient has remained free from clinical and radiologic signs of ORN. The MFP periosteal free flap provided an excellent result with minimal surgical complexity and morbidity in this case. Such treatment at an intermediate stage likely results in a reduction in segmental resections, less donor site morbidity, less operative time, less overall treatment time, and possibly fewer postoperative complications compared with the status quo.

Genicular Artery Embolization: A Review of Essential Anatomic Considerations

Genicular artery embolization is increasingly recognized as a safe and effective treatment option for symptomatic knee osteoarthritis and recurrent hemarthrosis after total knee arthroplasty. Genicular arteries are an essential contributor to vascular supply for the knee joint and demonstrate considerable variability. Familiarity with the anatomy and common variations is critical for preprocedural planning, accurate target selection, and minimizing adverse events in transarterial embolization procedures. This review aimed to provide a detailed discussion of the genicular artery anatomy that is relevant to interventional radiologists performing genicular artery embolization.

Reconstruction of the ulnar artery in Guyon's canal with an arterial graft: Anatomical study

Ulnar artery thrombosis in Guyon's canal can lead to vascular insufficiency in the fingers. The recommended treatment is resection and reconstruction of the pathological area. A bypass may be necessary, which may be venous or arterial. Arterial bypasses have better long-term patency; however, they are a source of donor-site complications. We carried out an anatomical study on 11 upper limbs and 7 lower limbs from cadavers to identify a technically accessible arterial graft, of a diameter suitable for bypassing the ulnar artery in Guyon's canal and with acceptable scar sequelae (few predicted postoperative complications, discreet size and/or location of scar). Three grafts were considered: anterior interosseous artery, radial recurrent artery and descending genicular artery. The various grafts were dissected and harvested from cadaver specimens, then their lengths and diameters were measured. The diameter of the candidate grafts was compared to the diameter of the distal ulnar artery. The diameter of the descending genicular artery matched the ulnar artery better than the radial recurrent artery or the anterior interosseous artery (103% vs 44% and 67%, respectively). Mean graft length was 6.6 cm. The anatomical configuration of the descending genicular artery allowed Y-shaped bypasses to be performed. Harvesting this artery appears to cause little damage and allows bypasses up to 6 cm to be performed. Despite its smaller diameter making it necessary to perform a microvascular size adjustment, the anterior interosseous artery is a candidate graft because it is long enough (119 mm) and located near the surgical site. LEVEL OF EVIDENCE: V.

Vascularized Medial Femoral Condyle Flap Reconstruction for Osseous Defects of the Hand and Wrist

Vascularized bone flaps from the descending genicular artery system are versatile and effective for the use of recalcitrant nonunions from the tubular bones of the hand to the long bones of the upper extremity. Familiarity with the vascular pedicle, various techniques of harvest and inset, and skin paddle harvest and application are essential for the reconstructive surgeon.

Medial Femoral Condyle Corticoperiosteal Flap for Failed Total Wrist Fusions

Background  Recalcitrant nonunion following total wrist arthrodesis is a rare but challenging problem. Most commonly, in the setting of failed fusion after multiple attempts of refixation and cancellous bone grafting, the underlying cause for the failure is invariably multifactorial and is often associated with a range of host issues in addition to poor local soft-tissue and bony vascularity. The vascularized medial femoral condyle corticoperiosteal (MFC-CP) flap has been shown to be a viable option in a variety of similar settings, which provides vascularity and rich osteogenic progenitor cells to a nonunion site, with relatively low morbidity. While its utility has been described for many other anatomical locations throughout the body, its use for the treatment of failed total wrist fusions has not been previously described in detail in the literature. Methods  In this article, we outline in detail the surgical technique for MFC-CP flap for the management of recalcitrant aseptic nonunions following failed total wrist arthrodesis. We discuss indications and contraindications, pearls and pitfalls, and potential complications of this technique. Results  Two illustrative cases are presented of patients with recalcitrant nonunions following multiple failed total wrist fusions. Conclusion  When all avenues have been exhausted, a free vascularized corticoperiosteal flap from the MFC is a sound alternative solution to achieve union, especially when biological healing has been compromised. We have been able to achieve good clinical outcomes and reliable fusion in this difficult patient population.

Vascularized Bone Graft Reconstruction for Upper Extremity Defects: A Review

Upper extremity reconstruction may pose clinical challenges for surgeons due to the often-critical, complex functional demands of the damaged and/or missing structures. The advent of vascularized bone grafts (VBGs) has aided in reconstruction of upper extremity (UE) defects due to their superior regenerative properties compared with nonvascularized bone grafts, ability to reconstruct large bony defects, and multiple donor site options. VBGs may be pedicled or free transfers and have the potential for composite tissue transfers when bone and soft tissue are needed. This article provides a comprehensive up-to-date review of VBGs, the commonly reported donor sites, and their indications for the treatment of specific UE defects.

Monitor selection according to the defect location in the medial femoral condyle flap. Injury 2022;53:4139-4145. [PMID: 36192200 DOI: 10.1016/j.injury.2022.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

Medial femoral condyle(MFC) flap is frequently used in hand reconstruction, but like other buried flaps, MFC is not easy to monitor and follow.In this study, we present our adipofascial and periosteal tissue technical modifications and results for MFC free flap monitoring and compare different monitoring methods.

