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Corticoperiosteal medial femoral condyle flap for recalcitrant nonunion in ankle and foot: Outcomes and radiological evaluation of donor site morbidity
Journal Pre-proof Corticoperiosteal medial femoral condyle flap for recalcitrant nonunion in ankle and foot: Outcomes and radiological evaluation of donor site morbidity Olga Politikou, Stephan Wirth, Thomas Giesen, Roman Guggenberger, Pietro Giovanoli, Maurizio Calcagni
PII:
S1268-7731(20)30007-2
DOI:
https://doi.org/10.1016/j.fas.2019.12.008
Reference:
FAS 1406
To appear in:
Foot and Ankle Surgery
Received Date:
11 September 2019
Revised Date:
11 November 2019
Accepted Date:
29 December 2019
Please cite this article as: Politikou O, Wirth S, Giesen T, Guggenberger R, Giovanoli P, Calcagni M, Corticoperiosteal medial femoral condyle flap for recalcitrant nonunion in ankle and foot: Outcomes and radiological evaluation of donor site morbidity, Foot and Ankle Surgery (2020), doi: https://doi.org/10.1016/j.fas.2019.12.008
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
Title Corticoperiosteal medial femoral condyle flap for recalcitrant nonunion in ankle and foot: outcomes and radiological evaluation of donor site morbidity
Authors’names and Affiliations Olga Politikou MDa,1
Rämistrasse 100, 8091 Zürich, Switzerland. Email: [email protected] Stephan Wirth MDb
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a. Division of Plastic Surgery and Hand Surgery, University Hospital Zurich,
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b. Division Foot and Ankle Surgery, Orthopaedics Department, University Hospital Balgrist, Forchstrasse 340, 8008 Zurich, Switzerland
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Email: [email protected]
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Thomas Giesen MDa,1
a. Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
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Email: [email protected] Roman Guggenberger MD a
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a. Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
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Email: [email protected]
Pietro Giovanoli MDa a. Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland. Email: [email protected] Maurizio Calcagni MDa 3
a. Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland. Email: [email protected]
Corresponding Author Olga Politikou MD, [email protected] Cantonal Hospital Luzern, Spitalstrasse 6000 Luzern 16
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Tel: +41 79 107 43 04
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Failed ankle and foot arthrodesis treated with free medial femoral condyle flap Union achieved in ten out of thirteen cases Complete radiological union achieved in mean 10 months No morbidity showed in CT and MRI examination of donor knee
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Highlights
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Abstract
Background: The aim of this study was to evaluate the effectiveness and
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safety of free corticoperiosteal medial femoral condyle (MFC) flap for ankle, hindfoot and midfoot reconstruction in patients with recalcitrant nonunion.
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Methods: Patients who underwent ankle and foot reconstruction using the MFC flap at our clinic were recruited for assessment of the union rate, time to union and functional outcome. Furthermore, a clinical and radiological examination of the donor knee was performed using both computed tomography and magnetic resonance imaging.
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Results: Thirteen patients with a mean follow-up time of 2.5 years were included; 10 of them had a previously failed ankle and foot arthrodesis. Union was achieved in 11 patients in an average time of 10 months after MFC flap surgery. Donor site morbidity was minor with no radiological evidence for soft tissue or bone complication. Conclusion: MFC flaps are a useful and safe reconstructive tool and may be
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considered after failed ankle and foot arthrodesis.
Keywords: bone flap, recalcitrant nonunion, medial femoral condyle, ankle
Introduction nonunion,
failed
arthrodesis and,
more
general,
poorly
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Recalcitrant
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1.
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arthrodesis, foot arthrodesis, donor site morbidity
vascularized bone defects of the ankle, hindfoot and midfoot joints remain a
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challenge for surgeons. For these cases, vascularized bone flaps have shown some advantages over conventional bone grafts in terms of osteocyte survival,
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mechanical properties and rate of union [1]. Free fibula flaps or deep circumflex iliac artery (DCIA) flaps are often either
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oversized and difficult to adapt to adjacent bones or associated with high donor site morbidity [2]. Alternatively, the free corticoperiosteal medial femoral condyle (MFC) flap has been successfully used in the reconstruction of the upper and lower extremity for the last decade [3]. However, the use of this flap for ankle and foot reconstruction after failed arthrodesis attempts is rare. Only 10 cases have been previously described in the literature, mostly included in 5
studies involving both upper and lower extremity reconstruction [4- 9]. Union was achieved in all cases. In different studies, the donor area appears to be associated with low morbidity with the most common complications being chronic knee pain and changes in sensory perception [10]. It is important to note that donor site morbidity was usually evaluated via clinical and functional outcomes; a comparative radiological assessment of both the donor and contralateral knee has yet to be
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carried out. The MFC flap has been used at our institution since 2010 to treat nonunion
after failed reconstruction or arthrodesis attempts in the distal leg and foot. The
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aim of this retrospective study was to assess its effectiveness in such complex cases. Therefore, the clinical and radiological union rate and time to union was
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examined. Furthermore, the long-term effects of flap harvest in the donor knee
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was investigated via patient-reported outcomes, clinical examination and radiological evaluation of both the donor and contralateral knee by magnetic
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2. Methods
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resonance imaging (MRI) and computed tomography (CT).
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2.1. Patient selection/Demographics After obtaining approval from the institutional review board, an independent observer reviewed the medical records of all patients treated with a free corticoperiosteal MFC flap for recalcitrant nonunion or avascular bone defects to the distal tibia, ankle joint, hindfoot and midfoot at our Institution from January 2010 to December 2016. We identified the patients through the institutional 6
register and retrospectively collected and analyzed their data. Inclusion criteria were treatment with MFC free flap for recalcitrant nonunion of the distal leg, ankle or foot and a minimum of 12 months follow-up. Pregnancy excluded patients from radiological assessment. Demographic data (age and gender), comorbidities relevant to microsurgery (diabetes, obesity with body mass index [BMI]>30.0, hypercholesterolemia and smoking), the number of previous applied surgeries and presence of
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osteomyelitis had been systematically recorded and were included for analysis. Furthermore, we invited patients to participate in the follow up for clinical and functional evaluation of the ankle and foot as well as for clinical, functional and
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radiological evaluation of the donor knee.
Fifteen patients were identified who met the inclusion criteria. Thirteen patients
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provided written consent and were included in this study. Demographic and
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disease-related data are shown in Table 1. Mean age was 45 (range, 29-57) years; 7 patients were smokers. The median number of previous applied surgeries was 3 (range, 1-7). Futhermore, there were no cases of osteomyelitis.
