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Cutaneous Angiosome Territory of the Medial Femoral Condyle Osteocutaneous Flap
SCIENTIFIC ARTICLE
Cutaneous Angiosome Territory of the Medial Femoral Condyle Osteocutaneous Flap Matthew L. Iorio, MD, Derek L. Masden, MD, James P. Higgins, MD Purpose The medial femoral condyle flap is used for treatment of nonunions with or without intercalary bone loss. Most reported uses have been without a skin segment, but this flap can provide a skin component supplied by the saphenous artery branch (SAB) of the descending genicular artery (DGA) pedicle. Experience with this flap suggests that an additional distinct, reliable, more-distal, DGA-cutaneous branch can be found at condyle level, capable of supporting skin without using the SAB. This cadaver study evaluated SAB and DGAcutaneous branch angiosome territories. A clinical case series assesses the DGA-cutaneous branch’s clinical utility. Methods The DGA and SAB were isolated in 12 cadaveric legs, divided, and separately cannulated. Red dye and methylene blue were selectively injected into each vessel manually. Skin perfusion was measured and photographed. Results In all specimens, the DGA was present, originating 14.2 cm proximal to the joint line, and demonstrated a distinct cutaneous branch at condyle level. This vessel provided an average perfusion area of 70 cm2, centered over the medial knee. The SAB was identified in 11 specimens (92%), with an average perfusion area of 361 cm2 along the medial aspect of the distal thigh and proximal leg. The DGA communicating branch was present and used for perfusion of the skin paddle in 17 of 20 cases. The SAB was present in 18 of 20 cases, used with DGA-communicating branch in 4 cases, and the sole source of skin perfusion in 1 case. In 2 remaining cases, neither the SAB nor DGA communicating branch was adequate for perfusion of a skin segment. Conclusions The medial femoral condyle flap can be harvested with a large skin paddle based on the SAB. A smaller skin segment can be harvested using the more distal DGAcommunicating branch at condyle level. Clinical relevance Improved understanding of the skin island associated with the DGA’s saphenous and cutaneous branches can provide a rapid, reliable method of skin-segment harvest. (J Hand Surg 2012;37A:1033–1041. Copyright © 2012 by the American Society for Surgery of the Hand. All rights reserved.) Key words Medial femoral condyle flap, nonunion, saphenous artery flap, vascularized bone. vascularized corticoperiosteal flaps for the treatment of nonunions have been well established in experimental1,2 and clinical settings.3–32 The free medial femoral condyle (MFC) corticoperiosteal flap has garnered increasing attention
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From the Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD. The authors thank Joyce Lavery for the illustration. Received for publication July 5, 2011; accepted in revised form February 23, 2012. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
over the last 20 years due to its many desirable attributes, including ease of dissection, surgical positioning facilitating a 2-team approach, low donor site morbidity, preservation of all major arteries to the distal extremity, variable size and shape for harvest and insetting, and osteogenic This study was funded by the Raymond M. Curtis Research Foundation, The Curtis National Hand Center, Baltimore, Maryland. Correspondingauthor: JamesP.Higgins,MD,c/oAnneMattson,TheCurtisNationalHandCenter, MedStar Union Memorial Hospital, 3333 North Calvert Street, Mezzanine, Baltimore, MD 21218; e-mail: [email protected]. 0363-5023/12/37A05-0026$36.00/0 doi:10.1016/j.jhsa.2012.02.033
© ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1033
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FIGURE 1: Diagram of the most common relationship of the DGA, SAB, and DGA-CB. The DGA-CB most often departs from the DGA at the point at which the DGA becomes intimately adherent to the periosteum of the condyle and in close proximity to the branch point of the superiomedial genicular artery. MMPA, medial metaphyseal periosteal artery; MCL, medial collateral ligament.
potential. Since its initial clinical descriptions in 1991,3–5 the MFC flap has been used in a multitude of different anatomic locations to address challenging cases of nonunion or avascular necrosis. It has been successfully used in the clavicle,6,7 humerus,4,7–10 radius,7,10–12 ulna,8,10,11,13 metacarpals,4,14 femur,7 tibia,7,8,15,16 phalanges,17 carpal and tarsal bones,4,15,18–21,33 orbit,22 maxilla/ mandible,5,23,24 and skull.3 Despite the growing number of indications, little investigation has been focused on this flap as an osteocutaneous skin-bearing flap. The purpose of this study was to examine the variations of blood supply to the skin overlying the medial knee that can be harvested in conjunction with the MFC vascularized bone flap. We provide our clinical experience with this flap, as well as a series of cadaveric dissections, and suggest a detailed harvest technique based on these clinical and experimental findings. MATERIALS AND METHODS Cadaveric study We dissected 12 fresh cadavers using the surgical approach described later. The distal course of the descending genicular artery (DGA) was cautiously dissected to pre-
vent any damage to the fine cutaneous perforating network. The saphenous branch of the DGA was identified by its close association with the saphenous nerve traveling deep to the sartorius tendon. The branch-points of the DGA and saphenous branch were recorded in relation to the joint line and superficial femoral artery (SFA). Separate, distinct cutaneous branches of the DGA (DGA-CB) were observed distal to the branch point of the saphenous artery branch (SAB). These demonstrated the potential for the DGA to perfuse the overlying skin without the contribution of the SAB (Fig. 1). The DGA and SAB were then divided and separately cannulated and secured to a 20-gauge vascular access device. Under manual pressure, the 2 vascular systems were successively irrigated with normal saline until clear return was seen in the femoral vein. A solution of methylene blue was then manually injected into the cannulated saphenous branch until cutaneous coloration was seen. The territory of skin perfusion was measured and photographed. The cannulated DGA was then injected with a solution of red dye until skin coloration was seen, and the region was similarly measured and photographed.
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FIGURE 2: Routine skin incision for osteocutaneous medial femoral condyle harvest. The initial incision will ultimately serve as the anterior margin of skin flap centered over the medial condyle, permitting orientation of ellipse in oblique or axial orientations depending on the intraoperative location of Doppler signal.