METHODS

Twenty one patients with wrist bone or metacarpal defect reconstructed with MFC flap were included in the study. Adipofascial tissue in wrist defect and periosteal tissue in metacarpal defect were selected as MFC flap's monitor. Patient characteristics, type of injury, flap size, early or late-period complications, flap elevation time,satisfaction scale, visual analogue scale (VAS) and postoperative X-ray view were noted.

RESULTS

There were 3 female and 18 male patients in the study. The mean age of the patients was 50.8 (38-68). The elevation times of flaps with adipofascial and periosteal monitors were 48 and 53.3 min, respectively. The satisfaction scale averages for the adipofascial and periosteal monitor groups were 3.5 and 3.54, respectively. The VAS scores of the adipofascial and periosteal monitor groups were 2.9 and 3.9, respectively. The flap sizes with periosteal and adipofascial monitors were 10.48 cm³ and 1.36 cm³, respectively. There was no statistically significant difference between flap elevation, VAS, and satisfaction scale (>0.05). There was a statistically significant difference in flap sizes. (<0.05) CONCLUSION: MFC free flap is frequently used in wrist and metacarpal reconstruction. Monitor selection according to the defect area positively affects the prognosis of the flap in the postoperative period.

Acute Thumb Reconstruction With Medial Femoral Condyle and Radial Forearm Free Flaps: A Case Report

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.

Anatomical implications of the subvastus approach on major vascular injury during a distal femoral osteotomy: a computed tomographic venography study

PURPOSE

This study evaluated major vascular injury risk in distal femoral osteotomy (DFO) via the subvastus approach and examined the relationship between the posterior border of the vastus medialis (VM) and the superficial femoral artery (SFA) and vein (SFV).

METHODS

Eighty limbs from 80 patients were evaluated using lower extremity computed tomographic venography. The positional relationship between the VM, SFA, and SFV was evaluated by measuring the angle between each structure and the horizontal reference point (VMA: VM angle, FAA (femoral arterial angle), FVA (femoral venous angle) and the distance between VM and the SFA and SFV (VMAD: VM-arterial distance, VMVD: VM-venous distance) in each axial slice (0/10/20/30/40 mm) proximal to the level of the superior patellar margin. The proximity of the posterior border of the VM and the SFA/SFV as a vertical distance, measured between the slice of the superior border of the patella and the slice where the posterior border of the VM contacted the SFA was evaluated. Single and multiple regression analyses were performed using the vertical distance as the objective variable.

RESULTS

As the slice shifted proximally, the VMA significantly increased (24.9 ± 8.5, 36.3 ± 8.8, 47.4 ± 11.8, 59.9 ± 14, 70.3 ± 13.7 degrees, respectively, p < 0.001 between all slices) and moved posteromedially from a medial direction. FAA (94.2 ± 7, 86.9 ± 9.2, 78.4 ± 9.7, 71.4 ± 9.8, 66.6 ± 10.5 degree, respectively, p < 0.001 between all slices) and FVA (100.6 ± 4.9, 98.3 ± 5.9, 93.7 ± 7.5, 88 ± 9.2, 81.1 ± 10.5 degrees, respectively, p < 0.001 between all slices) decreased and moved from a posterolateral to a posteromedial direction, while VMAD (35.4 ± 7.8, 24.1 ± 7.3, 14.3 ± 6, 8.4 ± 7, 6.2 ± 6.3 mm, respectively, p < 0.001 between all slices) and VMVD significantly decreased (42.7 ± 7.3, 32 ± 7.4, 22.4 ± 6.8, 14.5 ± 10.6, 8.7 ± 7.1 mm, respectively, p < 0.001 between all slices). The average vertical distance was 36 ± 9.3 mm (range 18.6-61.5 mm). The body height and the patellar length significantly affected the vertical distance.

CONCLUSION

The posterior border of the VM shifted posteromedially from distal to proximal and contacted the SFA at an average of 36 mm from the suprapatellar border. Surgeons should be aware of the risk of major vascular injury during exposure and osteotomy.

LEVEL OF EVIDENCE

Case series, Level IV.

Vascular and Bone Regeneration of the Donor Site After Corticoperiosteal Flap From the Medial Femoral Condyle

Background: The aim of this study was to evaluate the morbidity and regeneration of descending genicular artery and bone on the donor site, the medial condyle of the femur, after harvesting the corticoperiosteal flap and to report the clinical, functional, and radiographic outcomes of the treatment of atrophic nonunions of upper limb with corticoperiosteal vascularized flap at 5-year follow-up. Methods: From January 2011 to January 2018, 36 patients (average age of 45.8 years) were enrolled and evaluated with clinical and radiographic follow-up (average time of 66 months). In 20 patients, magnetic resonance angiography was also performed preoperatively and postoperatively to investigate the fate of the descending genicular artery after harvesting the corticoperiosteal flap. Results: Radiographic evaluation demonstrated a success rate of 94.4% (average time of bone healing of 5.2 months). At the recipient site, clinical evaluation showed excellent results in 75% to 80% of cases, and at the donor site, no statistical differences were found between before and after surgery clinical condition. In all patients who underwent magnetic resonance imaging, images showed a complete recovery of the blood supply of the medial femoral condyle. Conclusions: Medial condyle corticoperiosteal flap represents a valid choice for the treatment of upper limb nonunions. This technique brings a very low morbidity on the donor site, with complete restoration of blood supply and bone tissue. The limit of this flap is its low mechanical support, which suggests performing this technique especially for the treatment of upper limb nonunions.

