Donorsite defect of medial femoral condyle corticoperiostal flap in the treatment of lower limb infected nonunions

Abstract

Backgrounds Chronic osteomyelitis is a major challenge in orthopaedic surgery; it is the result of open fracture, periprosthetic infection and septic arthritis. Osteomyelitis leads to fracture nonunion. The treatment of bone infection and infected nonunion consists primarily of the complete removal of infected and avascular bone and soft tissue from the surgical site, followed by local and systemic pathogen-specific antibiotic therapy and temporary stabilisation, but may lead to massive skeletal and soft tissue defects. The use of free or pedicled vascularised bone transfers and callus distraction techniques (bone transport) has been recommended for large bone defects. The aim of this study is to evaluate the results of patients affected by infected non-unions of the lower limbs, treated with a corticoperiosteal flap from the medial femoral condyle and to investigate the donor site morbidity of this flap.

Materials and methods The patients were 11 males (average age of 45.6 years), who presented a nonunion of the tibial diaphysis in 7 cases and non-union of femoral diaphysis in 4 cases, treated with free or pedicled corticoperiosteal flap. In all patients, surgical debridement was performed before the flap of infected bone and soft tissues that would not contribute to wound healing. Clinical and radiographic evaluations of the recipient site were performed. Preoperative and postoperative X-ray and MRI scans after the 3-year follow-up of the donor site were performed, in order to observe possible bone restoration and any complications.

Results The patients reported complete clinical and radiographic bone healing in 90.9 % of cases. As regards donor site, there were no differences between the medial femoral donor condyle compared to the contralateral site, due to complete regeneration of donor site bone. MRI investigation showed complete restoration of the donor site with vascularised bone in all patients.

Conclusions Our results suggest that the use of bone flaps for the treatment of infected non-unions is an effective procedure, that must be performed after accurate debridement of the non-union site. The corticoperiosteal flap seems to have few morbidities on the donor site and a high percentage of successful bone healing.

Zusammenfassung

Einleitung Die chronische Osteomyelitis entwickelt sich häufig aus einer offenen Fraktur, bei periprothetischem Infekt oder bei septischer Arthritis und stellt bei infizierter Pseudoarthrose eine bedeutende Herausforderung der Orthopädie dar. Knocheninfekte und infizierte Pseudoarthrosen werden durch radikales, chirurgisches Debridement von Knochen und Weichgewebe verbunden mit lokaler und systemischer Behandlung mit Antibiotika und temporärer Stabilisierung behandelt. Bei größeren Defekten werden freie oder gestielte Knochen-Lappenplastiken oder Kallus-Distraktions-Techniken angewandt. In der vorliegenden Studie werden die Hebedefekte und Ergebnisse bei Patienten mit infizierten Pseudoarthrosen der unteren Extremitäten nach Behandlung mit freier, medialer Femur-Kondylen-Lappenplastik evaluiert.

Material und Methoden 11 Männer (Durchschnittsalter 45,6 Jahre) mit einer Pseudoarthrose der tibialen Diaphyse (7 Fälle) oder Pseudoarthrose der femoralen Diaphyse (4 Fälle) mit freier, medialer Femur-Kondylen-Lappenplastik werden untersucht. In allen Fällen wurde das chirurgische Debridement vor der Lappenplastik ausgeführt. Die klinischen und radiologischen Ergebnisse an der Empfängerstelle werden mittels prä- und postoperativee Röntgen- und MRT-Untersuchungen mit einem Follow-up von druchschnittlich 3 Jahren nachuntersucht.

Ergebnisse In 90,9 % der Fälle wird eine vollständige klinische und radiologische Knochenheilung beobachtet. Im Bereich des Hebedefekts gab es keine erkennbaren Unterschiede zwischen Entnahmeseite des medialen Femur-Kondylus und der kontralateralen Seite. Das Knochegewebe hatte sich im Bereich des Hebedefektes an die unverletzte Gegenseite angeglichen. Auch in der MRT wurde eine Ausheilung des Hebedefekts mir vaskularisiertem Knochen in allen Patienten beobachtet.

Schlussfolgerungen Diese Nachuntersuchung zeigt, dass der Einsatz von freien Knochen-Lappenplastiken ein wirksames Verfahren zur Behandlung von infizierten Pseudoarthrosen der unteren Extremität darstellt. Ein radikales Debridement der Pseudoarthrose ist Voraussetzung. Die Entnahme der freien, medialer Femur-Kondylen-Lappenplastik führt offenbar zu geringer Morbidität am Hebedefekt. Eine erfolgreiche Ausheilung der Pseudarthrose konnte so in einem Prozentsatz erreicht werden.​