Clinical series We performed a retrospective review that identified 20 consecutive MFC flap cases over a 2-year period. All anatomic variations of the skin component were recorded. The vessels used for skin flap harvest were recorded, and frequency of complications or flap loss was noted. Osteocutaneous medial femoral condyle harvest technique The flap dissection is approached with the intent of harvesting a skin paddle, regardless of the variations in anatomy. A Doppler signal can be routinely located over the apex of the medial condyle of the femur. A sweeping, curvilinear incision is created, starting at the Hunter canal and moving in distal and anterior directions to the midpoint between the medial border of the patella and the MFC, just anterior to the location of the Doppler signal. The incision then continues distal and posterior, stopping 2 to 3 cm below the joint line and just posterior to the mid-axis of the leg (Fig. 2). This skin incision is continued to the subfascial plane of the vastus medialis muscle, which allows the skin paddle to be rapidly elevated and retracted in a posterior direction as the vastus medialis is dissected in an anterior direction. The DGA can then be identified as the medial column of the femur is exposed. Dissecting subfascially ensures protection of all skin vessels that can branch off the distal DGA into the reflected skin. Through the fascial plane of the vastus medialis, the branching vessels emitting from the DGA can be identified, and the presence or absence of an SAB and/or DGA-CB is rapidly noted. Branches to the vastus medialis course in an anterior direction (penetrating the fascial plane) and
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are ligated. At this point, a decision is made regarding the approach for the skin paddle. In the majority of the cases reported here, the DGA-CB was selected if it was present, regardless of the presence of the SAB. This skin vessel is preferable because of the speed with which it can be dissected as well as the assurance that the skin and subcutaneous vasculature can be elevated anterior to the sartorius muscle and adductor tendon, keeping the skin and bone segments in the same dissection interval (between the vastus medialis and sartorius muscles). If the SAB is selected as the means of supplying the skin segment, it requires a careful distal dissection to determine whether it is supported by skin branches that pass anterior to the sartorius muscle (45%) and in the same surgical interval as the bone component or posterior to the sartorius muscle (55%).25 If it does pass posterior, it will require a distal elevation of the skin segment and careful passage deep to the sartorius muscle to reunite it with the bone segment before completing the flap harvest. After determining the presence or absence of the DGA-CB and the SAB, we prioritize the DGA-CB because of its speed of dissection and ease of visualization. If the skin segment is quite large, or if initial dissection reveals that the SAB contributes to the skin perfusion while passing anteriorly to the sartorius muscle, both sources of skin perfusion (SAB and DGA-CB) can be harvested en bloc (Fig. 3). Otherwise, the SAB is clamped, and the tourniquet is released. The Doppler signal over the apex of the MFC is again obtained. A persistent Doppler signal despite clamping of the SAB lends further support to the surgical selection of the DGA-CB for skin perfusion. In this setting, we ligate the SAB and rely on the DGA-CB for skin perfusion. The initial sweeping incision allows many variations of oblique or longitudinally oriented ellipses to be designed, using the initial incision as the anterior border of the skin component, while capturing the Doppler signal for the benefit of postoperative monitoring. Care is taken to harvest this in such a manner that primary closure is simply achieved. The elevation of the posterior margin of the skin requires making note of the immediate proximity of the DGA-CB to the anterior surface of the adductor tendon. This posterior incision should be carried down to the region posterior to the adductor tendon, giving wide berth to the DGA-CB. When deep and posterior to the adductor tendon, the scalpel is then used to approach the posterior aspect of the tendon and cautiously elevate the DGA-CB off the adductor tendon while maintaining the adductor tendon integrity and preserving the critical DGA-CB.
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FIGURE 3: Example of skin paddle harvested on both the cutaneous branch of the descending geniculate artery and the saphenous artery branch. This was performed because rapid dissection of the saphenous artery branch revealed that the vessels passed anterior to the sartorius muscle. The knee is to the right. A Before bone and skin elevation. B After elevation of both.
The skin component is usually elevated first, and attention is then turned to the bone segment. This is because posterior bone cuts will not be readily accessible until the skin paddle and the DGA-CB are reflected in an anterior direction. This will enable the entire DGA and its periosteal branches to be preserved undisturbed on the surface of the cortical bone. The bone segment is dissected in the width, length, and depth required, and the flap is then harvested on the common DGA origin vessel. RESULTS Cadaveric study The DGA was identified in all 12 cadaveric specimens. The origin of the DGA from the SFA was measured in reference to the joint line at an average distance of 14.2 ⫾ 1.6 cm. When the DGA was cannulated and injected with a solution of red dye, these injections stained an angiosome with an average area of 70 cm2 via a DGA-CB. The area of skin perfusion was predominantly in the region centered over the MFC. The angiosome did not extend in a posterior direction beyond the saphenous branch margin or in a distal direction beyond the proximal tibia. The saphenous branch was present in 11 of 12 (92%) of cadaveric specimens. The arterial branch was verified by its close approximation with the DGA in the adductor canal and a subsequent association with the saphenous nerve as it progressed medially toward the skin. The origin of the saphenous branch was measured in reference to the joint line with an average distance of 14.0 ⫾ 2.1 cm. The saphenous branch was cannulated and injected with a solution of methylene blue, which demonstrated an average skin perfusion area of 361
FIGURE 4: Vessel-specific catheterization: angiosome distribution of the DGA-CB shown in red and the saphenous artery branch in green. Note the overlap of the angiosomes, with the saphenous artery branch being a larger and more distally reaching territory.
cm.2 The region of skin coloration by the saphenous branch overlapped the angiosome of the DGA, extended farther in a posterior direction to the midline of the popliteal fossa, and continued distally beyond the proximal one-third of the tibia (Fig. 4). Three separate anatomic variations of the origin of the SAB were identified, including in a distal direction from the DGA, from a common origin with the DGA, and directly from the SFA proximal to the DGA. The SAB was identified originating from the DGA in 7 of 11 (64%) specimens, 3 of 11 (27%) that shared a common ostium from the SFA, and 1 of 11 (9%) with an independent origin from the SFA (Fig. 1). Clinical series The most frequent clinical indication for the MFC osteocutaneous flap in our cohort was a nonunion,13 fol-
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FIGURE 5: Recalcitrant nonunion of proximal phalanx of ring finger after attempted revision bone grafting. Adjacent index finger ray amputation from original injury.
lowed by osteomyelitis,4 oncology defect reconstruction,2 and malunion correction with opening wedge osteotomy.1 The majority of the cases were upper extremity cases. The series included reconstruction of the radius,6 ulna,4 metacarpal,3 phalanges,2 and wrist arthrodeses.2 The remaining were calcaneal, skull, and midface defects. All cases began with closed skin envelopes. The skin component provided ease of closure after conclusion of reconstruction and the ability to monitor the flap by surface Doppler and inspection. In 18 of 20 cases (90%), a perfused skin component was supported by branches of the DGA (SAB and/or DGA-CB). In the remaining 2 cases, the saphenous artery departed separately from the SFA, and no suitable distal DGA branches were available to support a skin paddle. These 2 flaps were raised as osseous flaps without skin. Of the 18 cases with a perfused skin segment, all 18 demonstrated the presence of an SAB, and 17 demonstrated the presence of DGA-CB. The DGA-CB was used for skin harvest in all 17 of these cases. In 4 of 17 of these cases, both SAB and DGA-CB were used to supply the skin paddle. In 13 of 17, the SAB was ligated because the DGA-CB was deemed adequate or more convenient for
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FIGURE 6: Appearance of medial femoral condyle vascularized bone at 8 weeks.
flap harvest and insetting. The branch point of the DGA-CB vessel was consistently identified at the level of the metaphyseal flare originating from the DGA, concurrent with the transition of the DGA from a subcutaneous vessel to a periosteal vessel. In the remaining case, the DGA-CB vessels could not be identified, and a viable skin segment was elevated on the SAB alone. All 18 of the skin segments were harvested as an ellipse centered over the MFC. All survived without venous congestion or partial necrosis, and there were no instances of seroma or donor site complications. Case examples Case 1: A 34-year-old man sustained an industrial injury to the right hand that required small finger amputation and plating of an open proximal phalanx fracture of the ring finger. The proximal phalanx fracture failed to unite, despite subsequent conventional bone grafting (Fig. 5). A free osteocutaneous corticocancellous MFC flap achieved osseous union (Figs. 6, 7). The skin segment was used for ease of inset and flap monitoring based only on the SAB (Figs. 8, 9). Case 2: A 21-year-old man had an infected proximal ulna nonunion (Fig. 10). After debridement and resolu-
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FIGURE 9: Skin segment allowing ease of closure and monitoring of flap on the ulnar aspect of the hand.