Treatment of Recalcitrant Femoral Shaft Nonunion With Medial Femoral Condyle Pedicled Autograft: Technical Trick

SUMMARY

Nonunited fractures of the femoral shaft and distal femur are usually successfully addressed with stabilization with or without autogenous bone grafting. For the small subset of these problems that prove recalcitrant to front-line treatment, a pedicled medial femoral condyle (MFC) bone flap can provide a source of vascularized autograft with minimal donor site morbidity. The MFC has gained recent widespread adoption as a free vascularized bone transfer, and here, we present a surgical technique and retrospective analysis of patients treated with a pedicled MFC technique. This serves as a useful treatment option for these difficult problems and may be especially helpful in low resource environments or where microsurgical anastomosis is not feasible.

Topographic Anatomy and Clinical Impact of Vascular Foramen on the Trochlear Groove of Adult Human Dry Femora

Objective

In this study, we aimed to assess the topographic anatomy and clinical impact of the vascular foramen on the trochlear groove of adult human dry femora.

Materials and methods

The incidence, shape, size, and location of the foramen present on the trochlear groove of the distal femur were studied using 33 adult human dry femora of unknown age and gender at the Department of Anatomy at Nowshera Medical College, Nowshera, Pakistan. Using a divider and scale, the incidence and structure of the vascular foramen in the trochlear groove were examined and its position in relation to the trochlear groove's upper and lower articulating edges was recorded.

Results

Out of 33 femora, 20 (60.6%) were right-sided and 13 (39.4%) were left-sided. All the foramina had round morphometry. In each of the 33 adult human dry femora, 15 (45.5%) had a single trochlear vascular foramen. One solitary trochlear vascular foramen was found in eight (53.3%) of the left femora and seven (46.7%) of the right femora. The diameter of each trochlear vascular foramina was about 2.5-4.5 mm with a mean diameter of 3.5 mm. Trochlear groove upper margin and foramen were 1.75-2.5 cm apart, whereas the lower margin was 0.5-01 cm apart. On average, foramen was 2.2 cm away from the upper margin, and 0.8 cm away from the lower margin. In the midline, nine (60%) trochlear vascular foramina were found, with five (55.5%) resting on the trochlear groove lower margin, and four (44.5%) lying mid-way at varying places from the upper and lower margins. The left of the centerline had six (40%) of the trochlear vascular foramen, whereas no trochlear vascular foramen was seen on the right side of the midline.

Conclusions

Based on our findings, a significant segment of our population has trochlear vascular foramen present on the trochlear groove as the rate of occurrence of this was found to be 45.5%. The trochlear groove center has the most foramen, accounting for 60% of all the foramen.

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

BACKGROUND

 The free medial femoral condyle (MFC) bone flap is an attractive option for reconstruction of scaphoid nonunion utilizing vascularized bone to augment bony healing, especially in cases of failed prior treatment or osteonecrosis. This review aims to determine the role and reliability of the free MFC flap for treatment of scaphoid nonunion.

METHODS

 A search of electronic databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles examining free MFC bone flaps for treatment of scaphoid nonunion were included for analysis. Outcomes of interest included flap failure, postoperative union rate, time to union, carpal indices, functional outcomes, and complications.

RESULTS

 Twelve articles met the inclusion criteria. A total of 262 patients underwent free MFC flaps for treatment of scaphoid nonunion. The most common site of nonunion was the proximal pole of the scaphoid with 47% of patients receiving prior attempts at operative management. Overall bony union rate was 93.4% with a mean time to union of 15.6 weeks. There were no flap failures reported. Improvements in carpal indices including scapholunate (p < 0.0004), radiolunate (p < 0.004), lateral interscaphoid angles (p < 0.035), and revised carpal ratio height (p < 0.024) were seen postoperatively. Visual analog scale improved postoperatively from 6.5 to 2.3 (p < 0.015). Postoperative complications were observed in 69 cases (26.3%), with 27 patients (10.3%) requiring further operative intervention. However, no major donor or recipient site morbidity was appreciated.

CONCLUSION

 MFC flaps provide a highly versatile and reliable option for reconstruction of scaphoid nonunion with excellent bony union rates and acceptable complication rates. The present literature suggests that MFC reconstruction of scaphoid nonunion restores radiocarpal anatomy and improves wrist function without causing significant donor or recipient site morbidity.

Addressing common orthopaedic calamities with microsurgical solutions

Reconstructive microsurgery has been an essential aspect of orthopaedic surgery and extremity reconstruction since the introduction of the operating microscope in the mid-20^th 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.

"Use of pedicled corticoperiosteal flap in resistant cases of distal femur non-union: Our learning experience"

INTRODUCTION

Nonunion of distal femur is a complex problem with the added burden of poor bone stock, osteopenia, and joint contracture. Various procedures are described ranging from osteosynthesis using auto/allograft, to use of mega prosthesis. Use of vascularized corticoperiosteal flap based on descending genicular artery and superomedial genicular artery is a new technique to provide living vascular graft for the nonunion site. Although few free corticoperiosteal flap reconstructions have been reported in the past for these distal femur nonunions, this flap has seldom been used as a pedicled variety. Through this article, we aimed at highlighting the main obstacles faced while using pedicled corticoperiosteal flap for these patients given its dearth in literature.

MATERIALS AND METHODS

Five patients of at least two previously failed osteosynthesis for distal femur fracture non-union were selected for performing corticoperiosteal flaps. The intraoperative findings that were both favourable and unfavourable were documented along with the outcome of procedure in the form of callus formation or fracture healing.