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Mean follow-up was 2.5 years (range 12 months-6 years)
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2.2. Surgery and postoperative protocol The index operation was conducted by 3 different senior surgeons (level of expertise: 4) [11]. Preoperative vascular assessment of the recipient leg was conducted by angiography. Harvesting was carried out as described by Sakai and Doi [12]. All flaps were harvested as corticoperiosteal flaps including the underlying cancellous bone and never as a chimeric skin paddle flap. Donor site defects were filled with porcine gelatin resorbable sponge (Spongostan 7
Standard, Ethicon, Inc. Somerville, NJ USA). The recipient vessel was chosen according to defect localization and the preoperative angiographic assessment. Arterial anastomosis was performed manually with Nylon 8/0 or 9/0, while vein anastomosis was performed either manually or by using a coupler (GEM microvascular anastomotic coupler system, Synovis Micro Companies Alliance, Birmingham, UK). Doppler probes were not implanted for postoperative flap monitoring. Postoperative prophylactic anticoagulation was achieved by the continuous intravenous infusion of heparin 10000UI/24 hours (B. Braun Medical
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AG, Sempach, Switzerland) for the first 48 hours after surgery. We then switched to low molecular weight heparin (5000UI/24hours, Fragmin Pfizer Switzerland GmbH) injections until full weightbearing. The operated leg was
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immobilized in a cast and partial weightbearing was initiated after the first
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radiological signs of union.
Surgery related data are shown in Table 1. Mean operative time was 337
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(range, 265-420) minutes. The descending genicular artery (DGA) was usually used as feeding vessel (Figure 1a, Figure 1b). In two cases, the DGA was
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absent and the superior medial genicular artery was used. Pedicle length was reported in 10 out of 13 cases and was 6.9 (range, 5-9) cm on average. The
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size of the bone flap was adapted to the defect and was 1.5 to 3.5 cm in length and 1 to 2.5 cm in width. Debridement of the necrotic bone up to good
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vascularized tissue and hardware removal was performed when indicated (Figure 2). The bone flap was then raised from the ipsilateral knee and fixed either with a compression plate and screws or with cannulated screws. In 2 cases, no extra fixation was needed and the press-fit technique was applied. In 2 other cases of ankle re-arthrodesis, an external fixator was applied. The
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vascular pedicle was anastomosed with the anterior tibial artery in all but 2 cases.
2.3. Clinical, functional and radiological assessment of the ankle and foot Clinical endpoints were dorsiflexion/plantarflexion (in cases without ankle arthrodesis), and pain relief at rest and during weightbearing, according to the visual analogue scale (VAS). We then used the Foot Function Index
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questionnaire for German-speaking patients (FFI-D). This questionnaire measures the foot pathology impact on function and consists of 18 items
separated into a pain and disability subscale (Supplemental file 1).
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Complications related to the index surgery, time to full weightbearing and time
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to return to work (months) were also recorded.
Time to complete radiological union was assessed by an independent
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experienced radiologist on CT scans (Siemens Healthcare) and plain x-rays in the following intervals: 6 weeks, 3 months, 6 months, 9 months, 1 year. If union
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progression could still be observed at the 1-year radiological follow up,
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radiological controls were continued in 3 months intervals.
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2.4. Assessment of donor site morbidity The donor site was assessed both clinically and radiologically at the last followup visit. The clinical endpoints were knee range of motion, pain at rest and during weightbearing (VAS), subjective rating of scar appearance (satisfied, not satisfied, indifferent) and complications. The donor and contralateral knee were also examined by CT and MRI (Siemens Healthcare) to look for osteoarthritis, 9
cortical lesions and damage to the medial collateral ligament or other soft tissue.
2.5. Statistical analysis Only descriptive statistics were performed due to the small number of participants and are presented as means (average) and ranges for continuous variables and medians and ranges for categorical variables. There was no
Results
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3.
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control group in this study.
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3.1. Clinical, functional and radiological outcomes
Union was achieved in 11 out of 13 cases. On average, complete radiological
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union was achieved after 10 (range, 3-15) months. The average time to full weightbearing was 4.8 (range, 1.5-12) months. One case of deep venous
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thrombosis of the operated leg was the only major complication. Outcomes are shown in Table 2.
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During the recruitment for functional and clinical assessment of the
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reconstructed area and radiological and clinical evaluation of the donor knee, one patient (Case 3) refused to participate and was excluded. Of the 12 remaining patients, one (Case 5) refused to participate in the radiological part, while another one (Case 8) was pregnant at the follow-up time and was excluded from radiological examination. Both patients participated in the clinical examination and functional assessment of the reconstructed and donor area.
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Pain reduction in the reconstructed area was achieved in all 12 patients. Complete pain relief at rest was reported in all but one case (Case 6, VAS 2); during weightbearing, the median VAS pain was 3 (range, 0-7). In 8 cases where ankle arthrodesis had not been performed, an average ankle dorsiflexion of 65 (range, 50-90) degrees, and an average plantarflexion of 23.1 (range, 045) degrees was observed. With regards to the FFI-D questionnaire, the average score was 30.4 (range, 4.1- 55.5) for the pain subscale and 38.1 (range, 5.5-79.1) for the functional subscale. Due to the retrospective nature of
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this study, preoperative FFI-D scores were not available. Therefore, an
assessment of its change over time could not be conducted. Eight out of 12 patients were able to return to their previous occupation over a mean time of
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3.4 (range, 1-8) months; one patient had to change occupation and 3 other
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patients received an invalidity pension (Table 4).
The radiological findings of an osteochondritis dissecans of the talus (Case 1)
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before and 6 months after index surgery are shown in Figure 3a and Figure 3b respectively. The radiological findings of a distal tibia bone infarct after a
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bimalleolar fracture treated with open reduction and plate fixation and a subsequent removal of the osteosynthesis material (Case 2) are shown in
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Figure 4a, while Figure 4b displays the results 6 months after index surgery. Another patient (Case 9) with recalcitrant talonavicular nonunion after 2 failed
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arthrodesis, initially talonavicular und subsequently both talonavicular and naviculocuneiform, is presented in Figure 5a. In this case union was achieved 15 months after MFC flap reconstruction and the radiological result is presented in Figure 5b.
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3.2. Donor site morbidity Nine out of 12 patients achieved pain free weightbearing on the donor knee after an average duration of 3.3 (range, 0.5-7) months after surgery, while the other 3 patients reported persistent light pain when walking (VAS 3-4). All but one were satisfied with scar appearance. All patients achieved full range of motion of the treated knee as well as movement symmetry compared with the contralateral side. Eight out of 12 patients complained about numbness in the
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medial knee area, but without neuropathic pain. Radiological evaluation of the donor site was performed in 10 patients using CT
and MRI scans of both knees. MRI revealed signs of osteoarthritis in the donor
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knee in one patient. However, this patient also had osteoarthritic changes in
the untreated contralateral knee, suggesting no association with the flap
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harvest procedure. No lesions of the medial collateral ligament were observed,
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although in 4 cases the proximal insertion of its superficial part was scarred.
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There were no fractures of the MFC in any of the patients.
4. Discussion
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Union was achieved in 11 out of 13 patients following treatment of recalcitrant
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nonunion of the distal leg, ankle and foot treated with a free corticoperiosteal MFC flap, while 2 patients showed poorer outcomes. The first patient (Case 3) had a history of seven failed reconstruction attempts prior to the index operation. The second patient (Case 7) was a heavy smoker (60 pack years) which may have contributed to the bad result. This suggests that strict patient selection is essential before utilizing free vascularized bone flaps.