FIGURE 7: Appearance of medial femoral condyle vascularized bone at 4 months, achieving osseous union.
FIGURE 8: Harvest of medial femoral condyle osteocutaneous flap with skin segment based on the saphenous artery branch. The saphenous artery branch departs from the DGA close to its origin from the superficial femoral artery. Knee is to the left.
tion of osteomyelitis, the 7-cm osseous defect was successfully united by postoperative week 8 (Fig. 11). The skin segment was harvested using the DGA-CB only (Figs. 12, 13). DISCUSSION Slightly greater than 100 cases of clinical use of the MFC vascularized bone flap have been reported in the
FIGURE 10: Infected proximal ulna nonunion.
literature. Of these, less than 20 have reportedly been transferred with a skin component. In the majority of cases, this flap has been harvested as a thin and malleable corticoperiosteal flap and, thus, might be capable of application without requirement of additional soft
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FIGURE 11: Osseous healing demonstrated at 8 weeks after medial femoral condyle reconstruction.
FIGURE 13: A 7-cm osseous component with similar proportioned skin segment. Note that the departure of the DGA-CB is distal on the descending genicular artery pedicle in close association with the bone segment.
FIGURE 12: Harvest of medial femoral condyle osteocutaneous flap with skin segment based on the DGA-CB. The saphenous artery branch was not used in this case. Knee is to the bottom left.
tissue coverage to achieve surgical closure. In many cases, the surgeon might feel confident in the ability to monitor the flap with an implantable Doppler. Some reconstructive surgeons might also feel that monitoring of the flap in this situation is not necessary, as an undetected thrombosis would not lead to a catastrophic outcome but might only convert the flap to a stillvaluable, but nonvascularized, bone graft reconstruction. Our institution has used this flap not only for small recalcitrant nonunions as a corticoperiosteal flap but also for large intercalary corticocancellous defects. Two
small reported series have likewise used the MFC as a large corticocancellous vascularized bone flap.15,23 These 2 reports have also frequently used skin paddles as part of the soft tissue reconstruction. It is our practice to always use this flap as an osteocutaneous flap if possible. The cutaneous skin paddle provides 2 advantages. The first is that it facilitates tension-free closure, particularly over the anastomosis. The second is that it permits accurate flap monitoring so that the detection of thrombosis can be achieved, vessels explored, and revision performed. Reexploration of promptly detected free flap thrombosis can yield a success rate34 of greater than 50%. The skin segment of the MFC flap provides a means of visual inspection of the patency of the microvascular anastomosis and, thus, the perfusion of the vascularized bone segment. A skin segment can, therefore, impart a method of preserving the benefit of the more complex and lengthy intervention (vascularized bone transfer) in the setting of microvascular thrombosis, rather than converting the vascularized bone to a less beneficial bone graft if thrombosis is undetected after surgery. The skin component is the most challenging portion of the flap dissection. There is considerable variability
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to the cutaneous branches arising from the DGA. Although sources initially reported clinical use of this flap in 1991,3,5,13 it appears that many subsequent authors have referred to the description of the arterial anatomy provided by Sakai and Doi.4 This landmark article describes only the blood supply to the skin component as being provided by the SAB. This initial series was a report of 6 cases in which only 1 case used a skin component. The subsequent series that have included cutaneous paddles in the flaps as part of the clinical series have relied and reported solely on use of the SAB as a blood supply to the skin paddle, with few exceptions.4,10,13,22,23 Only 2 studies have reported some noted variation in the skin paddle arterial anatomy. One of the original descriptions by Martin et al in 1991 reported on 2 cases using this flap with skin for mandibular reconstruction.5 In 1 of the 2 cases, the skin was noted to be supplied by the SAB. The second was reported to be fed by an “unnamed branch” originating from the DGA. More recently, Pelzer reported a series of 4 lower extremity cases using skin paddles.15 Similar to the report of Martin et al, 2 of these were supplied by the SAB, and 2 were noted from an “unnamed branch” originating from the DGA. Our clinical series of 20 osteocutaneous MFCs has reflected a high frequency of cutaneous blood supply provided by distal branches of the DGA-CB (Fig. 1). The DGA-CB most commonly occurs at the level of the MFC, but it can also take off the DGA at the supracondylar region distal to the takeoff of the SAB. These distal skin-carrying vessels can be found in addition to the SAB or in the absence of an SAB. The skin overlying the MFC can be supported by either of these 2 branches with reliability. The DGA-CB observed in our clinical series, as well as in our cadaveric dissections, is likely a cutaneous vessel that has been observed in previous studies of skin perforators in the angiosomes in the medial knee region29 –31 as well as a described medial genicular artery (fasciocutaneous) flap.32 The anatomy of the SAB, its origin, and its angiosome have been well described.25–28 This vessel exists as a branch of the DGA in 79% of cases27 and supplies a large angiosome extending from the medial knee to the medial aspect of the lower leg.25 A well-performed cadaveric and clinical study originally describing a saphenous fasciocutaneous free flap noted that the perforators to the skin coming from the saphenous artery pass anterior to the sartorius muscle in 45% of cases.25 In the remainder of cases, perforators pass posterior to the sartorius muscle. The variable presence of the SAB, as well as the variable location of its skin perforators,
makes the dissection of an osteocutaneous MFC flap difficult without a thorough understanding of the skin vessels in this region as well as an awareness of the potential presence of the more distal DGA-CB. The dissection technique outlined earlier allows identification of these skin vessels and tailoring the skin segment to the anatomy encountered. When treating recalcitrant nonunions in the setting of closed soft tissue, the skin segment used for MFC to permit ease of closure and monitoring was usually less than 4 ⫻ 8 cm, and primary closure of the donor site was always achieved. The smaller skin paddle available from the DGA-CB serves the surgeon well in this setting. The SAB, in contrast, has a larger angiosome and provides a greater freedom of insetting distinct from the bone segment because of its proximal branching point. If the surgeon chooses to use the MFC flap as a means of providing both vascularized bone and soft tissue coverage of extensive wounds, the extent of the angiosome of the SAB might make it a better choice for the reconstructive surgeon than the DGA-CB. Harvest of the osteocutaneous MFC bone flap provides simultaneous soft tissue and bone for reconstruction, ease of soft tissue recipient closure, and the ability to provide accurate postoperative monitoring of the microcirculation of the flap. Its routine use requires an understanding of the arterial variation of the DGA tree, as well as the blood supply to the overlying skin of the medial aspect of the knee. The surgeon should be aware of the variations in saphenous artery anatomy and the potential presence of one or more distal skin perforators branching from the DGA in order to provide reproducible results. REFERENCES 1. Camilli JA, Penteado CV. Bone formation by vascularized periosteal and osteoperiosteal grafts. An experimental study in rats. Arch Orthop Trauma Surg 1994;114:18 –24. 2. Romana MC, Masquelet AC. Vascularized periosteum associated with cancellous bone graft: an experimental study. Plast Reconstr Surg 1990;85:587–592. 3. Lapierre F, Masquelet A, Aesch B, Romana C, Goga D. Cranioplasties using free femoral osteo-periostal flaps [in French]. Chirurgie 1991;117:293–296. 4. Doi K, Sakai K. Vascularized periosteal bone graft from the supracondylar region of the femur. Microsurgery 1994;15:305–315. 5. Martin D, Bitonti-Grillo C, De BJ, Schott H, Mondie JM, Baudet J, et al. Mandibular reconstruction using a free vascularised osteocutaneous flap from the internal condyle of the femur. Br J Plast Surg 1991;44:397– 402. 6. Fuchs B, Steinmann SP, Bishop AT. Free vascularized corticoperiosteal bone graft for the treatment of persistent nonunion of the clavicle. J Shoulder Elbow Surg 2005;14:264 –268. 7. Choudry UH, Bakri K, Moran SL, Karacor Z, Shin AY. The vascularized medial femoral condyle periosteal bone flap for the treatment of recalcitrant bony nonunions. Ann Plast Surg 2008;60:174 –180.