RESULTS

Dissection of the flap was more tedious in these cases than when performed for a different indication in a virgin territory. However, despite the previous trauma resulting in decreased pliability of their vessels, all flaps were viable at the end of procedure with favourable cosmetic and functional outcomes.

CONCLUSION

Despite the complexities in flap harvest, use of the less morbid and technically easier "Pedicled corticoperiosteal flap" and osteosynthesis along with the auto technique is a worthwhile option for retaining the native joint with favourable outcome in non-unions of distal femur.

The Medial Femoral Condyle Free Flap for Reconstruction of Recalcitrant Defects in the Head and Neck

BACKGROUND

Small recalcitrant defects of the mandible and maxilla may be secondary to tumor, trauma, infection, and congenital origin. Vascularized bone grafting has been shown to effectively manage these defects; however, donor sites are limited. The vascularized medial femoral condyle (MFC) provides adequate cortical cancellous bone with the option of a skin island, consistent anatomy, and minimal donor site morbidity. This article outlines the use of the MFC flap for maxillomandibular reconstruction.

METHODS

A retrospective chart review of patients who required segmental maxillomandibular reconstruction with the MFC flap was conducted. A total of 9 patients (5 men and 5 women) with an average age of 45.3 years were identified. The etiology of the defects, flap sizes, and postoperative outcomes were recorded.

RESULTS

Three patients had osteoradionecrosis of the neomandible after irradiation of the free fibula reconstruction, 3 patients had defects after cancer extirpation (1 mandible, 2 maxillary), 1 patient had a maxillary defect from trauma, and 2 patients had a residual cleft palate defect. All defects failed initial treatment with nonvascularized bone grafts. The average dimensions of the MFC flaps were 1.2 × 2.5 × 4 cm. Two of 9 flaps included a skin island. Eight flaps survived completely, but 1 patient suffered from flap failure requiring debridement and resulted in an oroantral fistula. Four patients received endosseous dental implants. Average time to union was 6.7 months, and average time to implant was 6.75 months. The average follow-up time was 24.9 months.

CONCLUSIONS

The MFC flap is useful in the reconstruction of small segmental maxillomandibular defects and for the salvage of a neomandible after osteoradionecrosis. The MFC flap provides a reliable platform for endosseous dental implants and serves as an alternative source of vascularized bone reconstruction in the head and neck.

Five Wrist Operations That Give the Best Results

LEARNING OBJECTIVES

After reading this article and viewing the videos, the participant should be able to: 1. Recognize the following five wrist operations as consistent options for different wrist injuries: carpal tunnel release, medial femoral condyle bone flap for scaphoid nonunion associated with carpal collapse and avascular necrosis, scaphocapitate arthrodesis for Kienböck disease, percutaneous screw fixation of nondisplaced scaphoid fracture, and four-corner arthrodesis. 2. Know the state-of-the-art of these five procedures. 3. State the indications of each operation. 4. List the surgical steps of these five procedures.

SUMMARY

The wrist is a complex joint that concentrates different types of tissues (e.g., bone, cartilage, ligaments, nerves, vessels) and a broad different spectrum of diseases. Treatment of wrist injuries has improved during recent years, mainly because of improvement in strategy, techniques, microsurgical equipment, understanding anatomy and improvements in technology. In this article, we present the five operations (i.e., carpal tunnel release, medial femoral condyle bone flap for scaphoid nonunion associated with carpal collapse and avascular necrosis, scaphocapitate arthrodesis for Kienböck disease, percutaneous screw fixation of nondisplaced scaphoid fracture, and four-corner arthrodesis) that have consistently given good outcomes in patients suffering from different wrist injuries/maladies.

The Medial Femoral Condyle Flap in the Pediatric Patient

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.

Medial femoral trochlea flap reconstruction: Clinical outcomes and perspectives

INTRODUCTION

We report our experience with use of the medial femoral trochlea (MFT) osteochondral flap for carpal applications.

METHODS

Outcomes of all patients treated with MFT flaps were reviewed. Healing, range of motion, grip strength, carpal alignment, pain, and complication data were collected.

RESULTS

MFT flaps were performed on seven patients with a mean age of 26.1 (range, 17-42) years. Indications included scaphoid proximal pole nonunion (n = 3), Kienböck's disease (n = 3), and Preiser's disease (n = 1). The mean follow-up was 32.3 (range, 5-70) months. Union was achieved in five patients at a mean of 12 (range 6-22) weeks. All five patients had increased grip strength and absence of pain at follow-up. There were two failures due to graft resorption.

CONCLUSIONS

The MFT osteochondral flap is a technically challenging yet powerful tool to replace the loss of both carpal articular cartilage and adjacent bone.

Treatment of diaphyseal clavicular nonunion with special emphasis on microsurgery

Diaphyseal fractures of the clavicle had until recently the reputation to always heal with abundant callus formation, except if operated, due to a reported high rate of nonunion after plate fixation by older series. The reason would be that the bone has only periosteal vascularization, easily destroyed by periosteal stripping for implant apposition. Bone autograft and external fixation has been reported as the best technique to heal a nonunited clavicle nonunion. Are these classical considerations still valid nowadays? The purposes of this article focusing only on diaphyseal clavicular fractures are to review the vascularization of the bone, the rate of nonunion after nonoperative treatment, the indications and techniques of osteosynthesis, and the treatment possibilities of an established nonunion. This article will not deal with the specific problems of the lateral clavicular fractures, which are equivalent to acromio-clavicular fracture-dislocations, nor of medial fractures, close to the sterno-clavicular joint.