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In a previous study Cavadas et al. reported 21 cases of distal tibia metaphyseal reconstruction using MFC flaps with a 100% union rate, but no comorbidities associated with the impairment of bone healing (such as smoking) had been recorded. Moreover, the number of failed reconstructions prior to the index operation was lower [13]. Hintermann et al. also reported union in all 14 cases of talus shoulder reconstruction using MFC flaps [14]. Similarly, no information regarding comorbidities was given and the average number of previous reconstruction attempts was 1.8 (range 0-4) and thus lower than in the present
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study. Furthermore, in our series 10 out of 13 patients had recalcitrant nonunion after failed ankle, midfoot and hindfoot arthrodesis. These cases are particularly difficult to treat and, in our opinion, represent a group of more challenging
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indications. Previous studies did not include many of these cases, thus making
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a direct comparison of our results very difficult.
Morbidity of the donor site was minimal without any major complications. Light
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pain during full weightbearing was reported in only 3 cases, and knee numbness was observed in 8 cases. MRI of the donor site also demonstrated
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minimal changes without any injuries of the medial collateral ligament or meniscus impairment over an average follow-up period of 2.5 years. Scarring
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of the superficial part of the medial collateral ligament was revealed in 4 cases, but without any clinical correlate. Just one previous study assessed donor knee
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morbidity with MRI examination. However, the focus was on the harvest of a medial trochlea flap and therefore the data cannot be compared to ours [15]. There were no fractures of the MFC after harvesting the corticoperiosteal flap in any of our patients. Only one previous study reported this complication and the fracture was treated with internal fixation [16]. Rao et al. examined donor knee morbidity by CT with a follow-up period of more than a year and no major 13
complications or findings of new degenerative joint disease were reported [17]. We confirmed these findings after an even longer follow-up period. In 2012, an anatomical study by Katz et al. [18] showed that axial knee stability is not threatened by large bone flap harvesting. In a different anatomical study, Endara et al. examined torsional knee stability in relation to flap size and demonstrated that flap harvests larger than 7cm were associated with a higher frequency of iatrogenic fractures [19]. The size of our harvested bone flap was much smaller than this critical size. Our findings also confirm the outcomes of
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Mehio et al. and those of a systematic review published by Giladi et al. [10, 20]. The limitations of our study are its retrospective nature and the small number
of patients. However, these limitations were mitigated by a long follow-up
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period, which was longer than in all other previously published studies. We
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conclude that the free corticoperiosteal MFC flap for distal leg, ankle, midfoot and hindfoot reconstruction can be efficient in cases of recalcitrant nonunion
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and is associated with low donor site morbidity. Surgeons may consider this flap as a useful reconstruction option for patients with previous failed ankle and
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foot arthrodesis.
Declarations of interest: none
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This statement concerns all the above listed authors.
Conflict of interest statement The authors involved in this study declare that there are no existing conflicts of interest. 14
Funding No funding was sought for this research. The authors have no conflicts to disclose or competing interests.
References [1] Arata MA, Wood MB, Cooney WP, 3rd. Revascularized segmental
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diaphyseal bone transfers in the canine. An analysis of viability. J Reconstr Microsurg 1984;1:11-19. doi: 10.1055/s-2007-1007048
[2] Forrest C, Boyd B, Manktelow R, Zuker R, Bowen V. The free vascularised
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iliac crest tissue transfer: donor site complications associated with eighty-two
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cases. Br J Plast Surg 1992;45:89-93. doi: 10.1016/0007-1226(92)90163-R. [3] Kazmers NH, Thibaudeau S, Steinberger Z, Levin LS. Upper and lower
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extremity reconstructive applications utilizing free flaps from the medial genicular arterial system: A systematic review. Microsurgery 2018;38:328-343.
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doi: 10.1002/micr.30138.
[4] Rahmanian-Schwarz A, Spetzler V, Amr A, Pfau M, Schaller HE, Hirt B. A
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composite osteomusculocutaneous free flap from the medial femoral condyle
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for reconstruction of complex defects. J Reconstr Microsurg 2011;27:251-260. doi: 10.1055/s-0031-1275489. [5] Pelzer M, Reichenberger M, Germann G. Osteo-periosteal-cutaneous flaps of the medial femoral condyle: a valuable modification for selected clinical situations. J Reconstr Microsurg 2010;26:291-294. doi: 10.1055/s-00301248239. 15
[6] Holm J, Vangelisti G, Remmers J. Use of the medial femoral condyle vascularized bone flap in traumatic avascular necrosis of the navicular: a case report. J Foot Ankle Surg 2012;51:494-500. doi: 10.1053/j.jfas.2012.04.012. [7] Haddock NT, Alosh H, Easley ME, Levin LS, Wapner KL. Applications of the medial femoral condyle free flap for foot and ankle reconstruction. Foot Ankle Int 2013;34:1395-1402. doi: 10.1177/1071100713491077. [8] Tremp M, Haumer A, Wettstein R, Zhang YX, Honigmann P, Schaefer DJ,
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et al. The medial femoral trochlea flap with a monitor skin island-Report of two cases. Microsurgery 2017;37:431-435. doi: 10.1002/micr.30093.
[9] Kazmers NH, Thibaudeau S, Gerety P, Lambi AG, Levin LS. Versatility of
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the Medial Femoral Condyle Flap for Extremity Reconstruction and
Complications.
Ann
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2018;80:364-372.
doi:
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10.1097/sap.0000000000001332.
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Identification of Risk Factors for Nonunion, Delayed Time to Union, and
[10] Giladi AM, Rinkinen JR, Higgins JP, Iorio ML. Donor-Site Morbidity of
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Vascularized Bone Flaps from the Distal Femur: A Systematic Review. Plast Reconstr Surg 2018;142:363e-372e. doi: 10.1097/PRS.0000000000004691.
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[11] Tang JB, Giddins G. Why and how to report surgeons' levels of expertise.
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J Hand Surg Eur Vol 2016;41:365-366. doi: 10.1177/1753193416641590. [12] Doi K, Sakai K. Vascularized periosteal bone graft from the supracondylar region of the femur. Microsurgery 1994;15:305-315. [13] Cavadas PC, Landin L. Treatment of recalcitrant distal tibial nonunion using the descending genicular corticoperiosteal free flap. J Trauma 2008;64:144-150. 16
[14] Hintermann B, Wagener J, Knupp M, Schweizer C, D JS. Treatment of extended osteochondral lesions of the talus with a free vascularised bone graft from the medial condyle of the femur. Bone Joint J 2015;97-b:1242-1249. doi: 10.1302/0301-620x.97b9.35292. [15] Windhofer C, Wong VW, Larcher L, Paryavi E, Burger HK, Higgins JP. Knee Donor Site Morbidity Following Harvest of Medial Femoral Trochlea Osteochondral Flaps for Carpal Reconstruction. J Hand Surg Am 2016;41:610-
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614. doi: 10.1016/j.jhsa.2016.01.015. [16] Hamada Y, Hibino N, Kobayashi A. Expanding the utility of modified
vascularized femoral periosteal bone-flaps: An analysis of its form and a
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comparison with a conventional-bone-graft. J Clin Orthop Trauma 2014;5:6-17.
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doi: 10.1016/j.jcot.2014.01.002.