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8. Kaminski A, Burger H, Muller EJ. Free vascularised corticoperiosteal bone flaps in the treatment of non-union of long bones: an ignored opportunity? Acta Orthop Belg 2008;74:235–239. 9. Muramatsu K, Doi K, Ihara K, Shigetomi M, Kawai S. Recalcitrant posttraumatic nonunion of the humerus: 23 patients reconstructed with vascularized bone graft. Acta Orthop Scand 2003;74:95–97. 10. Del Pinal F, Garcia-Bernal FJ, Regalado J, Ayala H, Cagigal L, Studer A. Vascularised corticoperiosteal grafts from the medial femoral condyle for difficult non-unions of the upper limb. J Hand Surg 2007;32E:135–142. 11. De Smet L. Treatment of non-union of forearm bones with a free vascularised corticoperiosteal flap from the medial femoral condyle. Acta Orthop Belg 2009;75:611– 615. 12. Henry M. Genicular corticoperiosteal flap salvage of resistant atrophic non-union of the distal radius metaphysis. Hand Surg 2007;12: 211–215. 13. Sakai K, Doi K, Kawai S. Free vascularized thin corticoperiosteal graft. Plast Reconstr Surg 1991;87:290 –298. 14. Sammer DM, Bishop AT, Shin AY. Vascularized medial femoral condyle graft for thumb metacarpal reconstruction: case report. J Hand Surg 2009;34A:715–718. 15. 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. 16. Cavadas PC, Landin L. Treatment of recalcitrant distal tibial nonunion using the descending genicular corticoperiosteal free flap. J Trauma 2008;64:144 –150. 17. Grant I, Berger AC, Ireland DC. A vascularised bone graft from the medial femoral condyle for recurrent failed arthrodesis of the distal interphalangeal joint. Br J Plast Surg 2005;58:1011–1013. 18. Larson AN, Bishop AT, Shin AY. Free medial femoral condyle bone grafting for scaphoid nonunions with humpback deformity and proximal pole avascular necrosis. Tech Hand Up Extrem Surg 2007;11: 246 –258. 19. Jones DB Jr, Moran SL, Bishop AT, Shin AY. Free-vascularized medial femoral condyle bone transfer in the treatment of scaphoid nonunions. Plast Reconstr Surg 2010;125:1176 –1184. 20. Jones DB Jr, Burger H, Bishop AT, Shin AY. Treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapse. Surgical technique. J Bone Joint Surg 2009;91A (Suppl 2):169 –183. 21. Doi K, Oda T, Soo-Heong T, Nanda V. Free vascularized bone graft for nonunion of the scaphoid. J Hand Surg 2000;25A:507–519.
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22. Kobayashi S, Kakibuchi M, Masuda T, Ohmori K. Use of vascularized corticoperiosteal flap from the femur for reconstruction of the orbit. Ann Plast Surg 1994;33:351–357. 23. Gaggl A, Burger H, Chiari FM. The microvascular osteocutaneous femur transplant for covering combined alveolar ridge and floor of the mouth defects: preliminary report. J Reconstr Microsurg 2008; 24:169 –175. 24. Gaggl AJ, Burger HK, Chiari FM. Free microvascular transfer of segmental corticocancellous femur for reconstruction of the alveolar ridge. Br J Oral Maxillofac Surg 2008;46:211–217. 25. Acland RD, Schusterman M, Godina M, Eder E, Taylor GI, Carlisle I. The saphenous neurovascular free flap. Plast Reconstr Surg 1981; 67:763–774. 26. Lin SD, Lai CS, Chiu YT, Lin TM, Chou CK. Adipofascial flap of the lower leg based on the saphenous artery. Br J Plast Surg 1996; 49:390 –395. 27. Yamamoto H, Jones DB, Jr., Moran SL, Bishop AT, Shin AY. The arterial anatomy of the medial femoral condyle and its clinical implications. J Hand Surg 2010;35E:569 –574. 28. Kirschner MH, Menck J, Hennerbichler A, Gaber O, Hofmann GO. Importance of arterial blood supply to the femur and tibia for transplantation of vascularized femoral diaphyses and knee joints. World J Surg 1998;22:845– 851. 29. Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg 1998;102:599 – 616. 30. Ahmadzadeh R, Bergeron L, Tang M, Geddes CR, Morris SF. The posterior thigh perforator flap or profunda femoris artery perforator flap. Plast Reconstr Surg 2007;119:194 –200. 31. Hong JP, Koshima I. Using perforators as recipient vessels (supermicrosurgery) for free flap reconstruction of the knee region. Ann Plast Surg 2010;64:291–293. 32. Hayashi A, Maruyama Y. The medial genicular artery flap. Ann Plast Surg 1990;25:174 –180. 33. Jones DB Jr, Burger H, Bishop AT, Shin AY. Treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapse. A comparison of two vascularized bone grafts. J Bone Joint Surg 2008;90A:2616 –2625. 34. Khouri RK, Cooley BC, Kunselman AR, Landis JR, Yeramian P, Ingram D, et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998;102:711–721.