A Case Report of Bilateral Navicular Osteonecrosis Successfully Treated With Medial Femoral Condyle Vascularized Autografts: A Case Report

CASE

A 17-year-old boy with a history of chronic bilateral navicular osteonecrosis with fragmentation was treated with 6-month staged bilateral open reduction and internal fixation of tarsal navicular with debridement of the necrotic bone and ipsilateral medial femoral condyle vascularized bone grafting.

CONCLUSION

The patient progressed to full painless weight-bearing on each extremity by 4 months postoperatively with osseous union of both chronic fracture sites and incorporation of vascularized bone grafts. Patient-Reported Outcomes Measurement Information System (PROMIS) scores were improved from preoperative levels at 6 months from each operation. This patient's atypical presentation of a rare disease was successfully treated with the utilization of vascularized bone grafting to salvage the tarsal navicular and preserve the talonavicular joint, enabling return of function and avoidance of early arthrodesis procedure.

Use of a Free Vascularized Medial Femoral Condyle Flap for Revision Surgery in a Pediatric Patient with Congenital Pseudarthrosis of the Clavicle

The most common surgical treatment for congenital pseudarthrosis of the clavicle (CPC) is resection of the pseudarthrosis, placement of an autologous bone graft, and Kirschner wire or plate fixation. However, in some cases, bone fusion cannot be achieved at the first surgery, and an additional surgery is required. We present a case report of a boy with a right CPC who failed radiographic bone union after the first surgery. He subsequently underwent revision surgery with resection of the pseudarthrosis, plate fixation, and establishment of a vascularized medial femoral condyle (MFC) flap to ensure bone union. Three months after the revision surgery, a radiographic bone union was achieved, and no symptoms were observed for one year after the operation. There have been no previous reports of the use of a vascularized MFC flap as a treatment for CPC. We believe that this technique effectively ensures bone union during revision surgery for CPC.

The medial femoral condyle free flap: An excellent option for difficult cases: case series

The use of the medial femoral condyle free flap is a versatile option for the treatment of upper extremity non unions and reconstructive procedures associated with bone loss or osteonecrosis. The benefit of this type of flap is the viability of the bone which favors primary ossification and increases bone density. Vascularized free bone flaps are especially useful for the treatment of recalcitrant nonunions, or nonunions that have failed three or more treatments to obtain consolidation. We present a case series of three patients treated with medial femoral condyle free flap for reconstruction of the upper extremity of different etiologies at the level of the distal humerus, distal radius and distal phalanx of the thumb.

The vascularized medial femoral condyle free flap for reconstruction of segmental recalcitrant nonunion of the clavicle

BACKGROUND

Recalcitrant clavicular nonunion is a rare but complicated problem of clavicular fracture fixation. Nonunion is most often treated with clavicular shortening or in extreme cases vascularized bone grafting. Herein we describe our experience using the vascularized medial femoral condyle (MFC) free flap for the reconstruction of segmental defects in cases of recalcitrant clavicular nonunion.

METHODS

A retrospective chart review was conducted of patients with symptomatic recalcitrant nonunion of the clavicle who underwent reconstruction with the vascularized MFC free flap from June 2003 to January 2018. Patients' demographics, time to union, and postoperative complications were collected.

RESULTS

A total of 7 patients (6 women; 39.8 ± 9.01 years old) underwent clavicular reconstruction after an average of 3.7 ± 1.3 previous surgical procedures. Average preoperative visual analog scale score for pain was 4.1. The graft size ranged from 2 to 5 cm in length with approximately 1 cm in width and depth. The average time of total nonunion was 66 ± 48.2 months before surgery. All flaps survived and all clavicles healed with an average time to radiographic union of 15 ± 6.7 months. Patients regained full shoulder motion, and average postoperative visual analog scale score was 1.6 ± 1.8. All patients returned to their preoperative employment status. Donor site morbidity from the knee was minimal.

CONCLUSION

The MFC free flap is a good option for recalcitrant bone nonunion of the clavicle where larger vascularized flaps are not warranted. It is effective and offers minimal donor site morbidity.

Microvascular reconstructive techniques in orthopaedic traumatology

Great evolution has taken place in Orthopaedic Traumatology, regarding techniques, surgical means and equipment. However, we still encounter complicated cases of limb trauma that necessitate microvascular reconstruction. Through three different illustrative cases (one emergency foot revascularization by a free flap, covering an ankle arthrodesis and bridging the anterior tibial artery, one cure of a complex infected tibial non-union with extensive skeletal defect by double barrel fibular transfer and one osteo-chondral reconstruction of the scaphoid proximal pole using a vascularized graft harvested from the femoral medial condyle), the authors remind the Orthopaedic community about the benefits of microsurgery, especially if used in proper indication and timing. This article is a plea to preserve the knowledge and develop the technical abilities of microvascular techniques in the departments of Orthopaedics and Traumatology.