[17] Rao SS, Sexton CC, Higgins JP. Medial femoral condyle flap donor-site
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morbidity: a radiographic assessment. Plast Reconstr Surg 2013;131:357-362. doi: 10.1097/PRS.0b013e31827c6f38.
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[18] 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 femur
models.
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2012;32:213-218.
doi:
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composite
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10.1002/micr.20986.
[19] Endara MR, Brown BJ, Shuck J, Bachabi M, Parks BG, Higgins JP. Torsional stability of the femur after harvest of the medial femoral condyle corticocancellous flap. J Reconstr Microsurg 2015;31:364-368. doi: 10.1055/s0035-1546420.
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[20] Mehio G, Morsy M, Cayci C, Sabbagh MD, Shin AY, Bishop AT, et al. Donor Site Morbidity and Functional Status Following Medial Femoral Condyle Flap
Harvest.
Plast
Reconstr
Surg
2018;142(5):734e-741e.
doi:
10.1097/PRS.0000000000004886.
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Figure 1a: Harvesting of the corticoperiosteal MFC flap. Right cranial, left caudal. The descending genicular artery irrigating the bone flap, marked with the blue vessel loop. Length of the pedicle 6cm.
Figure 1b: The harvested corticoperiosteal MFC flap with adjacent cancellous bone and the donor site defect on the medial femoral condyle.
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Figure 2: Debridement of the avascular bone after failed calcaneocuboidal arthrodesis and preparation of the recipient vessel (anterior tibial artery).
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Figure 3a: A 36 years old man (Case 1) with osteochondritis dissecans of the talus, initially treated with retrograde drilling of the talar dome. T1- and T2weighted MRI images in anteroposterior view of the ankle.
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Figure 3b: Weightbearing X-rays of the ankle in anteroposterior and lateral views 6 months after treatment of the osteochondritis dissecans of the talus with debridement and reconstruction with cancellous bone and free corticoperiosteal MFC flap (Case 1).
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Figure 4a: A 29 years old man (Case 2) with a distal tibia bone infarct after bimalleolar fracture, treated with open reduction and plate fixation and afterwards removal of the osteosynthesis material. Anteroposterior and lateral T1-weighted MRI image of the ankle.
Figure 4b: Anteroposterior and lateral CT-scan images 6 months after distal tibia debridement and reconstruction with corticoperiosteal MFC flap (Case 2).
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Figure 5a: A 46-years old man (Case 9) with recalcitrant talonavicular joint arthritis after twice failed talonavicular and naviculocuneiform arthrodesis. Lateral CT-scan view.
Figure 5b: Union achieved 15 months after talonavicular re-arthrodesis and reconstruction with corticoperiosteal MFC flap (Case 9). Lateral CT-scan view.
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Figure 1a
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Figure 1b
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Figure 2
Figure 3a
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Figure 3b
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Figure 4a
Figure 4b
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Figure 5a
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Figure 5b
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Table 1. Patient demographics, comorbidities relevant to microsurgery, surgery indications, number of previous surgeries before index surgery and surgery related data. Size graft N
Operation
previous
duration
Length Use
Case
Age/Sex
Comorbidities
Smoker
Indication
(length pedicle
DGA/SMGA operations
(minutes)
Fixation
Ana
None
A
(pressfit)
a
None
A
(pressfit)
a
x (cm) width) cm
talus 36/M
none
no
osteochondritis
1
dissecans
yes (10 29/M
bone infarct distal
none
2 py)
tibia
Adipositas failed subtalar 3
46/M
BMI 30,5
no
7
arthrodesis
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kg/m2, AH
270
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2
265
DGA
8
3 x1
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1
355
DGA
5
NR
3.5mm
A SMGA
4
NR
cannulated
a screws
6.5mm
failed subtalar 4
49/F
none
yes
2
A 280
DGA
8
2 x2
cannulated
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arthrodesis
a screws
Hoffmann
failed ankle
56/M
none
no
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5
3.5 3
420
DGA
8
arthrodesis
x.2.5
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6
52/M
failed subtalar 6.5mm and
BMI 31
A. 4
py)
344
DGA
7
NR
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cannulated
calcaneocuboidal
kg/m2
7
a fixator
Adipositas
yes (25
A external
screws arthrodesis
failed yes (60
talonavicular/
AH
3 py)
307
DGA
6
4.5 LCP
A
plate
a
3.5 LC-
A
DCP plate
a
NR
naviculocuneiform arthrodesis
distal tibia 38/F 8
none
no
3
400
DGA
NR
1,5 x 2
nonunion
23
failed AH, HCL, 9
yes (25
talonavicular/
46/M
2 heart infarct
py)
270
SMGA
NR
3.5 VA-
A
LCP plate
a
4.5 LCP
A
plate
p
2,5 x 2
naviculocuneiform arthrodesis
failed ankle 10
54/M
none
no
2
383
DGA
7
3 x 1,5
arthrodesis
Illizarov yes (54 11
43/M
failed ankle
none
A 3
py)
320
DGA
NR
3 x2
external
arthrodesis
a fixator
failed 38/F
none
yes
calcaneocuboidal
3.0mm 7
failed ankle and 38/M
none
no
subtalar
DGA
9
4
DGA
7
2 x2
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arthrodesis
410
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M: male, F: female, AH: arterial hypertension, HCL: hypercholesterolemia, BMI:
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body mass index, py: packet years, N: number. DGA: descending genicular artery, SMGA: superior medial genicular artery, A: arteria. VA-LCP plate: variable angle locking compression plate, LC-DCP plate: limited contact dynamic compression
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plate. NR: not reported.
A
3 x2 X-Plate
arthrodesis
13
360
ro of
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Table 2. Time to radiological union and to full weightbearing. Clinical and functional results and complications after surgery.
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a
6.5 mm
A cannulated
a screws
Ankle
Case
Time to
Time to full
union
weightbearing
(months)
(months)
Time to
dorsiflexion/
Pain relief VAS
Complications
FFI-D score
return to
(rest/ plantarflexion
weightbearing)
(pain/function)
work (months)
(degrees)
1
6
3
none
50/20
0/ 3
15.2/24.4
1,5
2
3
1.5
CRPS foot
90/40
0/ 0
12.5/6.6
1
NA
NA
excluded
excluded
excluded
excluded
80/40
0/ 3
33.3/25.9
2
Not 3 achieved
Loosening 1 4
12
2
9
4.5
none
NA
6
12
7
none
60/20
NA
none
Not 7 achieved
9
4
none
9
15
7
none
4.1/ 26.3
5
2/ 7
55.5/64.4
8
60/0
nonunion
nonunion
invalidity
60/20
0/ 0
4.1/17.7
6
60/45
0/ 5
41.6/47.6
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8
0/ 0
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5
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screw
change work
Deep venous
10
15
3
NA
0/ 5
52.7/66.6
invalidity
NA
0/ 0
4.1/5.5
1
60/0
0/ 6
55.5/55.5
invalidity
NA
0/ 6
55.5/79.1
2.5
11
6
12
18
na
thrombosis
6
none
Neuropathy sural
ur 6
3
nerve
none
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13
12
CRPS: complex regional pain syndrome, NA: not applied (ankle arthrodesis), VAS: visual analogue scale, FFI-D: foot function index questionnaire for german speaking patients, pain: pain subscale, function: function subscale.
