Free Vascularized Medial Femoral Condyle Structural Flaps for Septic Terminal Digital Bone Loss

Abstract

A unique clinical problem exists when the majority of distal bone stock in a digit is destroyed by osteomyelitis, leaving a residual soft tissue envelope with tenuous, random perfusion surrounding a nidus of scar tissue. Pulp pinch is lost in the absence of bony support, and limited options exist. Apart from toe transfer or revision amputation with shortening, non-vascularized bone grafting inside the residual soft tissue envelope risks graft resorption and reactivation of infection. The purpose of this investigation was to evaluate the clinical outcomes of free vascularized medial femoral condyle structural bone flaps to restore lost pulp pinch in such cases. Nine patients (8 males, 1 female) with a mean age of 43 years sustained extensive terminal bone loss near digital tips following osteomyelitis. The mean length of bone defect was 28 mm (± 8.4). The patients were reconstructed at a mean of 12 weeks from initial trauma/infection, having undergone a mean of two prior surgeries. A structural block of vascularized bone from the medial femoral condyle replaced the missing bone at the digital tip defect, temporarily fixed with K-wires. The bone flap was encased by the residual soft tissue envelope after removing scar tissue from the prior trauma and infection. All bone flaps incorporated fully, restoring pulp pinch function to the respective digits with a mean time to union of 8.6 (± 2.1) weeks; range 6–11 weeks. With few alternative solutions able to address this unique and difficult problem, the structural block of vascularized bone proved able to resist resorption, nonunion, and reactivation of infection; the problems normally encountered under this scenario.

Keywords

Bone - Medial - Femoral - Condyle - Flap

• References

• 1 Hattori Y, Doi K, Ikeda K, Estrella EP. A retrospective study of functional outcomes after successful replantation versus amputation closure for single fingertip amputations. J Hand Surg Am 2006; 31: 811-818
• 2 Lin CH, Lin YT, Sassu P, Lin CH, Wei FC. Functional assessment of the reconstructed fingertips after free toe pulp transfer. Plast Reconstr Surg 2007; 120: 1315-1321
• 3 Camporro D, Gonzalez I, Martin C. Isolated second toe transfer after total amputation of the left fifth finger in a professional piano player. J Hand Surg Eu 2014; 39: 1003-1004
• 4 Tuncar S, Sezgin B, Kucuker I, Kaya B, Ayhan S. Reconstruction of the left thumb with a second toe transfer in a musician’s hand. J Plast Surg Hand Surg 2014; 48: 444-448
• 5 Lin PY, Sebastin SJ, Ono S, Belfi LT, Chung KW, Chung KC. A systematic review of outcomes of toe to thumb transfers for isolated traumatic thumb amputation. Hand 2011; 6: 235-243
• 6 Lau YY, Ho PC, Tse WL, Chow LT, Hung LK. Intraosseous glomus tumor treated by toe to finger transfer: case report. J Hand Surg Am 2009; 34: 710-714
• 7 Brunelli F, Spalvieri C, Rocchi L, Pivato G, Pajardi G. Reconstruction of the distal finger with partial second toe transfers by means of an exteriorized pedicle. J Hand Surg Eu 2008; 33: 457-461
• 8 Del Pinal F. The indications for toe transfer after “minor” finger injuries. J Hand Surg Br 2004; 29: 120-129
• 9 Kakinoki R, Ikeguchi R, Matsumoto T, Nakamura T. Reconstruction of a phalangeal bone using vascularized metacarpal bone graft nourished by a dorsal metacarpal artery. Injury 2008; 39: 25-28
• 10 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
• 11 De Smet L. Treatment of nonunion of forearm bones with a free vascularized corticoperiosteal flap from the medial femoral condyle. Acta Orthop Belg 2009; 75: 611-615
• 12 Sakai K, Doi K, Kawai S. Free vascularized thin corticoperiosteal graft. Plast Reconstr Surg 1991; 87: 290-298
• 13 Doi K, Sakai K. Vascularized periosteal bone graft from the supracondylar region of the femur. Microsurgery 1994; 15: 305-315
• 14 Kakar S, Duymaz A, Steinmann S, Shin AY, Moran SL. Vascularized medial femoral condyle corticoperiosteal flaps for the treatment of recalcitrant humeral nonunions. Microsurgery 2011; 31: 85-92
• 15 Doi K, Hattori Y. Vascularized bone graft from the supracondylar region of the femur. Microsurgery 2009; 29: 379-384
• 16 Del Pinal F, Garcia-Bernal FJ, Regalado J, Ayala H, Cagigal L, Studer A. Vascularised corticoperiosteal grafts from the medial femoral condyle for difficult nonunions of the upper limb. J Hand Surg Eu 2007; 32: 135-142
• 17 Jones Jr DB, 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
• 18 Grant I, Berger AC, Ireland DC. A vascularized bone graft from the medial femoral condyle for recurrent failed arthrodesis of the distal interphalangeal joint. Br J Plast Surg 2005; 58: 1011-1013
• 19 Malizos KN, Dailiana ZH, Innocenti M, Mathoulin CL, Mattar Jr R, Sauerbier M. Vascularized bone grafts for upper limb reconstruction: defects at the distal radius, wrist, and hand. J Hand Surg Am 2010; 35: 1710-1718
• 20 Al-Jabri T, Mannan A, Giannoudis P. The use of the free vascularized bone graft for nonunion of the scaphoid: a systematic review. J Orthop Surg Res 2014; 9: 21
• 21 Henry M. Genicular corticoperiosteal flap salvage of resistant atrophic nonunion of the distal radius metaphysis. Hand Surg 2007; 12: 211-215
• 22 Burger HK, Windhofer C, Gaggl AJ, Higgins JP. Vascularized medial femoral trochlea osteocartilaginous flap reconstruction of proximal pole scaphoid nonunions. J Hand Surg Am 2013; 38: 690-700
• 23 Higgins JP, Burger HK. Proximal scaphoid arthroplasty using the medial femoral trochlea flap. J Wrist Surg 2013; 2: 228-233
• 24 Higgins JP, Burger HK. Osteochondral flaps from the distal femur: expanding applications, harvest sites, and indications. J Reconstr Microsurg 2014; 30: 483-490
• 25 Burger HK, Windhofer C, Gaggl AJ, Higgins JP. Vascularized medial femoral trochlea osteochondral flap reconstruction of advanced kienbock disease. J Hand Surg Am 2014; 39: 1313-1322
• 26 Sammer DM, Bishop AT, Shin AY. Vascularized medial femoral condyle graft for thumb metacarpal reconstruction: case report. J Hand Surg Am 2009; 34: 715-718
• 27 Van Dijck C, Mattelaer B, De DeGreef I, De Smet L. Arterial anatomy of the free vascularized corticoperiosteal graft from the medial femoral condyle. Acta Orthop Belg 2011; 77: 502-505
• 28 Iorio ML, Masden DL, Higgins JP. The limits of medial femoral condyle corticoperiosteal flaps. J Hand Surg Am 2011; 36: 1592-1596
• 29 Yamamoto H, Jones Jr DB, Moran SL, Bishop AT, Shin AY. The arterial anatomy of the medial femoral condyle and its clinical implications. J Hand Surg Eu 2010; 35: 569-574