Vascular coverage of the anterior knee region - an anatomical study

Descriptions of vessel angiosomes or perforasomes throughout the human body are quite frequent, and led to the development of flaps nowadays commonly used to surgically cover skin and soft tissue defects. In these procedures, the surgeon requires a profound anatomical knowledge of the respective blood vessels and the extent of the perfused area to define the size of the graft. In the region of the knee joint, descriptions of flaps based on the superior lateral genicular artery and descending genicular artery are quite frequent. In contrast, information regarding other popliteal branches is scarce or non‐existent. The aim of this study was to provide a concise and complete overview on the extent and variability of the perforator angiosomes of the femoral and popliteal arteries in the anterior knee region. Twenty lower extremities were dissected, the respective perforators identified and perfused with dye. All resulting angiosomes were marked and documented. A total of 84 angiosomes were identified in all specimens, with an average of 4.2 (3–6) angiosomes per specimen. The average size of the angiosomes was 97.04 ± 72.30 cm² (8.61–360.41 cm²), their source vessels had an average diameter of 1.42 ± 0.54 mm (0.60–3.25 mm). The complex and highly variable distribution of perforator angiosomes of the anterior knee region and especially of its less frequently investigated distal part was demonstrated. Based on these results, the planning of existing perforator flaps in this region and the development of flaps including the inferior medial or inferior lateral genicular arteries may be facilitated.

Total Knee Arthroplasty Wound Complication Treatment Algorithm: Current Soft Tissue Coverage Options

BACKGROUND

Wound complications associated with soft tissue defects following total knee arthroplasty present challenges for the orthopedic surgeon. The scale of early complications include less morbid problems, such as quickly resolving drainage and small superficial eschars, to persistent drainage and full-thickness tissue necrosis, which may require advanced soft tissue coverage.

METHODS

This review outlines current wound management strategies and provides an algorithm to help guide treatment and clinical decision-making.

CONCLUSION

A surgeon's understanding of soft tissue coverage options is essential in protecting the knee prosthesis from a deep infection and to obtain an optimal functional outcome.

Cutaneous angiosome of the chimeric SLGA perforator flap: Anatomical study and clinical considerations

BACKGROUND

The superior lateral genicular artery (SLGA) is the basis for a chimeric perforator flap in the lateral knee region, which may include bone, cartilage, fascia, and/or skin. To the best of our knowledge, a detailed description of the corresponding perforator-based skin area is missing in the literature. The aim of this study was to describe the extent and possible variations of the cutaneous angiosome of the SLGA.

METHODS

In an anatomical study on 21 fresh frozen lower limbs, the SLGA was injected with toluidine blue. The anatomy of the vessel and its perforators was explored, and the skin containing the cutaneous angiosome was harvested and photo-documented. Evaluation of the images was performed using ImageJ software. In addition, the versatility of the SLGA perforator flap is illustrated as both a pedicled local and a free tissue transfer.

RESULTS

For each vessel, there were 1.75 ± 0.9 (range 1-3) perforators at an average position of 47.3 ± 21.3 mm lateral to the superolateral patella and 42.5 ± 18.7 mm proximal to the knee joint. The angiosome area was 222.8 ± 57.6 cm² with a length of 20.9 ± 3.0 cm and a width of 15.4 ± 3.0 cm. At the longitudinal axis of the highest perforator density, the proximal end and the distal end of perfusion averaged 13.4 ± 4.1 cm proximal and 2.5 ± 2.0 cm distal to the knee joint, respectively.

CONCLUSION

Our results show that the SLGA supplies a constant angiosome over the anterolateral proximal knee joint. Its description and visualization will guide surgeons in preoperative planning and further extend the use of this versatile chimeric perforator flap.

An Innovative Application of the Free Vascularized Medial Femoral Condyle Flap in the Prevention of Recurring Neuropathic Ulcer in the Diabetic Foot: A Case Report

Despite various therapy options, the prophylactic and symptomatic treatment of recurrent ulcerations in the diabetic foot are still challenging. We report the application of a free vascularized medial femoral condyle flap to prevent the recurrence of pressure ulcer in a patient with diabetic foot syndrome. Our patient had type 2 diabetes and presented with pressure ulcers and osteomyelitis of metatarsal heads 2 and 3 after a great toe amputation. We chose to use a medial femoral condyle flap as a damper in the area of the metatarsal heads because of the relatively young age and good vascularity of our patient. We shaped the graft like a ski to distribute the pressure and prevent perforation of the plantar skin. Good results were achieved for wound healing, pain reduction, and improvement of gait. No pressure ulceration had recurred after a 3-year follow-up period. The versatility of the osteomyocutaneous graft from the medial femoral condyle is an important reconstructive tool for addressing major surgical problems. We present the first use of a medial femoral condyle flap in the treatment of a pressure ulcer in a diabetic foot. In selected patients, our method could prevent premature and extended amputations, thereby providing good improvement in patients' quality of life.