25
PII:
S1268-7731(20)30007-2
DOI:
https://doi.org/10.1016/j.fas.2019.12.008
Reference:
FAS 1406
To appear in:
Foot and Ankle Surgery
Received Date:
11 September 2019
Revised Date:
11 November 2019
Accepted Date:
29 December 2019
Please cite this article as: Politikou O, Wirth S, Giesen T, Guggenberger R, Giovanoli P, Calcagni M, Corticoperiosteal medial femoral condyle flap for recalcitrant nonunion in ankle and foot: Outcomes and radiological evaluation of donor site morbidity, Foot and Ankle Surgery (2020), doi: https://doi.org/10.1016/j.fas.2019.12.008
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
Title Corticoperiosteal medial femoral condyle flap for recalcitrant nonunion in ankle and foot: outcomes and radiological evaluation of donor site morbidity
Authors’names and Affiliations Olga Politikou MDa,1
Rämistrasse 100, 8091 Zürich, Switzerland. Email: [email protected] Stephan Wirth MDb
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a. Division of Plastic Surgery and Hand Surgery, University Hospital Zurich,
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b. Division Foot and Ankle Surgery, Orthopaedics Department, University Hospital Balgrist, Forchstrasse 340, 8008 Zurich, Switzerland
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Email: [email protected]
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Thomas Giesen MDa,1
a. Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
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Email: [email protected] Roman Guggenberger MD a
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a. Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.
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Email: [email protected]
Pietro Giovanoli MDa a. Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland. Email: [email protected] Maurizio Calcagni MDa 3
a. Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Rämistrasse 100, 8091 Zürich, Switzerland. Email: [email protected]
Corresponding Author Olga Politikou MD, [email protected] Cantonal Hospital Luzern, Spitalstrasse 6000 Luzern 16
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Tel: +41 79 107 43 04
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Failed ankle and foot arthrodesis treated with free medial femoral condyle flap Union achieved in ten out of thirteen cases Complete radiological union achieved in mean 10 months No morbidity showed in CT and MRI examination of donor knee
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Highlights
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Abstract
Background: The aim of this study was to evaluate the effectiveness and
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safety of free corticoperiosteal medial femoral condyle (MFC) flap for ankle, hindfoot and midfoot reconstruction in patients with recalcitrant nonunion.
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Methods: Patients who underwent ankle and foot reconstruction using the MFC flap at our clinic were recruited for assessment of the union rate, time to union and functional outcome. Furthermore, a clinical and radiological examination of the donor knee was performed using both computed tomography and magnetic resonance imaging.
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Results: Thirteen patients with a mean follow-up time of 2.5 years were included; 10 of them had a previously failed ankle and foot arthrodesis. Union was achieved in 11 patients in an average time of 10 months after MFC flap surgery. Donor site morbidity was minor with no radiological evidence for soft tissue or bone complication. Conclusion: MFC flaps are a useful and safe reconstructive tool and may be
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considered after failed ankle and foot arthrodesis.
Keywords: bone flap, recalcitrant nonunion, medial femoral condyle, ankle
Introduction nonunion,
failed
arthrodesis and,
more
general,
poorly
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Recalcitrant
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1.
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arthrodesis, foot arthrodesis, donor site morbidity
vascularized bone defects of the ankle, hindfoot and midfoot joints remain a
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challenge for surgeons. For these cases, vascularized bone flaps have shown some advantages over conventional bone grafts in terms of osteocyte survival,
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mechanical properties and rate of union [1]. Free fibula flaps or deep circumflex iliac artery (DCIA) flaps are often either
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oversized and difficult to adapt to adjacent bones or associated with high donor site morbidity [2]. Alternatively, the free corticoperiosteal medial femoral condyle (MFC) flap has been successfully used in the reconstruction of the upper and lower extremity for the last decade [3]. However, the use of this flap for ankle and foot reconstruction after failed arthrodesis attempts is rare. Only 10 cases have been previously described in the literature, mostly included in 5
studies involving both upper and lower extremity reconstruction [4- 9]. Union was achieved in all cases. In different studies, the donor area appears to be associated with low morbidity with the most common complications being chronic knee pain and changes in sensory perception [10]. It is important to note that donor site morbidity was usually evaluated via clinical and functional outcomes; a comparative radiological assessment of both the donor and contralateral knee has yet to be
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carried out. The MFC flap has been used at our institution since 2010 to treat nonunion
after failed reconstruction or arthrodesis attempts in the distal leg and foot. The
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aim of this retrospective study was to assess its effectiveness in such complex cases. Therefore, the clinical and radiological union rate and time to union was
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examined. Furthermore, the long-term effects of flap harvest in the donor knee
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was investigated via patient-reported outcomes, clinical examination and radiological evaluation of both the donor and contralateral knee by magnetic
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2. Methods
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resonance imaging (MRI) and computed tomography (CT).
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2.1. Patient selection/Demographics After obtaining approval from the institutional review board, an independent observer reviewed the medical records of all patients treated with a free corticoperiosteal MFC flap for recalcitrant nonunion or avascular bone defects to the distal tibia, ankle joint, hindfoot and midfoot at our Institution from January 2010 to December 2016. We identified the patients through the institutional 6
register and retrospectively collected and analyzed their data. Inclusion criteria were treatment with MFC free flap for recalcitrant nonunion of the distal leg, ankle or foot and a minimum of 12 months follow-up. Pregnancy excluded patients from radiological assessment. Demographic data (age and gender), comorbidities relevant to microsurgery (diabetes, obesity with body mass index [BMI]>30.0, hypercholesterolemia and smoking), the number of previous applied surgeries and presence of
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osteomyelitis had been systematically recorded and were included for analysis. Furthermore, we invited patients to participate in the follow up for clinical and functional evaluation of the ankle and foot as well as for clinical, functional and
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radiological evaluation of the donor knee.
Fifteen patients were identified who met the inclusion criteria. Thirteen patients
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provided written consent and were included in this study. Demographic and
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disease-related data are shown in Table 1. Mean age was 45 (range, 29-57) years; 7 patients were smokers. The median number of previous applied surgeries was 3 (range, 1-7). Futhermore, there were no cases of osteomyelitis.
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Mean follow-up was 2.5 years (range 12 months-6 years)
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2.2. Surgery and postoperative protocol The index operation was conducted by 3 different senior surgeons (level of expertise: 4) [11]. Preoperative vascular assessment of the recipient leg was conducted by angiography. Harvesting was carried out as described by Sakai and Doi [12]. All flaps were harvested as corticoperiosteal flaps including the underlying cancellous bone and never as a chimeric skin paddle flap. Donor site defects were filled with porcine gelatin resorbable sponge (Spongostan 7
Standard, Ethicon, Inc. Somerville, NJ USA). The recipient vessel was chosen according to defect localization and the preoperative angiographic assessment. Arterial anastomosis was performed manually with Nylon 8/0 or 9/0, while vein anastomosis was performed either manually or by using a coupler (GEM microvascular anastomotic coupler system, Synovis Micro Companies Alliance, Birmingham, UK). Doppler probes were not implanted for postoperative flap monitoring. Postoperative prophylactic anticoagulation was achieved by the continuous intravenous infusion of heparin 10000UI/24 hours (B. Braun Medical
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AG, Sempach, Switzerland) for the first 48 hours after surgery. We then switched to low molecular weight heparin (5000UI/24hours, Fragmin Pfizer Switzerland GmbH) injections until full weightbearing. The operated leg was
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immobilized in a cast and partial weightbearing was initiated after the first
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radiological signs of union.
