The condylar capping for microvascular temporomandibular joint reconstruction: A preliminary study.

BACKGROUND: Defects of the temporomandibular joint (TMJ) are often difficult to be reconstructed in the correct dimensions and function. This preliminary study aims to describe a novel technique of condylar reconstruction with a microvascular flap in case of deforming arthrosis of the TMJ: condylar capping. PATIENTS AND METHODS: Four patients between 22 and 62 years old-three females and one male-with severe unilateral arthrosis of the TMJ underwent condylar capping. All patients had already had a failed conservative treatment, followed by arthroscopy with lysis and lavage and later open surgery with total or subtotal diskectomy combined with a condylar arthroplasty. Nevertheless, their pain was still at level six or more on a visual analogue scale. Moreover, they could eat only soft food. At this stage, they underwent condylar capping using an osteochondral lateral femoral condyle (LFC) flap. The surgical technique and the postoperative management are described in detail. Crucially the attachment of the lateral pterygoid muscle to the condylar neck was preserved in all cases. The patients were followed up clinically and by CT scan preoperatively, 6, and 12 months postoperatively. RESULTS: The mean height of the reconstructed neo-condyle was 6.0 mm, the mean width 16.2 mm, and the mean sagittal length 9.8 mm. The follow-up period ranged from 14 to 64 months. The procedures were uneventful for all patients, and the donor site morbidity was negligible. Twelve months later, the patients were all pain-free and able to have a regular diet. The TMJ and the knee had a normal range of movement and power. Postoperative imaging demonstrated bone healing and stable and anatomically correct condyle reconstruction. CONCLUSIONS: Based on the author's experience, the condylar capping with the LFC appears promising for reconstructing the condylar head in cases of severe osteoarthritis. Preserving the attachment of the lateral pterygoid muscle allows a complete restoration of the physiologic range of movement, including protrusion and laterotrusion of the mandible.

Combined Free Flaps for Optimal Orthoplastic Lower Limb Reconstruction: A Retrospective Series.

Background and Objectives: Open fracture of the lower limb can lead to substantial bone and soft tissue damage, resulting in a challenging reconstructive scenarios, especially in presence of bone or periosteal loss, with a relevant risk of non-union. This work analyzes outcomes of using a double approach for orthoplastic reconstruction, adopting the free medial condyle flap to solve the bone defects, associated to a second free flap for specific soft tissue coverage. Indications, outcomes and reconstructive rationales are discussed. Materials and Methods: A retrospective investigation was performed on patients who underwent complex two-flap microsurgical reconstruction from January 2018 to January 2022. Inclusion criteria in this study were the use of a free femoral condyle periostal/bone flap together with a second skin-only flap. Only distal third lower limb reconstructions were included in order to help equalize our findings. Out of the total number of patients, only patients with complete pre- and post-operative follow-up (minimum 6 months) data were included in the study. Results: Seven patients were included in the study, with a total of 14 free flaps. The average age was 49. Among comorbidities, four patients were smokers and none suffered from diabetes. Etiology of the defect was acute trauma in four cases and septic non-union in three cases. No major complications occurred, and all flaps healed uneventfully with complete bone union. Conclusions: Combining a bone periosteal FMC to a second skin free flap for tailored defect coverage allowed achievement of bone union in all patients, despite the lack of initial bone vascularization or chronic infection. FMC is confirmed to be a versatile flap for small-to-medium bone defects, especially considering its use as a periosteal-only flap, with minimal donor site morbidity. Choosing a second flap for coverage allows for a higher inset freedom and tailored reconstruction, finally enhancing orthoplastic success.

Vascularized osteochondral free flaps from the femoral trochlea as versatile procedure for reconstruction of osteochondral lesions of the talus.

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.

The fasciocutaneous iliotibial band perforator flap in soft tissue and tendon reconstruction of the foot: A case report.