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Cutaneous Angiosome Territory of the Medial Femoral Condyle Osteocutaneous Flap Matthew L. Iorio, MD, Derek L. Masden, MD, James P. Higgins, MD Purpose The medial femoral condyle flap is used for treatment of nonunions with or without intercalary bone loss. Most reported uses have been without a skin segment, but this flap can provide a skin component supplied by the saphenous artery branch (SAB) of the descending genicular artery (DGA) pedicle. Experience with this flap suggests that an additional distinct, reliable, more-distal, DGA-cutaneous branch can be found at condyle level, capable of supporting skin without using the SAB. This cadaver study evaluated SAB and DGAcutaneous branch angiosome territories. A clinical case series assesses the DGA-cutaneous branch’s clinical utility. Methods The DGA and SAB were isolated in 12 cadaveric legs, divided, and separately cannulated. Red dye and methylene blue were selectively injected into each vessel manually. Skin perfusion was measured and photographed. Results In all specimens, the DGA was present, originating 14.2 cm proximal to the joint line, and demonstrated a distinct cutaneous branch at condyle level. This vessel provided an average perfusion area of 70 cm2, centered over the medial knee. The SAB was identified in 11 specimens (92%), with an average perfusion area of 361 cm2 along the medial aspect of the distal thigh and proximal leg. The DGA communicating branch was present and used for perfusion of the skin paddle in 17 of 20 cases. The SAB was present in 18 of 20 cases, used with DGA-communicating branch in 4 cases, and the sole source of skin perfusion in 1 case. In 2 remaining cases, neither the SAB nor DGA communicating branch was adequate for perfusion of a skin segment. Conclusions The medial femoral condyle flap can be harvested with a large skin paddle based on the SAB. A smaller skin segment can be harvested using the more distal DGAcommunicating branch at condyle level. Clinical relevance Improved understanding of the skin island associated with the DGA’s saphenous and cutaneous branches can provide a rapid, reliable method of skin-segment harvest. (J Hand Surg 2012;37A:1033–1041. Copyright © 2012 by the American Society for Surgery of the Hand. All rights reserved.) Key words Medial femoral condyle flap, nonunion, saphenous artery flap, vascularized bone. vascularized corticoperiosteal flaps for the treatment of nonunions have been well established in experimental1,2 and clinical settings.3–32 The free medial femoral condyle (MFC) corticoperiosteal flap has garnered increasing attention
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HE BENEFITS OF
From the Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD. The authors thank Joyce Lavery for the illustration. Received for publication July 5, 2011; accepted in revised form February 23, 2012. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
over the last 20 years due to its many desirable attributes, including ease of dissection, surgical positioning facilitating a 2-team approach, low donor site morbidity, preservation of all major arteries to the distal extremity, variable size and shape for harvest and insetting, and osteogenic This study was funded by the Raymond M. Curtis Research Foundation, The Curtis National Hand Center, Baltimore, Maryland. Correspondingauthor: JamesP.Higgins,MD,c/oAnneMattson,TheCurtisNationalHandCenter, MedStar Union Memorial Hospital, 3333 North Calvert Street, Mezzanine, Baltimore, MD 21218; e-mail: [email protected]. 0363-5023/12/37A05-0026$36.00/0 doi:10.1016/j.jhsa.2012.02.033
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FIGURE 1: Diagram of the most common relationship of the DGA, SAB, and DGA-CB. The DGA-CB most often departs from the DGA at the point at which the DGA becomes intimately adherent to the periosteum of the condyle and in close proximity to the branch point of the superiomedial genicular artery. MMPA, medial metaphyseal periosteal artery; MCL, medial collateral ligament.
potential. Since its initial clinical descriptions in 1991,3–5 the MFC flap has been used in a multitude of different anatomic locations to address challenging cases of nonunion or avascular necrosis. It has been successfully used in the clavicle,6,7 humerus,4,7–10 radius,7,10–12 ulna,8,10,11,13 metacarpals,4,14 femur,7 tibia,7,8,15,16 phalanges,17 carpal and tarsal bones,4,15,18–21,33 orbit,22 maxilla/ mandible,5,23,24 and skull.3 Despite the growing number of indications, little investigation has been focused on this flap as an osteocutaneous skin-bearing flap. The purpose of this study was to examine the variations of blood supply to the skin overlying the medial knee that can be harvested in conjunction with the MFC vascularized bone flap. We provide our clinical experience with this flap, as well as a series of cadaveric dissections, and suggest a detailed harvest technique based on these clinical and experimental findings. MATERIALS AND METHODS Cadaveric study We dissected 12 fresh cadavers using the surgical approach described later. The distal course of the descending genicular artery (DGA) was cautiously dissected to pre-
vent any damage to the fine cutaneous perforating network. The saphenous branch of the DGA was identified by its close association with the saphenous nerve traveling deep to the sartorius tendon. The branch-points of the DGA and saphenous branch were recorded in relation to the joint line and superficial femoral artery (SFA). Separate, distinct cutaneous branches of the DGA (DGA-CB) were observed distal to the branch point of the saphenous artery branch (SAB). These demonstrated the potential for the DGA to perfuse the overlying skin without the contribution of the SAB (Fig. 1). The DGA and SAB were then divided and separately cannulated and secured to a 20-gauge vascular access device. Under manual pressure, the 2 vascular systems were successively irrigated with normal saline until clear return was seen in the femoral vein. A solution of methylene blue was then manually injected into the cannulated saphenous branch until cutaneous coloration was seen. The territory of skin perfusion was measured and photographed. The cannulated DGA was then injected with a solution of red dye until skin coloration was seen, and the region was similarly measured and photographed.
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FIGURE 2: Routine skin incision for osteocutaneous medial femoral condyle harvest. The initial incision will ultimately serve as the anterior margin of skin flap centered over the medial condyle, permitting orientation of ellipse in oblique or axial orientations depending on the intraoperative location of Doppler signal.