Surgery related data are shown in Table 1. Mean operative time was 337
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(range, 265-420) minutes. The descending genicular artery (DGA) was usually used as feeding vessel (Figure 1a, Figure 1b). In two cases, the DGA was
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absent and the superior medial genicular artery was used. Pedicle length was reported in 10 out of 13 cases and was 6.9 (range, 5-9) cm on average. The
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size of the bone flap was adapted to the defect and was 1.5 to 3.5 cm in length and 1 to 2.5 cm in width. Debridement of the necrotic bone up to good
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vascularized tissue and hardware removal was performed when indicated (Figure 2). The bone flap was then raised from the ipsilateral knee and fixed either with a compression plate and screws or with cannulated screws. In 2 cases, no extra fixation was needed and the press-fit technique was applied. In 2 other cases of ankle re-arthrodesis, an external fixator was applied. The
8
vascular pedicle was anastomosed with the anterior tibial artery in all but 2 cases.
2.3. Clinical, functional and radiological assessment of the ankle and foot Clinical endpoints were dorsiflexion/plantarflexion (in cases without ankle arthrodesis), and pain relief at rest and during weightbearing, according to the visual analogue scale (VAS). We then used the Foot Function Index
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questionnaire for German-speaking patients (FFI-D). This questionnaire measures the foot pathology impact on function and consists of 18 items
separated into a pain and disability subscale (Supplemental file 1).
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Complications related to the index surgery, time to full weightbearing and time
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to return to work (months) were also recorded.
Time to complete radiological union was assessed by an independent
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experienced radiologist on CT scans (Siemens Healthcare) and plain x-rays in the following intervals: 6 weeks, 3 months, 6 months, 9 months, 1 year. If union
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progression could still be observed at the 1-year radiological follow up,
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radiological controls were continued in 3 months intervals.
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2.4. Assessment of donor site morbidity The donor site was assessed both clinically and radiologically at the last followup visit. The clinical endpoints were knee range of motion, pain at rest and during weightbearing (VAS), subjective rating of scar appearance (satisfied, not satisfied, indifferent) and complications. The donor and contralateral knee were also examined by CT and MRI (Siemens Healthcare) to look for osteoarthritis, 9
cortical lesions and damage to the medial collateral ligament or other soft tissue.
2.5. Statistical analysis Only descriptive statistics were performed due to the small number of participants and are presented as means (average) and ranges for continuous variables and medians and ranges for categorical variables. There was no
Results
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3.
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control group in this study.
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3.1. Clinical, functional and radiological outcomes
Union was achieved in 11 out of 13 cases. On average, complete radiological
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union was achieved after 10 (range, 3-15) months. The average time to full weightbearing was 4.8 (range, 1.5-12) months. One case of deep venous
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thrombosis of the operated leg was the only major complication. Outcomes are shown in Table 2.
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During the recruitment for functional and clinical assessment of the
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reconstructed area and radiological and clinical evaluation of the donor knee, one patient (Case 3) refused to participate and was excluded. Of the 12 remaining patients, one (Case 5) refused to participate in the radiological part, while another one (Case 8) was pregnant at the follow-up time and was excluded from radiological examination. Both patients participated in the clinical examination and functional assessment of the reconstructed and donor area.
10
Pain reduction in the reconstructed area was achieved in all 12 patients. Complete pain relief at rest was reported in all but one case (Case 6, VAS 2); during weightbearing, the median VAS pain was 3 (range, 0-7). In 8 cases where ankle arthrodesis had not been performed, an average ankle dorsiflexion of 65 (range, 50-90) degrees, and an average plantarflexion of 23.1 (range, 045) degrees was observed. With regards to the FFI-D questionnaire, the average score was 30.4 (range, 4.1- 55.5) for the pain subscale and 38.1 (range, 5.5-79.1) for the functional subscale. Due to the retrospective nature of
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this study, preoperative FFI-D scores were not available. Therefore, an
assessment of its change over time could not be conducted. Eight out of 12 patients were able to return to their previous occupation over a mean time of
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3.4 (range, 1-8) months; one patient had to change occupation and 3 other
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patients received an invalidity pension (Table 4).
The radiological findings of an osteochondritis dissecans of the talus (Case 1)
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before and 6 months after index surgery are shown in Figure 3a and Figure 3b respectively. The radiological findings of a distal tibia bone infarct after a
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bimalleolar fracture treated with open reduction and plate fixation and a subsequent removal of the osteosynthesis material (Case 2) are shown in
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Figure 4a, while Figure 4b displays the results 6 months after index surgery. Another patient (Case 9) with recalcitrant talonavicular nonunion after 2 failed
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arthrodesis, initially talonavicular und subsequently both talonavicular and naviculocuneiform, is presented in Figure 5a. In this case union was achieved 15 months after MFC flap reconstruction and the radiological result is presented in Figure 5b.
11
3.2. Donor site morbidity Nine out of 12 patients achieved pain free weightbearing on the donor knee after an average duration of 3.3 (range, 0.5-7) months after surgery, while the other 3 patients reported persistent light pain when walking (VAS 3-4). All but one were satisfied with scar appearance. All patients achieved full range of motion of the treated knee as well as movement symmetry compared with the contralateral side. Eight out of 12 patients complained about numbness in the
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medial knee area, but without neuropathic pain. Radiological evaluation of the donor site was performed in 10 patients using CT
and MRI scans of both knees. MRI revealed signs of osteoarthritis in the donor
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knee in one patient. However, this patient also had osteoarthritic changes in
the untreated contralateral knee, suggesting no association with the flap
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harvest procedure. No lesions of the medial collateral ligament were observed,
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although in 4 cases the proximal insertion of its superficial part was scarred.
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There were no fractures of the MFC in any of the patients.
4. Discussion
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Union was achieved in 11 out of 13 patients following treatment of recalcitrant
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nonunion of the distal leg, ankle and foot treated with a free corticoperiosteal MFC flap, while 2 patients showed poorer outcomes. The first patient (Case 3) had a history of seven failed reconstruction attempts prior to the index operation. The second patient (Case 7) was a heavy smoker (60 pack years) which may have contributed to the bad result. This suggests that strict patient selection is essential before utilizing free vascularized bone flaps.
12
In a previous study Cavadas et al. reported 21 cases of distal tibia metaphyseal reconstruction using MFC flaps with a 100% union rate, but no comorbidities associated with the impairment of bone healing (such as smoking) had been recorded. Moreover, the number of failed reconstructions prior to the index operation was lower [13]. Hintermann et al. also reported union in all 14 cases of talus shoulder reconstruction using MFC flaps [14]. Similarly, no information regarding comorbidities was given and the average number of previous reconstruction attempts was 1.8 (range 0-4) and thus lower than in the present
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study. Furthermore, in our series 10 out of 13 patients had recalcitrant nonunion after failed ankle, midfoot and hindfoot arthrodesis. These cases are particularly difficult to treat and, in our opinion, represent a group of more challenging
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indications. Previous studies did not include many of these cases, thus making
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a direct comparison of our results very difficult.
