Periosteal medial femoral condyle free flap for metacarpal nonunion

Abstract

Background: Metacarpal nonunion is a rare condition. The osteogenic capacity of periosteal free flap was investigated in five patients with metacarpal nonunion and impaired bone vascularization.Patients and methods: Surgery was performed between 64 and 499 days after the initial bone osteosynthesis. The average age was 27.6 (range 16-32) years. Nonunion was caused by excessive periosteal removal in two patients, extensive open trauma in three. Four nonunions were diaphyseal, one metaphyseal. A periosteal medial femoral condyle free flap was raised on the descending genicular artery for four patients, the superomedial genicular artery for one. After osteosynthesis with a plate, the flap was wrapped around the metacarpal, overlapping the bone proximally and distally.The recipient vessel were the dorsal branch of the radial artery and a vena comitans in the anatomical snuffbox in four patients, at the base of the first webspace in one. Results:The flap size ranged from 5 Â 3.5 cm to 8 Â 4 cm. No postoperative complication occurred. Radiological bone union was achieved 3 to 8 months after surgery.One patient had a full range of motion, one a slight extension lag of the proximal interphalangeal joint, two moderate joint stiffness of the proximal interphalangeal or metacarpophalangeal joint (one requiring plate removal and extensor tenolysis), one severe stiffness that allowed using a hook grip which was the aim of the surgery. Conclusion:In case of metacarpal nonunion with impaired bone vascularization, the periosteal medial femoral condyle free flap provides an effective and biomimetic approach to bone healing.

Medial Femoral Condyle Free Flap: A Systematic Review and Proportional Meta-analysis of Applications and Surgical Outcomes

“…Donor site morbidity was reported in 36 studies. 2,4,5,7–11,13–15,17–26,28–42 The most reported postoperative symptoms were transient paresthesia, knee pain, and/or decreased knee mobility. Major complications were rare, with only three cases of femoral fractures, one case of superficial femoral artery injury, one case of medial collateral ligament of the knee injury, and one septic shock due to postoperative pacemaker colonization reported.…”

“…2,7,10,[20][21][22]36 Flap size was described in square centimeters (cm 2 ) and cubic centimeters (cm 3 ), limiting comparability but the mean flap surface ranged from 4.9 to 25.5 cm 2 , and the mean flap volume ranged from 3.6 to 36.1 cm 3 . 2,4,5,10,14,16,18,[20][21][22]28,29,33,36,38,41,42 The mean procedure time ranged from 243 to 540 minutes. 7,8,23,24,29,30,36,37 The overall flap failure rate was 2% (95% CI, 0%-4%; Fig.…”

“…In the upper limb, the main indications were bony nonunion, avascular necrosis (AVN) of carpal bones and traumatic bone loss. 4,11,[13][14][15][16][17][18][19]24,25,28,[30][31][32]34,35 The treated bones included the clavicle, humerus, radius, ulna, carpal bones, metacarpal bones, and phalanx. Henry et al described the use of MFC-FF for replacing bone loss due to osteomyelitis in the distal fingers.…”

“…2 Multiple uses have been described in the literature affirming versatility with applications in different regions of the body. [3][4][5] This study aims at reviewing all retrospective and prospective studies on the application of MFC-FF in bone reconstruction to assess safety by performing a meta-analysis of reconstructive failure rates and donor site complications. A previous review focused exclusively on the head and neck, but this review aims at illustrating and expanding the different applications of this flap.…”

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

“…We, therefore suggest that, even in small bone gaps (mono- or bi-cortical), the use of vascularized bone and/or periosteal transfer: the cortical portion can be tailored according to the gap requiring reconstruction. In the case of free periosteal grafts, this flap can be wrapped around the defect and sutured to itself, providing a proper scaffold with a regeneration chamber that can stimulate physiological pathways and, finally, promote bone union [ 19 ]. Indeed, periosteum provides cells for both chondrogenesis and osteogenesis, being involved in all phases of the fracture repair process, and participating in intramembranous and endochondral ossification [ 20 ].…”