In cases of large defects of the limbs, post-traumatic deformity and disability can have devastating effects on patients' quality of life. The purpose of this report is to describe the technique for raising a fasciocutaneous iliotibial perforator flap and present its application in the reconstruction of a complex soft tissue defect of the foot. The patient was a 13-year-old male who had suffered a crush injury to the foot in a motor vehicle accident 5 years earlier. Due to retraction of the skin, together with the extensor tendons of the digits, the patient could not flex the digits II, III, IV, and V. To reconstruct the defect, the authors harvested a fasciocutaneous flap based on a perforator branch of the superior lateral genicular artery and accompanying veins. The immediate postoperative course was uneventful, with progressive and complete recovery of power and range of motion in the foot and knee within 6 weeks. Despite the tendency to form hypertrophic scars again, the functionality of the operated foot was excellent 29 months after the reconstruction. According to the American Orthopedic Foot and Ankle Society scale, the patient scored 100 points on the midfoot section and 93 points on the section forefoot rays two to five. The iliotibial perforator flap could be a new tool for a state-of-the-art functional reconstruction of soft tissues defects of the limbs and head and neck.

Nonvascularized Cartilage Grafts Versus Vascularized Cartilage Flaps: Comparison of Cartilage Quality 6 Months After Transfer.

PURPOSE: Subchondral perfusion of osteochondral grafts has been shown to be important in preventing long-term cartilage degeneration. In carpal reconstruction, subchondral perfusion from the graft bed is limited. This study's purpose was to compare the histological characteristics of cartilage in osteochondral grafts supported by synovial imbibition alone to cartilage of vascularized osteochondral flaps that have both synovial and vascular pedicle perfusion. METHODS: Two adjacent osteochondral segments were harvested on the medial femoral trochlea in domestic 6- to 8-month-old pigs. Each segment measured approximately 12 mm × 15 mm × 17 mm. One segment was maintained on the descending geniculate artery vascular pedicle. The adjacent segment was separated from the pedicle to serve as a nonvascularized graft. A thin layer of methylmethacrylate cement was used to line the harvest site defect to prevent vascular ingrowth to the subsequently replaced specimens. The pigs were maintained on a high-calorie feed and returned to ambulation and full weight-bearing on the surgical legs. The animals were sacrificed after 6 months and the specimens were reharvested, sectioned, and examined. The cartilage was graded by 2 pathologists blinded to the origin of specimens as vascularized flaps or nonvascularized grafts. RESULTS: All specimens were assigned scores utilizing the International Cartilage Repair Society grading system. Scoring for chondrocyte viability, cartilage surface morphology, and cell and matrix appearance was significantly higher in the vascularized osteochondral group than in the graft group. CONCLUSIONS: When deprived of subchondral perfusion from underlying bone, osteochondral vascularized flaps in an intrasynovial environment demonstrate superior cartilage quality and survival compared with nonvascularized grafts. CLINICAL RELEVANCE: In locations in which perfusion from surrounding bone may be limited (ie, proximal scaphoid or proximal lunate reconstruction), articular reconstruction using vascularized osteochondral flaps will yield superior cartilage organization and architecture than nonvascularized osteochondral grafts. The clinical and functional relevance of this finding requires further study.

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.

Knee Donor Site Morbidity Following Harvest of Medial Femoral Trochlea Osteochondral Flaps for Carpal Reconstruction.