Morbidity of the donor site was minimal without any major complications. Light
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pain during full weightbearing was reported in only 3 cases, and knee numbness was observed in 8 cases. MRI of the donor site also demonstrated
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minimal changes without any injuries of the medial collateral ligament or meniscus impairment over an average follow-up period of 2.5 years. Scarring
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of the superficial part of the medial collateral ligament was revealed in 4 cases, but without any clinical correlate. Just one previous study assessed donor knee
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morbidity with MRI examination. However, the focus was on the harvest of a medial trochlea flap and therefore the data cannot be compared to ours [15]. There were no fractures of the MFC after harvesting the corticoperiosteal flap in any of our patients. Only one previous study reported this complication and the fracture was treated with internal fixation [16]. Rao et al. examined donor knee morbidity by CT with a follow-up period of more than a year and no major 13
complications or findings of new degenerative joint disease were reported [17]. We confirmed these findings after an even longer follow-up period. In 2012, an anatomical study by Katz et al. [18] showed that axial knee stability is not threatened by large bone flap harvesting. In a different anatomical study, Endara et al. examined torsional knee stability in relation to flap size and demonstrated that flap harvests larger than 7cm were associated with a higher frequency of iatrogenic fractures [19]. The size of our harvested bone flap was much smaller than this critical size. Our findings also confirm the outcomes of
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Mehio et al. and those of a systematic review published by Giladi et al. [10, 20]. The limitations of our study are its retrospective nature and the small number
of patients. However, these limitations were mitigated by a long follow-up
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period, which was longer than in all other previously published studies. We
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conclude that the free corticoperiosteal MFC flap for distal leg, ankle, midfoot and hindfoot reconstruction can be efficient in cases of recalcitrant nonunion
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and is associated with low donor site morbidity. Surgeons may consider this flap as a useful reconstruction option for patients with previous failed ankle and
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foot arthrodesis.
Declarations of interest: none
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This statement concerns all the above listed authors.
Conflict of interest statement The authors involved in this study declare that there are no existing conflicts of interest. 14
Funding No funding was sought for this research. The authors have no conflicts to disclose or competing interests.
References [1] Arata MA, Wood MB, Cooney WP, 3rd. Revascularized segmental
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diaphyseal bone transfers in the canine. An analysis of viability. J Reconstr Microsurg 1984;1:11-19. doi: 10.1055/s-2007-1007048
[2] Forrest C, Boyd B, Manktelow R, Zuker R, Bowen V. The free vascularised
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iliac crest tissue transfer: donor site complications associated with eighty-two
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cases. Br J Plast Surg 1992;45:89-93. doi: 10.1016/0007-1226(92)90163-R. [3] Kazmers NH, Thibaudeau S, Steinberger Z, Levin LS. Upper and lower
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extremity reconstructive applications utilizing free flaps from the medial genicular arterial system: A systematic review. Microsurgery 2018;38:328-343.
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doi: 10.1002/micr.30138.
[4] Rahmanian-Schwarz A, Spetzler V, Amr A, Pfau M, Schaller HE, Hirt B. A
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composite osteomusculocutaneous free flap from the medial femoral condyle
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for reconstruction of complex defects. J Reconstr Microsurg 2011;27:251-260. doi: 10.1055/s-0031-1275489. [5] Pelzer M, Reichenberger M, Germann G. Osteo-periosteal-cutaneous flaps of the medial femoral condyle: a valuable modification for selected clinical situations. J Reconstr Microsurg 2010;26:291-294. doi: 10.1055/s-00301248239. 15
[6] Holm J, Vangelisti G, Remmers J. Use of the medial femoral condyle vascularized bone flap in traumatic avascular necrosis of the navicular: a case report. J Foot Ankle Surg 2012;51:494-500. doi: 10.1053/j.jfas.2012.04.012. [7] Haddock NT, Alosh H, Easley ME, Levin LS, Wapner KL. Applications of the medial femoral condyle free flap for foot and ankle reconstruction. Foot Ankle Int 2013;34:1395-1402. doi: 10.1177/1071100713491077. [8] Tremp M, Haumer A, Wettstein R, Zhang YX, Honigmann P, Schaefer DJ,
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et al. The medial femoral trochlea flap with a monitor skin island-Report of two cases. Microsurgery 2017;37:431-435. doi: 10.1002/micr.30093.
[9] Kazmers NH, Thibaudeau S, Gerety P, Lambi AG, Levin LS. Versatility of
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the Medial Femoral Condyle Flap for Extremity Reconstruction and
Complications.
Ann
Plast
Surg
2018;80:364-372.
doi:
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10.1097/sap.0000000000001332.
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Identification of Risk Factors for Nonunion, Delayed Time to Union, and
[10] Giladi AM, Rinkinen JR, Higgins JP, Iorio ML. Donor-Site Morbidity of
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Vascularized Bone Flaps from the Distal Femur: A Systematic Review. Plast Reconstr Surg 2018;142:363e-372e. doi: 10.1097/PRS.0000000000004691.
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[11] Tang JB, Giddins G. Why and how to report surgeons' levels of expertise.
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J Hand Surg Eur Vol 2016;41:365-366. doi: 10.1177/1753193416641590. [12] Doi K, Sakai K. Vascularized periosteal bone graft from the supracondylar region of the femur. Microsurgery 1994;15:305-315. [13] Cavadas PC, Landin L. Treatment of recalcitrant distal tibial nonunion using the descending genicular corticoperiosteal free flap. J Trauma 2008;64:144-150. 16
[14] Hintermann B, Wagener J, Knupp M, Schweizer C, D JS. Treatment of extended osteochondral lesions of the talus with a free vascularised bone graft from the medial condyle of the femur. Bone Joint J 2015;97-b:1242-1249. doi: 10.1302/0301-620x.97b9.35292. [15] Windhofer C, Wong VW, Larcher L, Paryavi E, Burger HK, Higgins JP. Knee Donor Site Morbidity Following Harvest of Medial Femoral Trochlea Osteochondral Flaps for Carpal Reconstruction. J Hand Surg Am 2016;41:610-
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614. doi: 10.1016/j.jhsa.2016.01.015. [16] Hamada Y, Hibino N, Kobayashi A. Expanding the utility of modified
vascularized femoral periosteal bone-flaps: An analysis of its form and a
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comparison with a conventional-bone-graft. J Clin Orthop Trauma 2014;5:6-17.
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doi: 10.1016/j.jcot.2014.01.002.
[17] Rao SS, Sexton CC, Higgins JP. Medial femoral condyle flap donor-site
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morbidity: a radiographic assessment. Plast Reconstr Surg 2013;131:357-362. doi: 10.1097/PRS.0b013e31827c6f38.
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[18] 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 femur
models.
