The medial femoral condyle free corticoperiosteal flap versus traditional bone graft for treatment of nonunions of long bones. a retrospective comparative cohort study

Fracture healing is a complex process and many factors change the local biology of the fracture and reduce the physiologic repair process. Since 1991 the free vascularised corticoperiosteal graft has been proposed to treat nonunions. In this study we compare the healing rate and the healing time of the free vascularised corticoperiosteal graft harvested from medial femoral condyle versus the traditional cancellous bone graft from the iliac crest combined with other biologic or pharmacologic factors. We performed a retrospective cohort study. The main measures of outcomes were the rate of bone union and the mean healing time from surgery. The authors performed 10 free vascularised corticoperiosteal grafts in the cohort A and 10 patients received traditional cancellous bone graft plus other biologic or pharmacologic treatment in the same period in the cohort B. The mean follow up in cohort A was 18.6 months with a healing rate of 100% (10/10). In cohort B the mean follow up was 22.5 month with a healing rate of 90%. The mean time to obtain union (healing time) in the group that was treated with the free flap procedure was significantly shorter, 3.2 months versus a mean time of 8.8 months in the other group. Some studies describe a high healing rate of recalcitrant nonunions with treatments different from vascularized bone flaps: it is difficult to compare the results of vascularized bone transfers with the results of other case series. Our groups are very homogeneous even if it is difficult to define correct inclusion criteria because there is still no agreement about what is defined a recalcitrant or difficult nonunion, and the number of trials of previous surgery before to perform a vascularized free flap. Even if our study cohort is small, we have demonstrated that the MFCCF generally seems to give a better healing chance with a shorter healing time compared to other treatments

Treatment of flexor tendon reconstruction failures: multicentric experience with Brunelli active tendon implant

Introduction: Secondary repair of flexor tendon injuries remain a challenging procedure for hand surgeons. Usually, secondary reconstruction should be performed by staged approach. When the tendon and pulley integrity are intact, tenolysis may be the first surgical option. One-/two-stage tendon grafts are suggested when the integrity of flexor tendon is compromised. Active tendon implants (Brunelli prostheses) may represent an efficient option in patients with a poor prognosis, as well as whenever classical techniques fail. Due to lack of literature about this second-line treatment, the authors present the experience of two different orthopedic departments with the permanent active tendon implant. Materials and method: Nineteen consecutive patients with failed previous flexor tendons repairs were treated with active tendon implants between 2000 and 2011. The functional outcome of the patients was examined with a mean follow-up of 5.6 years, using Strickland assessment and QuickDASH. Results: In 16 cases, the tendon implants were well tolerated and patients resulted satisfied with a QuickDASH score less than 33. Strickland score was fair to excellent in 10 patients. We registered adhesion complications in 3 cases. Conclusion: We can conclude that these prostheses represent an alternative to biological reconstructions and a potentially permanent procedure in complicated flexor tendon injuries. Level of evidence: Multicentric case series, Level IV

Lembi perforanti sul modello animale vivente. CAPITOLO 03.

La tecnica operatoria che permette di alle- stire i lembi perforanti richiede delicatezza e precisione. Questo tipo di dissezione deve essere ap- preso ed af nato prima di arrivare alla esperienza clinica sull\u2019 umano ed il metodo migliore per otte- nere questa esperienza \ue8 l\u2019esercizio assiduo. In generale i modelli per l\u2019esercizio chirurgico di tecniche ni come la microchirurgia sono quel- li sintetici e i piccoli animali (ratti, conigli). Ove l\u2019esercizio da apprendere non sia di pura micro- chirurgia (con le anastomosi microvascolari) ma di preparazione di lembi perforanti, siano essi pe- duncolati o microchirurgici, i metodi migliori per fare esperienza sembrerebbero essere la pratica su cadavere e la pratica su modello vivente ani- male.1 L\u2019esercizio su cadavere \ue8 molto utile soprattutto per l\u2019apprendimento della reale dimensione e di- stribuzione dei vasi perforanti e in generale delle strutture anatomiche nell\u2019essere umano. Gli svan- taggi della dissezione su cadavere sono quello della impossibilit\ue0 di simulare le reali dif colt\ue0 che si incontrano in clinica. In particolare la mancanza di una circolazione sanguigna attiva, fa s\uec che il campo operatorio sia sempre pulito e che possa- no essere trascurati alcuni aspetti fondamentali come la precisa e dettagliata emostasi di tutti i vasi minori che non sia necessario preservare. \uc8 questa la ragione per cui riteniamo molto utile la pratica chirurgica dei lembi perforanti sul model- lo animale vivente che ha l\u2019enorme vantaggio di riprodurre fedelmente tutte le possibili dif colt\ue0 chirurgiche incontrate in clinica. I tessuti inoltre hanno la consistenza e la malleabilit\ue0 che han- no i tessuti umani. Alla ne della dissezione del lembo, \ue8 possibile veri care la vitalit\ue0 del lembo, sia per la perfusione arteriosa che per il drenag- gio venoso e quindi in conclusione la correttezza dell\u2019esercizio chirurgico

Orthoplastic limb reconstruction using free fibula flap after trauma: Outcomes from a retrospective European multicenter study.

Free vascularized fibula flap represents the gold standard vascularized bone graft for the management of segmental long bone defects after traumatic injury. The current study represents the largest retrospective multicenter data collection on the use of free fibula flap (FFF) for extremities' orthoplastic reconstruction after trauma aiming to highlight current surgical practice and to set the basis for updating current surgical indications. The study is designed as a retrospective analysis of prospectively collected data between 2009 and 2021 from six European University hospitals. Patients who underwent fibula flap reconstruction after acute traumatic injury (AF) or as a late reconstruction (LF) after post-traumatic non-union of upper or lower limb were included. Only extra-articular, diaphyseal fracture were included in the study. Surgical data were collected. Time to bone healing and complications were reported as clinical outcomes. Sixty-two patients were included in the study (27 in the AF group and 35 in the LF group). The average patients' age at the time of the traumatic event was 45.3 ± 2.9 years in the AF group and 41.1 ± 2.1 years in the LF group. Mean bone defect size was 7.7 ± 0.6 cm for upper limb and 11.2 ± 1.1 cm (p = .32) for lower limb. Bone healing was uneventful in 69% of treated patients, reaching 92% after complementary procedures. Bone healing time was 7.6 ± 1.2 months in the acute group and 9.6 ± 1.5 months in the late group. An overall complication rate of 30.6% was observed, with a higher percentage of late bone complications in the LF group (34%), mostly non-union cases. FFF reconstruction represents a reliable and definitive solution for long bone defects with bone healing reached in 92% cases with a 8.4 months of average bone healing time