PURPOSE: This study examines donor site morbidity associated with the medial femoral trochlea (MFT) when used as a donor site for vascularized osteochondral flaps for reconstruction of challenging carpal defects such as proximal pole scaphoid nonunion and advanced Kienböck disease. METHODS: The retrospective study population included all patients who had undergone MFT flap harvest for scaphoid or lunate reconstruction. Chart review, patient questionnaires, and validated knee function assessment tools were used: International Knee Documentation Committee Subjective Knee Form scores ranged from 0 (maximal disability) to 100 (no disability). Western Ontario and McMaster Universities osteoarthritis index scores ranged from 0% (no disability) to 100% (maximal disability). Magnetic resonance imaging and radiographs were obtained on the donor knee on the majority of patients. RESULTS: Questionnaire response rate was 79% (45 of 57 patients). Average patient age was 35 ± 11 years (range, 19-70 years). Average postoperative follow-up was 27 ± 17 months (range, 9-108 months). The indication for MFT flap reconstruction was scaphoid nonunion in 30 patients and Kienböck disease in 15 patients. All 45 patients had a stable knee on examination. Magnetic resonance and radiographic imaging obtained on 35 patients exhibited no pathological changes. Average duration of postoperative pain was 56 ± 59 days (range, 0-360 days); average duration until patients reported the knee returning to normal was 90 ± 60 days (range, 14-360 days). Forty-three of 44 patients would have the same surgery again if needed; overall satisfaction with the surgery was rated as 5 ± 1 (range, 2-5) on a scale from 0 (no satisfaction) to 5 (maximal satisfaction). Average International Knee Documentation Committee score was 96 ± 9 (range, 56.3-100) and the average Western Ontario and McMaster Universities score was 6% ± 16% (range, 0%-68%). CONCLUSIONS: Medial femoral trochlea osteochondral flap harvest results in minimal donor site morbidity in the majority of patients. Symptoms are time limited. Intermediate-term follow-up demonstrates excellent results in subjective outcome measures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Lateral Femoral Condyle Flap: An Alternative Source of Vascularized Bone From the Distal Femur.

PURPOSE: To elucidate the vascular anatomy of the superolateral geniculate artery (SLGA) and its supply to the periosteum of the lateral femoral condyle (LFC) and to provide guidelines for flap design and describe an illustrative case. METHODS: Thirty-one fresh cadaveric limbs were dissected. The vascular anatomy of the SLGA and its distal branches to skin, muscle, and periosteum were identified. Fluoroscopic images were taken during continuous perfusion of a radiopaque contrast dye into the SLGA. Intra-arterial injections of latex rubber were performed in 12 cadaver limbs. The vascular territory was traced from the SLGA to its distal branches, and surrounding soft tissues were dissected. RESULTS: The SLGA originated from the popliteal artery 4.9 ± 1.2 cm (range, 2.8-7 cm) from the knee joint and its pedicle diameter was 1.8 ± 0.5 mm (range, 1-3 mm). SGLA pedicle-specific fluoroscopic angiography demonstrated a dense filigree of vessels over the lateral distal femur. Arterial latex injections confirmed that the SLGA supplied the periosteum of the LFC and distal femur shaft. The proximal-most extent of periosteal perfusion was 11.7 ± 2.1 cm (range, 9.3-14.1 cm) from the knee joint. The average pedicle length of LFC osteoperiosteal flaps was 4.8 ± 0.9 cm (range, 3.5-6.3 cm). CONCLUSIONS: The LFC flap consistently demonstrated almost 12 cm of femur length perfusion based on the SLGA pedicle. The anatomy of this flap enables chimeric designs combining soft tissue, bone, and cartilage. CLINICAL RELEVANCE: The vascularized LFC flap is an option for reconstruction of osseous defects of the upper extremity.

Vascularized medial femoral trochlea osteochondral flap reconstruction of advanced Kienböck disease.

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.

Osteochondral flaps from the distal femur: expanding applications, harvest sites, and indications.