Clinical series We performed a retrospective review that identified 20 consecutive MFC flap cases over a 2-year period. All anatomic variations of the skin component were recorded. The vessels used for skin flap harvest were recorded, and frequency of complications or flap loss was noted. Osteocutaneous medial femoral condyle harvest technique The flap dissection is approached with the intent of harvesting a skin paddle, regardless of the variations in anatomy. A Doppler signal can be routinely located over the apex of the medial condyle of the femur. A sweeping, curvilinear incision is created, starting at the Hunter canal and moving in distal and anterior directions to the midpoint between the medial border of the patella and the MFC, just anterior to the location of the Doppler signal. The incision then continues distal and posterior, stopping 2 to 3 cm below the joint line and just posterior to the mid-axis of the leg (Fig. 2). This skin incision is continued to the subfascial plane of the vastus medialis muscle, which allows the skin paddle to be rapidly elevated and retracted in a posterior direction as the vastus medialis is dissected in an anterior direction. The DGA can then be identified as the medial column of the femur is exposed. Dissecting subfascially ensures protection of all skin vessels that can branch off the distal DGA into the reflected skin. Through the fascial plane of the vastus medialis, the branching vessels emitting from the DGA can be identified, and the presence or absence of an SAB and/or DGA-CB is rapidly noted. Branches to the vastus medialis course in an anterior direction (penetrating the fascial plane) and
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are ligated. At this point, a decision is made regarding the approach for the skin paddle. In the majority of the cases reported here, the DGA-CB was selected if it was present, regardless of the presence of the SAB. This skin vessel is preferable because of the speed with which it can be dissected as well as the assurance that the skin and subcutaneous vasculature can be elevated anterior to the sartorius muscle and adductor tendon, keeping the skin and bone segments in the same dissection interval (between the vastus medialis and sartorius muscles). If the SAB is selected as the means of supplying the skin segment, it requires a careful distal dissection to determine whether it is supported by skin branches that pass anterior to the sartorius muscle (45%) and in the same surgical interval as the bone component or posterior to the sartorius muscle (55%).25 If it does pass posterior, it will require a distal elevation of the skin segment and careful passage deep to the sartorius muscle to reunite it with the bone segment before completing the flap harvest. After determining the presence or absence of the DGA-CB and the SAB, we prioritize the DGA-CB because of its speed of dissection and ease of visualization. If the skin segment is quite large, or if initial dissection reveals that the SAB contributes to the skin perfusion while passing anteriorly to the sartorius muscle, both sources of skin perfusion (SAB and DGA-CB) can be harvested en bloc (Fig. 3). Otherwise, the SAB is clamped, and the tourniquet is released. The Doppler signal over the apex of the MFC is again obtained. A persistent Doppler signal despite clamping of the SAB lends further support to the surgical selection of the DGA-CB for skin perfusion. In this setting, we ligate the SAB and rely on the DGA-CB for skin perfusion. The initial sweeping incision allows many variations of oblique or longitudinally oriented ellipses to be designed, using the initial incision as the anterior border of the skin component, while capturing the Doppler signal for the benefit of postoperative monitoring. Care is taken to harvest this in such a manner that primary closure is simply achieved. The elevation of the posterior margin of the skin requires making note of the immediate proximity of the DGA-CB to the anterior surface of the adductor tendon. This posterior incision should be carried down to the region posterior to the adductor tendon, giving wide berth to the DGA-CB. When deep and posterior to the adductor tendon, the scalpel is then used to approach the posterior aspect of the tendon and cautiously elevate the DGA-CB off the adductor tendon while maintaining the adductor tendon integrity and preserving the critical DGA-CB.
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FIGURE 3: Example of skin paddle harvested on both the cutaneous branch of the descending geniculate artery and the saphenous artery branch. This was performed because rapid dissection of the saphenous artery branch revealed that the vessels passed anterior to the sartorius muscle. The knee is to the right. A Before bone and skin elevation. B After elevation of both.
The skin component is usually elevated first, and attention is then turned to the bone segment. This is because posterior bone cuts will not be readily accessible until the skin paddle and the DGA-CB are reflected in an anterior direction. This will enable the entire DGA and its periosteal branches to be preserved undisturbed on the surface of the cortical bone. The bone segment is dissected in the width, length, and depth required, and the flap is then harvested on the common DGA origin vessel. RESULTS Cadaveric study The DGA was identified in all 12 cadaveric specimens. The origin of the DGA from the SFA was measured in reference to the joint line at an average distance of 14.2 ⫾ 1.6 cm. When the DGA was cannulated and injected with a solution of red dye, these injections stained an angiosome with an average area of 70 cm2 via a DGA-CB. The area of skin perfusion was predominantly in the region centered over the MFC. The angiosome did not extend in a posterior direction beyond the saphenous branch margin or in a distal direction beyond the proximal tibia. The saphenous branch was present in 11 of 12 (92%) of cadaveric specimens. The arterial branch was verified by its close approximation with the DGA in the adductor canal and a subsequent association with the saphenous nerve as it progressed medially toward the skin. The origin of the saphenous branch was measured in reference to the joint line with an average distance of 14.0 ⫾ 2.1 cm. The saphenous branch was cannulated and injected with a solution of methylene blue, which demonstrated an average skin perfusion area of 361
FIGURE 4: Vessel-specific catheterization: angiosome distribution of the DGA-CB shown in red and the saphenous artery branch in green. Note the overlap of the angiosomes, with the saphenous artery branch being a larger and more distally reaching territory.
cm.2 The region of skin coloration by the saphenous branch overlapped the angiosome of the DGA, extended farther in a posterior direction to the midline of the popliteal fossa, and continued distally beyond the proximal one-third of the tibia (Fig. 4). Three separate anatomic variations of the origin of the SAB were identified, including in a distal direction from the DGA, from a common origin with the DGA, and directly from the SFA proximal to the DGA. The SAB was identified originating from the DGA in 7 of 11 (64%) specimens, 3 of 11 (27%) that shared a common ostium from the SFA, and 1 of 11 (9%) with an independent origin from the SFA (Fig. 1). Clinical series The most frequent clinical indication for the MFC osteocutaneous flap in our cohort was a nonunion,13 fol-
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FIGURE 5: Recalcitrant nonunion of proximal phalanx of ring finger after attempted revision bone grafting. Adjacent index finger ray amputation from original injury.
lowed by osteomyelitis,4 oncology defect reconstruction,2 and malunion correction with opening wedge osteotomy.1 The majority of the cases were upper extremity cases. The series included reconstruction of the radius,6 ulna,4 metacarpal,3 phalanges,2 and wrist arthrodeses.2 The remaining were calcaneal, skull, and midface defects. All cases began with closed skin envelopes. The skin component provided ease of closure after conclusion of reconstruction and the ability to monitor the flap by surface Doppler and inspection. In 18 of 20 cases (90%), a perfused skin component was supported by branches of the DGA (SAB and/or DGA-CB). In the remaining 2 cases, the saphenous artery departed separately from the SFA, and no suitable distal DGA branches were available to support a skin paddle. These 2 flaps were raised as osseous flaps without skin. Of the 18 cases with a perfused skin segment, all 18 demonstrated the presence of an SAB, and 17 demonstrated the presence of DGA-CB. The DGA-CB was used for skin harvest in all 17 of these cases. In 4 of 17 of these cases, both SAB and DGA-CB were used to supply the skin paddle. In 13 of 17, the SAB was ligated because the DGA-CB was deemed adequate or more convenient for
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FIGURE 6: Appearance of medial femoral condyle vascularized bone at 8 weeks.
flap harvest and insetting. The branch point of the DGA-CB vessel was consistently identified at the level of the metaphyseal flare originating from the DGA, concurrent with the transition of the DGA from a subcutaneous vessel to a periosteal vessel. In the remaining case, the DGA-CB vessels could not be identified, and a viable skin segment was elevated on the SAB alone. All 18 of the skin segments were harvested as an ellipse centered over the MFC. All survived without venous congestion or partial necrosis, and there were no instances of seroma or donor site complications. Case examples Case 1: A 34-year-old man sustained an industrial injury to the right hand that required small finger amputation and plating of an open proximal phalanx fracture of the ring finger. The proximal phalanx fracture failed to unite, despite subsequent conventional bone grafting (Fig. 5). A free osteocutaneous corticocancellous MFC flap achieved osseous union (Figs. 6, 7). The skin segment was used for ease of inset and flap monitoring based only on the SAB (Figs. 8, 9). Case 2: A 21-year-old man had an infected proximal ulna nonunion (Fig. 10). After debridement and resolu-
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FIGURE 9: Skin segment allowing ease of closure and monitoring of flap on the ulnar aspect of the hand.