Key words

Nonunion - corticoperiosteal - flap - infected - lower limb

Schlüsselwörter

Pseudoarthrose - kortikoperiostal - Lappen - infiziert - untere Extremität

Publication History

Received: 28 July 2020

Accepted: 11 August 2020

Article published online:
12 November 2020

• References

• 1 Cui T, Li J, Zhen P. et al. Masquelet induced membrane technique for treatment of rat chronic osteomyelitis. Exp Ther Med 2018; 16: 3060-3064
• 2 Kanakaris NK, Tosounidis TH, Giannoudis PV. Surgical management of infected non-unions: An update. Injury, Int J. Care Injured 2015; 46: 25-32
• 3 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78: 285-292
• 4 Yokoyama K, Itoman M, Nakamura K. et al. Free Vascularized Fibular graft vs. Ilizarov method for post-traumatic tibial bone defect. J Reconstructive Microsurg 2001; 17: 17-25
• 5 Toia F, Zabbia G, Scirpo R. et al. Microsurgery and external fixation in orthoplastic reconstruction of tibial injuries. Handchir Mikrochir Plast Chir 2019; 51: 484-491
• 6 Philandrianos C, Moullot P, Gay AM. et al. Soft Tissue Coverage in Distal Lower Extremity Open Fractures: Comparison of Free Anterolateral Thigh and Free Latissimus Dorsi Flaps. J Reconstr Microsurg 2018; 34: 121-129
• 7 Cho EH, Shammas RL, Carney MJ. et al. Muscle versus Fasciocutaneous Free Flaps in Lower Extremity Traumatic Reconstruction: A Multicenter Outcomes Analysis. Plast Reconstr Surg 2018; 141: 191-199
• 8 Sakai K, Doi K, Kawai S. Free vascularized thin corticoperiosteal graft. Plast Reconstr Surg 1991; 87: 290-298
• 9 Hamada Y, Hibino N, Kobayashi A. Expanding the utility of modified vascularized femoral periosteal bone-flaps: An analysis of its form and a comparison with a conventional bone graft. J Clin Orthop Trauma 2014; 5: 6-17
• 10 Rossello C, Antonini A, Zoccolan A. et al. Reconstructive surgery for thumb osteomyelitis: a new way of remodelling the vascularized medial femoral condyle flap. A case report. Handchir Mikrochir Plast Chir 2019; 51: 440-443
• 11 Guzzini M, Calderaro C, Guidi M. et al. Treatment of a Femur Nonunion with Microsurgical Corticoperiosteal Pedicled Flap from the Medial Femoral Condyle. Case Rep Orthop 2016; 5125861
• 12 Rein S, Hörnig J, Houschyar KS. et al. Microsurgical soft tissue reconstruction in lower extremity osteitis. Handchir Mikrochir Plast Chir 2018; 23
• 13 Guzzini M, Lanzetti RM, Perugia D. et al. The treatment of long bones nonunions of upper limb with microsurgical cortico-periosteal free flap. Injury 2017; 48: 66-70
• 14 Panteli M, Giannoudis PV. Chronic osteomyelitis: what the surgeon needs to know. EFORT Open Rev 2017; 1: 128-135
• 15 Masquelet AC, Fitoussi F, Begue T. et al. Reconstruction of the long bones by the induced membrane and spongy autograft. Ann Chir Plast Esthet 2000; 45: 346-353
• 16 Doi K, Sakai K. Vascularized periosteal bone graft from the supracondylar region of the femur. Microsurgery 1994; 15: 305-315
• 17 Choudry UH, Bakri K, Moran SL. et al. The vascularized medial femoral condyle periosteal bone flap for the treatment of recalcitrant bony nonunions. Ann Plast Surg 2008; 60: 174-180
• 18 Bakri K, Shin AY, Moran SL. The Vascularized Medial Femoral Corticoperiosteal Flap for Reconstruction of Bony Defects within the Upper and Lower Extremities. Semin Plast Surg 2008; 22: 228-233
• 19 Mehio G, Morsy M, Cayci C. et al. Donor-Site Morbidity and Functional Status following Medial Femoral Condyle Flap Harvest. Plast Reconstr Surg 2018; 142: 734-741
• 20 Rhinelander FW. The normal microcirculation of diaphyseal cortex and its response to fracture. J Bone Joint Surg Am 1968; 50: 784-800
• 21 Katz RD, Parks BG, Higgins JP. The axial stability of the femur after harvest of the medial femoral condyle corticocancellous flap: a biomechanical study of composite femur models. Microsurgery 2012; 32: 213-218
• 22 Dimitriou R, Mataliotakis GI, Angoules AG. et al. Complications following autologous bone graft harvesting from the iliac crest and using the RIA: a systematic review. Injury 2011; 42: 3-15
• 23 Schwartz CE, Martha JF, Kowalski P. et al. Prospective evaluation of chronic pain associated with posterior autologous iliac crest bone graft harvest and its effect on postoperative outcome. Health Qual Life Outcomes 2009; 7: 49
• 24 Ahlmann E, Patzakis M, Roidis N. et al. Comparison of anterior and posterior iliac crest bone grafts in terms of harvest-site morbidity and functional outcomes. J Bone Joint Surg Am 2002; 84: 716-720
• 25 Ling XF, Peng X. What is the price to pay for a free fibula flap? A systematic review of 30 donor-site morbidity following free fibula flap surgery. Plast Reconstr Surg 2012; 129: 657-674