BACKGROUND: The medial and lateral femur provide a source of convex osteochondral vascularized bone. The medial trochlea has been demonstrated to have similar contour to the proximal scaphoid, lunate, and capitate. Other sites of osteochondral harvest such as the posteromedial femur and the lateral trochlea are similar in morphology to the humeral capitellum and medial talus, respectively. These analogous structures offer potential solutions to difficult articular problems. PATIENTS AND METHODS: Patients who underwent osteochondral reconstruction of the extremities were reviewed. These included 16 medial femoral trochlea (MFT) scaphoid nonunion reconstructions, 16 MFT Kienböck lunate reconstructions, 5 MFT capitate reconstructions, 2 lateral femoral trochlea osteochondral reconstructions of medial tarsal avascular necrosis, and 5 posteromedial femoral osteochondral reconstructions of the humeral capitellum for posttraumatic arthritis. RESULTS: Computed tomography (CT) imaging demonstrated 15 of 16 reconstructed scaphoids achieving union. Follow-up wrist motion averaged 46.0 degrees extension and 43.8 degrees flexion, similar to preoperative measurements. CT imaging confirmed healing in 15 of 16 reconstructed lunates. Lichtman staging remained unchanged in 10 patients, improved in 4 patients (3A-2), and worsened in 2 patients (3A-3B). All but one patient experienced improvement in wrist pain. Wrist range of motion at follow-up averaged 50 degrees extension and 38 degrees flexion, similar to preoperative measurements. Capitate, talar, and capitellar reconstructions all resulted in achievement of osseous healing and restoration of joint alignment. CONCLUSIONS: Vascularized osteochondral flaps provide a useful tool in the treatment of difficult articular problems in the extremities. Clinical experience thus far demonstrates a high rate of achieving union with acceptable range of motion and good pain relief.

Vascularized medial femoral trochlea osteocartilaginous flap reconstruction of proximal pole scaphoid nonunions.

PURPOSE: The descending geniculate artery's branching pattern includes periosteal vessels supplying the cartilage-bearing trochlea of the medial patellofemoral joint. Previous cadaveric studies described anatomic similarities between the greater curvature of the proximal scaphoid and the convex surface of the medial femoral trochlea (MFT). We describe the technique and report our first 16 consecutive cases of vascularized osteocartilaginous arthroplasty for chronic scaphoid proximal pole nonunions using the MFT, with a minimum of 6 months of follow-up. METHODS: Chart reviews of 16 consecutive cases of osteocartilaginous MFT flap transfers for scaphoid reconstruction were performed at 2 institutions. Follow-up data were recorded at a minimum of 6 months, with an average of 14 months (range, 6-72 mo). Patient age and sex, duration of nonunion, number of previous surgical procedures, surgical technique, achievement of osseous union, preoperative and postoperative scapholunate angles, preoperative and postoperative range of motion, and pain relief were recorded. RESULTS: Computed tomography imaging confirmed healing in 15 of 16 reconstructed scaphoids. Mean patient age was 30 years (range, 18-47 y). The average number of previous surgical procedures was 1 (range, 0-3). All patients experienced some wrist pain improvement (12/16 complete relief, 4/16 incomplete relief). Wrist range of motion at follow-up averaged 46° extension (range, 28° to 80°) and 44° flexion (range, 10° to 80°), which was similar to preoperative measurements (average 46° extension and 43° flexion). Scapholunate relationship remained unchanged with average scapholunate angles of 52° before surgery and 49° after surgery. CONCLUSIONS: Osteochondral vascularized MFT flaps provide a reliable means of achieving resolution of difficult proximal pole scaphoid nonunions. These flaps allow resection of the proximal portion of the unhealed scaphoid and reconstruction with an anatomically analogous convex segment of cartilage-bearing bone. This technique provides the advantages of vascularized bone and ease of fixation. Early follow-up demonstrates a high rate of union with acceptable motion and pain relief. CLINICAL RELEVANCE: Early follow-up suggests that the vascularized MFT osteocartilaginous flap is a valuable tool for treating challenging proximal pole scaphoid nonunions.

Metacarpophalangeal Joint Reconstruction of a Complex Hand Injury with a Vascularized Lateral Femoral Condyle Flap Using an Individualized 3D Printed Model-A Case Report.