FIGURE 7: Appearance of medial femoral condyle vascularized bone at 4 months, achieving osseous union.
FIGURE 8: Harvest of medial femoral condyle osteocutaneous flap with skin segment based on the saphenous artery branch. The saphenous artery branch departs from the DGA close to its origin from the superficial femoral artery. Knee is to the left.
tion of osteomyelitis, the 7-cm osseous defect was successfully united by postoperative week 8 (Fig. 11). The skin segment was harvested using the DGA-CB only (Figs. 12, 13). DISCUSSION Slightly greater than 100 cases of clinical use of the MFC vascularized bone flap have been reported in the
FIGURE 10: Infected proximal ulna nonunion.
literature. Of these, less than 20 have reportedly been transferred with a skin component. In the majority of cases, this flap has been harvested as a thin and malleable corticoperiosteal flap and, thus, might be capable of application without requirement of additional soft
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FIGURE 11: Osseous healing demonstrated at 8 weeks after medial femoral condyle reconstruction.
FIGURE 13: A 7-cm osseous component with similar proportioned skin segment. Note that the departure of the DGA-CB is distal on the descending genicular artery pedicle in close association with the bone segment.
FIGURE 12: Harvest of medial femoral condyle osteocutaneous flap with skin segment based on the DGA-CB. The saphenous artery branch was not used in this case. Knee is to the bottom left.
tissue coverage to achieve surgical closure. In many cases, the surgeon might feel confident in the ability to monitor the flap with an implantable Doppler. Some reconstructive surgeons might also feel that monitoring of the flap in this situation is not necessary, as an undetected thrombosis would not lead to a catastrophic outcome but might only convert the flap to a stillvaluable, but nonvascularized, bone graft reconstruction. Our institution has used this flap not only for small recalcitrant nonunions as a corticoperiosteal flap but also for large intercalary corticocancellous defects. Two
small reported series have likewise used the MFC as a large corticocancellous vascularized bone flap.15,23 These 2 reports have also frequently used skin paddles as part of the soft tissue reconstruction. It is our practice to always use this flap as an osteocutaneous flap if possible. The cutaneous skin paddle provides 2 advantages. The first is that it facilitates tension-free closure, particularly over the anastomosis. The second is that it permits accurate flap monitoring so that the detection of thrombosis can be achieved, vessels explored, and revision performed. Reexploration of promptly detected free flap thrombosis can yield a success rate34 of greater than 50%. The skin segment of the MFC flap provides a means of visual inspection of the patency of the microvascular anastomosis and, thus, the perfusion of the vascularized bone segment. A skin segment can, therefore, impart a method of preserving the benefit of the more complex and lengthy intervention (vascularized bone transfer) in the setting of microvascular thrombosis, rather than converting the vascularized bone to a less beneficial bone graft if thrombosis is undetected after surgery. The skin component is the most challenging portion of the flap dissection. There is considerable variability
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to the cutaneous branches arising from the DGA. Although sources initially reported clinical use of this flap in 1991,3,5,13 it appears that many subsequent authors have referred to the description of the arterial anatomy provided by Sakai and Doi.4 This landmark article describes only the blood supply to the skin component as being provided by the SAB. This initial series was a report of 6 cases in which only 1 case used a skin component. The subsequent series that have included cutaneous paddles in the flaps as part of the clinical series have relied and reported solely on use of the SAB as a blood supply to the skin paddle, with few exceptions.4,10,13,22,23 Only 2 studies have reported some noted variation in the skin paddle arterial anatomy. One of the original descriptions by Martin et al in 1991 reported on 2 cases using this flap with skin for mandibular reconstruction.5 In 1 of the 2 cases, the skin was noted to be supplied by the SAB. The second was reported to be fed by an “unnamed branch” originating from the DGA. More recently, Pelzer reported a series of 4 lower extremity cases using skin paddles.15 Similar to the report of Martin et al, 2 of these were supplied by the SAB, and 2 were noted from an “unnamed branch” originating from the DGA. Our clinical series of 20 osteocutaneous MFCs has reflected a high frequency of cutaneous blood supply provided by distal branches of the DGA-CB (Fig. 1). The DGA-CB most commonly occurs at the level of the MFC, but it can also take off the DGA at the supracondylar region distal to the takeoff of the SAB. These distal skin-carrying vessels can be found in addition to the SAB or in the absence of an SAB. The skin overlying the MFC can be supported by either of these 2 branches with reliability. The DGA-CB observed in our clinical series, as well as in our cadaveric dissections, is likely a cutaneous vessel that has been observed in previous studies of skin perforators in the angiosomes in the medial knee region29 –31 as well as a described medial genicular artery (fasciocutaneous) flap.32 The anatomy of the SAB, its origin, and its angiosome have been well described.25–28 This vessel exists as a branch of the DGA in 79% of cases27 and supplies a large angiosome extending from the medial knee to the medial aspect of the lower leg.25 A well-performed cadaveric and clinical study originally describing a saphenous fasciocutaneous free flap noted that the perforators to the skin coming from the saphenous artery pass anterior to the sartorius muscle in 45% of cases.25 In the remainder of cases, perforators pass posterior to the sartorius muscle. The variable presence of the SAB, as well as the variable location of its skin perforators,
makes the dissection of an osteocutaneous MFC flap difficult without a thorough understanding of the skin vessels in this region as well as an awareness of the potential presence of the more distal DGA-CB. The dissection technique outlined earlier allows identification of these skin vessels and tailoring the skin segment to the anatomy encountered. When treating recalcitrant nonunions in the setting of closed soft tissue, the skin segment used for MFC to permit ease of closure and monitoring was usually less than 4 ⫻ 8 cm, and primary closure of the donor site was always achieved. The smaller skin paddle available from the DGA-CB serves the surgeon well in this setting. The SAB, in contrast, has a larger angiosome and provides a greater freedom of insetting distinct from the bone segment because of its proximal branching point. If the surgeon chooses to use the MFC flap as a means of providing both vascularized bone and soft tissue coverage of extensive wounds, the extent of the angiosome of the SAB might make it a better choice for the reconstructive surgeon than the DGA-CB. Harvest of the osteocutaneous MFC bone flap provides simultaneous soft tissue and bone for reconstruction, ease of soft tissue recipient closure, and the ability to provide accurate postoperative monitoring of the microcirculation of the flap. Its routine use requires an understanding of the arterial variation of the DGA tree, as well as the blood supply to the overlying skin of the medial aspect of the knee. The surgeon should be aware of the variations in saphenous artery anatomy and the potential presence of one or more distal skin perforators branching from the DGA in order to provide reproducible results. REFERENCES 1. Camilli JA, Penteado CV. Bone formation by vascularized periosteal and osteoperiosteal grafts. An experimental study in rats. Arch Orthop Trauma Surg 1994;114:18 –24. 2. Romana MC, Masquelet AC. Vascularized periosteum associated with cancellous bone graft: an experimental study. Plast Reconstr Surg 1990;85:587–592. 3. Lapierre F, Masquelet A, Aesch B, Romana C, Goga D. Cranioplasties using free femoral osteo-periostal flaps [in French]. Chirurgie 1991;117:293–296. 4. Doi K, Sakai K. Vascularized periosteal bone graft from the supracondylar region of the femur. Microsurgery 1994;15:305–315. 5. Martin D, Bitonti-Grillo C, De BJ, Schott H, Mondie JM, Baudet J, et al. Mandibular reconstruction using a free vascularised osteocutaneous flap from the internal condyle of the femur. Br J Plast Surg 1991;44:397– 402. 6. Fuchs B, Steinmann SP, Bishop AT. Free vascularized corticoperiosteal bone graft for the treatment of persistent nonunion of the clavicle. J Shoulder Elbow Surg 2005;14:264 –268. 7. Choudry UH, Bakri K, Moran SL, Karacor Z, Shin AY. The vascularized medial femoral condyle periosteal bone flap for the treatment of recalcitrant bony nonunions. Ann Plast Surg 2008;60:174 –180.