The Efficacy of Vascularized Bone Grafts in the Treatment of Scaphoid Nonunions and Kienbock Disease: A Systematic Review in 917 Patients

Background Vascularized bone grafts have become one of the first treatment options for scaphoid nonunions and Kienböck's disease. The aim of this study is to review the current body of the literature regarding the use of four vascularized bone grafts (1,2 ICSRA [1,2 intercompartmental supraretinacular artery] graft, 4+5 ECA [4+5 extracompartmental artery] graft, volar radial graft, and free medial femoral condyle graft) in these pathologies. Patients and Methods A search on MEDLINE and Google Scholar was performed. Exclusion criteria included language other than English, studies with no full text available, case reports, letters, editorials, and review articles. The primary outcomes included consolidation rate of the grafts and time to union regarding scaphoid nonunion, as well as the clinical outcomes (pain, grip strength, range of motion), revascularization of the lunate, and progression of the disease regarding Kienböck's disease. Results A total of 37 articles were included in the study enrolling 917 patients. Regarding scaphoid nonunion, the consolidation rate was 86.3% for the 1,2 ICSRA graft, 93.9% for the volar radial bone graft, and 88.8% for the free medial femoral condyle graft. In patients with Kienböck's disease, progression of the disease was observed in 13% of patients, and grip strength and pain were substantially improved whereas range of motion did not demonstrate statistically significant improvement ( p < 0.05). Conclusion Vascularized bone grafts yield successful outcomes in patients with scaphoid nonunions demonstrating a high union rate. In patients with Kienböck's disease, vascularized grafts lead to revascularization of the lunate in most of the cases with concomitant improvement of the clinical parameters.

How to determine the surgical approach in Hoffa fractures?

Surgical approach selection and fixation of Hoffa fractures is difficult and remains controversial. Evolving trends emphasize the importance of fracture morphology, fracture location, and comminution, all of which guide decisions regarding surgical approach and implant selection. This focused review highlights factors affecting Hoffa fracture available surgical approaches, treatment outcomes, and recommendations for selecting an optimal approach.

Femoral Osteonecrosis after Medial Femoral Condyle Bone Graft Harvest

The medial femoral condyle vascularized graft has become a useful resource in reconstructive microsurgery due to the rate of bony union, and the low rate of complication. We report osteonecrosis of the medial femoral condyle in a 65-year-old woman after harvesting a corticocancellous medial femoral condyle graft to treat a tarsometatarsal nonunion. We were not able to define whether a vascular or mechanical disorder could be the ultimate cause. However, because of the severity of the complication, we suggest informing patients who will undergo a medial femoral condyle flap about this infrequent complication.

Chimeric Medial Femoral Condyle Osteocutaneous Flap for Reconstruction of Multiple Metacarpal Defects

When faced with reconstructing metacarpal defects, various options have been described. We describe a chimeric medial femoral condyle osteocutaneous flap as a new method for providing multiple bone grafts as well as soft tissue coverage in a single stage. The medial femoral condyle has become an area of increased interest given the versatility it allows in harvesting the bone. This osteocutaneous flap is useful when reconstructing small- to medium-sized adjacent metacarpal bone defects. The chimeric design of the flap lends flexibility at the time of inset that is absent for other options of vascularized bone grafts. The ease of harvest, straightforward anatomy, flexibility at inset, and limited donor site morbidity make this flap an effective option when treating such injuries.

MEDIAL FEMORAL CONDYLE CORTICOPERIOSTEAL FLAP: ANATOMIC STUDY

Objective

The medial femoral condyle corticoperiosteal flap is irrigated by the descending genicular artery, and when this is absent, by the superior medial genicular artery. The descending genicular artery divides into the muscular, saphenous, and osteoarticular branches. The objective of this study was to describe the variables involved in the dissection of the medial femoral condyle flap.

Methods

Thirty thighs from 20 cadavers were dissected and the following variables were recorded: age, height, weight, thigh length, presence of the descending genicular artery, whether the saphenous branch originated from the descending genicular artery, the length of the branches originating from the descending genicular artery, and the diameter of the descending genicular artery and the vena comitans.

Results

The descending genicular artery was present in 93.3% of the specimens (28/30). The saphenous branch originated from this artery in 76.7% of the dissections (23/70). The mean distance between the origin of the descending genicular artery and the knee joint was 13.4 cm (±١.4), the mean length of the descending genicular artery was 7.5 cm (±1.5), the mean diameter of the descending genicular artery was 1.9 mm (±٠.3), and the mean diameter of the vena comitans was 1.7 mm (±٠.3).

Conclusion

The vascularized medial femoral condyle is a versatile option for reconstruction of musculoskeletal injuries. It allows transference of bone associated with muscle and skin, which are each nourished by independent branches. Level of Evidence IV; Case series.

Descending genicular artery. Branching patterns and measuring parameters: A systematic review and meta-analysis of several anatomical studies

BACKGROUND

The medial femoral condyle (MFC) flap is based on the descending genicular artery (DGA), which is a vessel with different variations in its course and branching patterns. Many studies have dealt with the vascular anatomy of the MFC. However, the results of the investigations differ markedly.

METHODS

The authors performed a systematic literature search in MEDLINE for articles published until May 2017 on the vascular anatomy of the DGA. After the screening, 23 relevant studies with a similar topic were included into this comprehensive analysis.

RESULTS

The systematic review examined the lengths and diameters of the individual arteries with regard to the vascularized bone flap of the MFC. The DGA is present in 94% of cases with an average length of 1.8 cm. In 63% of the investigated cases, the DGA divides into three terminal branches. The articular branch has an average length of 7.7 cm, the saphenous branch has a length of 10.7 cm, and the muscular branch has a length of 3.2 cm.

CONCLUSION

To ensure a secured survival of this free flap, a detailed understanding of the convoluted vascular anatomy above the MFC is necessary. We recommend the Dubois classification for a systematic classification of the anatomical patterns of the DGA.We present a summary of all anatomical studies dealing with the vascular supply to the MFC and the DGA to date.