This case report describes the surgical management of a patient with a complex hand trauma. This injury included tendon, vascular, and nerve injuries, a partial amputation of the index finger, fractures of the third proximal phalanx, and destruction of the metacarpophalangeal joint of the fifth finger. Firstly, the acute treatment of a complex hand injury is described. Secondly, the planning and execution of a joint reconstruction using a vascularized lateral femoral condylar flap, assisted by an individual 3D model, is illustrated. Precise reconstruction of the affected structures resulted in good revascularization as well as an anatomical bone consolidation. Intensive physical therapy, including autonomous proprioceptive range-of-motion exercises by the patient, resulted in significant functional improvement of the hand in daily life. Overall, we report on the successful reconstruction of a metacarpophalangeal joint by using a vascularized flap from the lateral femoral condyle. Furthermore, this case report highlights the efficacy of integrating individualized 3D printing technology to plan complex reconstructions, opening up promising opportunities for personalized and optimized interventions.

The microvascular corticocancellous femur flap for reconstruction of the anterior maxilla in adult cleft lip, palate, and alveolus patients.

OBJECTIVE: Free nonvascularized alveolar bone grafting in severe defects of the cleft region often results in poor implant bed conditions. Here an alternative augmentation technique using a new technique of vascularized bone transfer is described. DESIGN: In five patients with clefts of the lip, palate, and alveolus (four unilateral, one bilateral) there was a severe defect of the anterior maxillary alveolar ridge after tooth loss. The patients previously had augmentative surgery one to three times without success. The defect was covered using a microvascular corticocancellous transplant from the medial distal femur. The defects to be corrected measured 2.5 to 4.0 cm long, 1.0 to 1.5 cm wide, and 1 to 1.5 cm high. The microvascular pedicle of the femur bone flap was 3 to 7 cm long. The descending genicular artery was anastomosed to the facial or labial superior artery and the accompanying veins accordingly. In every case, the anastomoses were performed via an intraoral transmucosal approach. RESULTS: There were no serious complications and no flap loss. In all patients the defect was covered by a flap of the correct size and design. All patients were treated with dental implants (13 total) 6 months after successful reconstruction of the ridge. The implants were loaded 4 to 6 months after placement with fixed superstructures. There were good peri-implant conditions and no implant loss. CONCLUSION: The microvascular osteoperiosteal femur flap can be used successfully in individual reconstruction of segmental defects of the alveolar ridge in adult cleft patients.

Free vascularised osteochondral flap for the treatment of osteochondritis dissecans of the talus.

We present a case report of a man in his 20s with osteochondritis dissecans of the talus, treated with autologous transplantation of a vascularised osteochondral flap. The patient with high level of activity presented to our orthopaedic outpatient department for progressive limping and pain, mainly related to sports. An osteochondritis dissecans grade IV of the medial talus was identified by MRI. A microvascular transfer of osteochondral tissue was performed successfully. At follow-up 1 year after surgery, the MRI examination revealed vital cartilage; the patient was free of pain and had returned to his previous level of activity.

Comparative study of the osseointegration of dental implants after different bone augmentation techniques: vascularized femur flap, non-vascularized femur graft and mandibular bone graft.

OBJECTIVES: The purpose of this study was to evaluate the osseointegration of the dental implants placed into the mandible augmented with different techniques in pigs. MATERIAL AND METHODS: Four adult domestic pigs were used. Horizontal augmentation of the mandible was performed in animals by using vascularized femur flap (VFF), non-vascularized femur graft (NVFG) and monocortical mandibular block graft (MG). After 5 months of healing 10 dental implants were placed into each augmented site. The pigs were sacrificed after 3 months of healing. Undecalcified sections were prepared for histomorphometric analysis. RESULTS: Mean bone-implant contact (BIC) values for implants placed into MG, NVFG and VFF were 57.38 ± 11.97%, 76.5 ± 7.88%, 76.53 ± 8.15%, respectively. The BIC values of NVFG and VFF group were significantly greater than MG group (P<0.001). On the other hand, there was not statistically significant difference between NVFG group and VFF group (P=0.999). CONCLUSION: NVFG as well as VFF can be considered as a promising method for augmentation of alveolar defects and the placement of the implants. The selection of non-vascularized graft or vascularized flap depends on the condition of the recipient site.

The free vascularized lateral femoral trochlea osteochondral graft: a reliable alternative for Stage III Kienböck's disease.