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8. Kaminski A, Burger H, Muller EJ. Free vascularised corticoperiosteal bone flaps in the treatment of non-union of long bones: an ignored opportunity? Acta Orthop Belg 2008;74:235–239. 9. Muramatsu K, Doi K, Ihara K, Shigetomi M, Kawai S. Recalcitrant posttraumatic nonunion of the humerus: 23 patients reconstructed with vascularized bone graft. Acta Orthop Scand 2003;74:95–97. 10. Del Pinal F, Garcia-Bernal FJ, Regalado J, Ayala H, Cagigal L, Studer A. Vascularised corticoperiosteal grafts from the medial femoral condyle for difficult non-unions of the upper limb. J Hand Surg 2007;32E:135–142. 11. De Smet L. Treatment of non-union of forearm bones with a free vascularised corticoperiosteal flap from the medial femoral condyle. Acta Orthop Belg 2009;75:611– 615. 12. Henry M. Genicular corticoperiosteal flap salvage of resistant atrophic non-union of the distal radius metaphysis. Hand Surg 2007;12: 211–215. 13. Sakai K, Doi K, Kawai S. Free vascularized thin corticoperiosteal graft. Plast Reconstr Surg 1991;87:290 –298. 14. Sammer DM, Bishop AT, Shin AY. Vascularized medial femoral condyle graft for thumb metacarpal reconstruction: case report. J Hand Surg 2009;34A:715–718. 15. 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. 16. Cavadas PC, Landin L. Treatment of recalcitrant distal tibial nonunion using the descending genicular corticoperiosteal free flap. J Trauma 2008;64:144 –150. 17. Grant I, Berger AC, Ireland DC. A vascularised bone graft from the medial femoral condyle for recurrent failed arthrodesis of the distal interphalangeal joint. Br J Plast Surg 2005;58:1011–1013. 18. Larson AN, Bishop AT, Shin AY. Free medial femoral condyle bone grafting for scaphoid nonunions with humpback deformity and proximal pole avascular necrosis. Tech Hand Up Extrem Surg 2007;11: 246 –258. 19. Jones DB Jr, Moran SL, Bishop AT, Shin AY. Free-vascularized medial femoral condyle bone transfer in the treatment of scaphoid nonunions. Plast Reconstr Surg 2010;125:1176 –1184. 20. Jones DB Jr, Burger H, Bishop AT, Shin AY. Treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapse. Surgical technique. J Bone Joint Surg 2009;91A (Suppl 2):169 –183. 21. Doi K, Oda T, Soo-Heong T, Nanda V. Free vascularized bone graft for nonunion of the scaphoid. J Hand Surg 2000;25A:507–519.
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22. Kobayashi S, Kakibuchi M, Masuda T, Ohmori K. Use of vascularized corticoperiosteal flap from the femur for reconstruction of the orbit. Ann Plast Surg 1994;33:351–357. 23. Gaggl A, Burger H, Chiari FM. The microvascular osteocutaneous femur transplant for covering combined alveolar ridge and floor of the mouth defects: preliminary report. J Reconstr Microsurg 2008; 24:169 –175. 24. Gaggl AJ, Burger HK, Chiari FM. Free microvascular transfer of segmental corticocancellous femur for reconstruction of the alveolar ridge. Br J Oral Maxillofac Surg 2008;46:211–217. 25. Acland RD, Schusterman M, Godina M, Eder E, Taylor GI, Carlisle I. The saphenous neurovascular free flap. Plast Reconstr Surg 1981; 67:763–774. 26. Lin SD, Lai CS, Chiu YT, Lin TM, Chou CK. Adipofascial flap of the lower leg based on the saphenous artery. Br J Plast Surg 1996; 49:390 –395. 27. Yamamoto H, Jones DB, Jr., Moran SL, Bishop AT, Shin AY. The arterial anatomy of the medial femoral condyle and its clinical implications. J Hand Surg 2010;35E:569 –574. 28. Kirschner MH, Menck J, Hennerbichler A, Gaber O, Hofmann GO. Importance of arterial blood supply to the femur and tibia for transplantation of vascularized femoral diaphyses and knee joints. World J Surg 1998;22:845– 851. 29. Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg 1998;102:599 – 616. 30. Ahmadzadeh R, Bergeron L, Tang M, Geddes CR, Morris SF. The posterior thigh perforator flap or profunda femoris artery perforator flap. Plast Reconstr Surg 2007;119:194 –200. 31. Hong JP, Koshima I. Using perforators as recipient vessels (supermicrosurgery) for free flap reconstruction of the knee region. Ann Plast Surg 2010;64:291–293. 32. Hayashi A, Maruyama Y. The medial genicular artery flap. Ann Plast Surg 1990;25:174 –180. 33. Jones DB Jr, Burger H, Bishop AT, Shin AY. Treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapse. A comparison of two vascularized bone grafts. J Bone Joint Surg 2008;90A:2616 –2625. 34. Khouri RK, Cooley BC, Kunselman AR, Landis JR, Yeramian P, Ingram D, et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998;102:711–721.
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