Reexploring the Anatomy of the Distal Humerus for its Role in Providing Vascularized Bone

Background:

The lateral arm flap is used for composite defects in need of vascularized soft tissue, skin, and bone. From its original description, the distal humeral metaphysis can be included with the flap, supplied by the periosteal extensions of the posterior branch of the radial collateral artery. We sought to reexplore the anatomy of the lateral arm to determine its utility as a donor site for vascularized bone.

Methods:

Twelve fresh, silicone-injected cadaver dissections were performed. Arteriovenous anatomy, pedicle length and diameter, and anatomic variability as well as photo documentation was recorded.

Results:

The distal extent of the deltoid, lateral intermuscular septum and lateral humeral epicondyle were identified before the dissection. A septocutaneous perforator was consistently located 10 cm proximal to the lateral humeral epicondyle, which could be used for a skin paddle to monitor. Harvest of a 1.5 cm × 2 cm corticocancellous bone graft was performed. Average pedicle length was 9.1 ± 1.1 cm, and average pedicle diameter was 1.74 ± 0.52 mm. The inferior lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm were consistently identified and preserved.

Conclusion:

The predictable anatomy of the lateral distal humerus make it an ideal donor site for small segments of vascularized bone.

The treatment of long bones nonunions of upper limb with microsurgical cortico-periosteal free flap

BACKGROUND AND PURPOSE

Medial condyle corticoperiosteal flap is an emerging option for the treatment of upper limb non-infected nonunions. The hypothesis of our study is that corticoperiosteal flap could be an effective and safe procedure for the treatment of upper limb non-infected nonunions, evaluating radiographic and clinical outcome.

METHODS

We enrolled 14 patients who underwent vascularized medial femoral condyle corticoperiosteal free flaps from January 2011 to December 2014. All patients were clinically evaluated (VAS, DASH) before surgery and at 6 and 12 months post surgery. The radiographic evaluation was performed every 30 days until the complete healing and at 12-month follow-up. We also recorded the range of motion pre and post surgery at the donor site.

RESULTS

All nonunion sites healed primarily at an average time period of 5.2 months ±1. Preoperative DASH score was 70 ± 15.6; at 6 month follow-up was 21.51 ± 10.63; at 12 month follow-up 18.0 ± 9.9. Preoperative VAS was 7.05 ± 2; at 6-month follow-up was 2.1 ± 2; at 12-month follow-up was 1.8 ± 1.16. Statistical analysis showed a significant difference (p <0.001) about the preoperative and the postoperative VAS and DASH evaluation both at 6 and 12-month follow-up, but we did not record any statistical difference between the 6-month and 12-month follow-up. At the donor site, the mean VAS score was 2 ± 2.1 at seven days post operatively. All patients restore the full ROM at 7 days post surgery.

CONCLUSIONS

Vascularized medial condyle corticoperiosteal free flap represents an effective and safe procedure for the treatment of upper limb nonunions.

Technique for 3-Dimesional (3D) Modeling of Osteoarticular Medial Femoral Condyle Vascularized Grafting to Replace the Proximal Pole of Unsalvagable Scaphoid Nonunions

This study describes a novel technique for the preoperative surgical planning for an osteoarticular medial femoral condyle (MFC) graft to replace the proximal pole of a scaphoid. In cases of proximal pole scaphoid nonunion or in Preiser disease, fragmentation of the articular surface can occur, leading to significant pain and disability. Osteoarticular MFC bone grafting can be used to treat these injuries by providing a vascularized osteoarticular surface. Using 3-dimensional imaging and printing we are able to precisely model the injured scaphoid, and also accurately plan the harvest of MFC osteoarticular graft. This technique allows for accurate preoperative planning of a complex 3-dimensional bone, and has improved our execution of the plan intraoperatively.

Vascularized Medial Femoral Condyle Bone Graft for Resistant Nonunion of the Distal Radius

Background: Nonunion involving the metaphyseal region of the distal radius is exceedingly rare, usually involving co-morbidity. Patients that have failed multiple prior conventional surgical interventions represent an even more difficult subset to treat; this investigation examined the utility of a specially designed free vascularized medial femoral condyle flap consisting of a central structural block graft with an extended corticoperiosteal sleeve to wrap around the junctions.

Methods: Six patients (5 males, 1 female) with a mean age of 52 years had failed to achieve union involving the distal radius metaphysis after a mean of 3.7 prior surgeries occurring over a mean period of 24 months. Comorbidities included smoking, alcoholism, chronic nutritional deficiency, and prior osteomyelitis. The unique descending genicular artery medial femoral condyle flap designed to address these patients consisted of a central structural block graft in continuity with an extended corticoperiosteal sleeve. The structural block filled the bone defect, and the corticoperiosteal sleeve wrapped around the bone junctions and the neighboring bone margins. The mean flap size was 5.3 (+/- 1.3) cm long by 4.5 (+/- 0.9) cm wide. Pre-operative to post-operative DASH scores were compared using the paired student’ s t-test, with p < 0.05.

Results: All flaps achieved union at a mean of 6.8 (+/- 2.1) weeks following surgery, using the criteria of bridging trabeculae on all 3 radiographs: coronal, sagittal, and oblique. The mean pre-operative DASH score of 63 (+/- 10) was statistically significantly different compared to the mean post-operative DASH score of 18 (+/- 8).

Conclusions: With few alternative solutions able to address this unique and difficult problem, the structural block of vascularized bone with the extended corticoperiosteal sleeve proved able to achieve a union that had failed multiple previous attempts and able to resist reactivation of infection, in a challenging group of patients with comorbidities.