Microsurgery
2012;32:213-218.
doi:
ur
composite
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10.1002/micr.20986.
[19] Endara MR, Brown BJ, Shuck J, Bachabi M, Parks BG, Higgins JP. Torsional stability of the femur after harvest of the medial femoral condyle corticocancellous flap. J Reconstr Microsurg 2015;31:364-368. doi: 10.1055/s0035-1546420.
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[20] Mehio G, Morsy M, Cayci C, Sabbagh MD, Shin AY, Bishop AT, et al. Donor Site Morbidity and Functional Status Following Medial Femoral Condyle Flap
Harvest.
Plast
Reconstr
Surg
2018;142(5):734e-741e.
doi:
10.1097/PRS.0000000000004886.
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Figure 1a: Harvesting of the corticoperiosteal MFC flap. Right cranial, left caudal. The descending genicular artery irrigating the bone flap, marked with the blue vessel loop. Length of the pedicle 6cm.
Figure 1b: The harvested corticoperiosteal MFC flap with adjacent cancellous bone and the donor site defect on the medial femoral condyle.
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Figure 2: Debridement of the avascular bone after failed calcaneocuboidal arthrodesis and preparation of the recipient vessel (anterior tibial artery).
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Figure 3a: A 36 years old man (Case 1) with osteochondritis dissecans of the talus, initially treated with retrograde drilling of the talar dome. T1- and T2weighted MRI images in anteroposterior view of the ankle.
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Figure 3b: Weightbearing X-rays of the ankle in anteroposterior and lateral views 6 months after treatment of the osteochondritis dissecans of the talus with debridement and reconstruction with cancellous bone and free corticoperiosteal MFC flap (Case 1).
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Figure 4a: A 29 years old man (Case 2) with a distal tibia bone infarct after bimalleolar fracture, treated with open reduction and plate fixation and afterwards removal of the osteosynthesis material. Anteroposterior and lateral T1-weighted MRI image of the ankle.
Figure 4b: Anteroposterior and lateral CT-scan images 6 months after distal tibia debridement and reconstruction with corticoperiosteal MFC flap (Case 2).
18
Figure 5a: A 46-years old man (Case 9) with recalcitrant talonavicular joint arthritis after twice failed talonavicular and naviculocuneiform arthrodesis. Lateral CT-scan view.
Figure 5b: Union achieved 15 months after talonavicular re-arthrodesis and reconstruction with corticoperiosteal MFC flap (Case 9). Lateral CT-scan view.
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Figure 1a
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Figure 1b
19
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Figure 2
Figure 3a
20
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Figure 3b
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Figure 4a
Figure 4b
21
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Figure 5a
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Figure 5b
22
Table 1. Patient demographics, comorbidities relevant to microsurgery, surgery indications, number of previous surgeries before index surgery and surgery related data. Size graft N
Operation
previous
duration
Length Use
Case
Age/Sex
Comorbidities
Smoker
Indication
(length pedicle
DGA/SMGA operations
(minutes)
Fixation
Ana
None
A
(pressfit)
a
None
A
(pressfit)
a
x (cm) width) cm
talus 36/M
none
no
osteochondritis
1
dissecans
yes (10 29/M
bone infarct distal
none
2 py)
tibia
Adipositas failed subtalar 3
46/M
BMI 30,5
no
7
arthrodesis
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kg/m2, AH
270
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2
265
DGA
8
3 x1
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1
355
DGA
5
NR
3.5mm
A SMGA
4
NR
cannulated
a screws
6.5mm
failed subtalar 4
49/F
none
yes
2
A 280
DGA
8
2 x2
cannulated
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arthrodesis
a screws
Hoffmann
failed ankle
56/M
none
no
na
5
3.5 3
420
DGA
8
arthrodesis
x.2.5
ur
6
52/M
failed subtalar 6.5mm and
BMI 31
A. 4
py)
344
DGA
7
NR
Jo 57/M
cannulated
calcaneocuboidal
kg/m2
7
a fixator
Adipositas
yes (25
A external
screws arthrodesis
failed yes (60
talonavicular/
AH
3 py)
307
DGA
6
4.5 LCP
A
plate
a
3.5 LC-
A
DCP plate
a
NR
naviculocuneiform arthrodesis
distal tibia 38/F 8
none
no
3
400
DGA
NR
1,5 x 2
nonunion
23
failed AH, HCL, 9
yes (25
talonavicular/
46/M
2 heart infarct
py)
270
SMGA
NR
3.5 VA-
A
LCP plate
a
4.5 LCP
A
plate
p
2,5 x 2
naviculocuneiform arthrodesis
failed ankle 10
54/M
none
no
2
383
DGA
7
3 x 1,5
arthrodesis
Illizarov yes (54 11
43/M
failed ankle
none
A 3
py)
320
DGA
NR
3 x2
external
arthrodesis
a fixator
failed 38/F
none
yes
calcaneocuboidal
3.0mm 7
failed ankle and 38/M
none
no
subtalar
DGA
9
4
DGA
7
2 x2
-p
arthrodesis
410
re
M: male, F: female, AH: arterial hypertension, HCL: hypercholesterolemia, BMI:
lP
body mass index, py: packet years, N: number. DGA: descending genicular artery, SMGA: superior medial genicular artery, A: arteria. VA-LCP plate: variable angle locking compression plate, LC-DCP plate: limited contact dynamic compression
Jo
ur
na
plate. NR: not reported.
A
3 x2 X-Plate
arthrodesis
13
360
ro of
12
Table 2. Time to radiological union and to full weightbearing. Clinical and functional results and complications after surgery.
24
a
6.5 mm
A cannulated
a screws
Ankle
Case
Time to
Time to full
union
weightbearing
(months)
(months)
Time to
dorsiflexion/
Pain relief VAS
Complications
FFI-D score
return to
(rest/ plantarflexion
weightbearing)
(pain/function)
work (months)
(degrees)
1
6
3
none
50/20
0/ 3
15.2/24.4
1,5
2
3
1.5
CRPS foot
90/40
0/ 0
12.5/6.6
1
NA
NA
excluded
excluded
excluded
excluded
80/40
0/ 3
33.3/25.9
2
Not 3 achieved
Loosening 1 4
12
2
9
4.5
none
NA
6
12
7
none
60/20
NA
none
Not 7 achieved
9
4
none
9
15
7
none
4.1/ 26.3
5
2/ 7
55.5/64.4
8
60/0
nonunion
nonunion
invalidity
60/20
0/ 0
4.1/17.7
6
60/45
0/ 5
41.6/47.6
lP
re
8
0/ 0
-p
5
ro of
screw
change work
Deep venous
10
15
3
NA
0/ 5
52.7/66.6
invalidity
NA
0/ 0
4.1/5.5
1
60/0
0/ 6
55.5/55.5
invalidity
NA
0/ 6
55.5/79.1
2.5
11
6
12
18
na
thrombosis
6
none
Neuropathy sural
ur 6
3
nerve
none
Jo
13
12
CRPS: complex regional pain syndrome, NA: not applied (ankle arthrodesis), VAS: visual analogue scale, FFI-D: foot function index questionnaire for german speaking patients, pain: pain subscale, function: function subscale.
25