Lunate reconstruction using a lateral femoral trochlea osteochondral graft was carried out in 27 patients with Stage III Kienböck's disease from 2012 to 2019. Twenty-three of these patients could be followed-up in this retrospective study. Ten were women and 13 men. Nine were Lichtman Stage IIIA, seven Stage IIIB and seven Stage IIIC. The mean follow-up was 39 months (range 12-86). Bony consolidation was found in 18 of the 23 patients, with no graft loss. The mean Disabilities of the Arm, Shoulder and Hand score (DASH score) was 11 and the Modified Mayo Wrist Score was 83. There were only two radiological deteriorations, with the same or improved Lichtman classifications in the other patients and a significant reduction in pain. Postoperative extension of the wrist (52°) and flexion (48°) were comparable with preoperative values and, respectively, 81% and 72% of the contralateral side. Grip strength and pinch grip were 32 kg and 12 kg, 88% and 94% of the other hand, respectively, and an insignificant increase compared with the preoperative values. The vascularized lateral femoral trochlea osteochondral graft yields good short- and mid-term results in Grade III Kienböck's disease.Level of evidence: IV.

Medial Femoral Trochlea Osteochondral Flap: Applications for Scaphoid and Lunate Reconstruction.

Vascularized osteochondral flaps are a new technique described for the reconstruction of challenging articular defects of the carpus. The medial femoral trochlea osteochondral flap is supplied by the descending geniculate artery. This osteochondral flap has shown promise in the treatment of recalcitrant scaphoid proximal pole nonunions and advanced avascular necrosis of the lunate. The anatomy, surgical technique, and results are discussed, with clinical cases provided.

Free corticoperiosteal flap in the treatment of an infected bone defect of the tibia. A case report.

The treatment of septic bone defects represents a significant challenge in orthopaedic surgery. Non-vascularised cancellous bone grafts are very commonly used. In contrast, thin and malleable periosteal grafts have generally only been investigated in animal models. The free corticoperiosteal flap is used only in exceptional cases in traumatology. This case report describes the treatment of an infected and non-reactive bone defect in the shaft of the tibia. This case involves a septic non-union over two years old with evidence of methicillin-resistant Staph. aureus. A vascularised corticoperiosteal flap was used to bridge this defect. The procedure was supplemented by rigid internal fixation. There were no postoperative complications. Bone healing was documented eleven months after the described treatment. No further invasive procedures were required. The patient was able to return to his original occupation as a store manager. Stable internal fixation is an important precondition for successful treatment. The method described in this article can be considered for short defects when a conventional cancellous bone graft appears to be contraindicated.

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 ±â€¯21.3 mm lateral to the superolateral patella and 42.5 ±â€¯18.7 mm proximal to the knee joint. The angiosome area was 222.8 ±â€¯57.6 cm2 with a length of 20.9 ±â€¯3.0 cm and a width of 15.4 ±â€¯3.0 cm. At the longitudinal axis of the highest perforator density, the proximal end and the distal end of perfusion averaged 13.4 ±â€¯4.1 cm proximal and 2.5 ±â€¯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.

Free vascularised corticoperiosteal bone flaps in the treatment of non-union of long bones: an ignored opportunity?

Five patients with atrophic or septic non-union of long bones were treated with free vascularised corticoperiosteal bone flaps. The patients had undergone an average of nine prior operations (range, 2-29). The treatment was combined with repeat internal fixation in four patients,. Treatment took place an average of 25.5 months (range 5-83 months) after the initial injury. The thin corticoperiosteal grafts were harvested from the supracondylar region of the femur. One patient died from unrelated causes 2.5 months postoperatively. In the other four patients, bone healing was documented after an average of 7.7 months (range 6-11 months). No further operations were necessary during the follow-up period of 13.7 months on average (range 10-17 months). There were no complications associated with the procedure. The treatment presented here is complex but was successful in this small population. The procedure has the potential to become established as a treatment option for problematic bone defects.