Treatment of a Femur Nonunion with Microsurgical Corticoperiosteal Pedicled Flap from the Medial Femoral Condyle

Introduction.Te vascularized corticoperiosteal fap is harvested from the medial femoral condyle and it is nourished by the articular branch of the descending genicular artery and the superomedial genicular artery. Tis fap is usually harvested as a free fap for the reconstruction of bone defects at forearm, distal radius, carpus, hand, and recently at lower limb too. Case Report. A 50-year-old Caucasian man referred to our department for hypertrophic nonunion of the distal femur, refractory to the conservative treatments. Te frst surgical choice was the revision of the nail and the bone reconstruction with a corticoperiosteal pedicled fap from the medial femoral condyle. We considered union to have occurred 3.5 months afer surgery when radiographs showed bridging of at least three of the four bony cortices and clinically the patient was able to walk with full weight bearing without any pain. At the last follow-up (25 months), the patient was completely satisfed with the procedure. Discussion. Te corticoperiosteal fap allows a faster healing of fractures with a minimal morbidity at the donor site. We suggest that the corticoperiosteal pedicled fap graf is a reliable and efective treatment for distal femur nonunion

How future surgery will benefit from SARS-COV-2-related measures: a SPIGC survey conveying the perspective of Italian surgeons

COVID-19 negatively affected surgical activity, but the potential benefits resulting from adopted measures remain unclear. The aim of this study was to evaluate the change in surgical activity and potential benefit from COVID-19 measures in perspective of Italian surgeons on behalf of SPIGC. A nationwide online survey on surgical practice before, during, and after COVID-19 pandemic was conducted in March-April 2022 (NCT:05323851). Effects of COVID-19 hospital-related measures on surgical patients' management and personal professional development across surgical specialties were explored. Data on demographics, pre-operative/peri-operative/post-operative management, and professional development were collected. Outcomes were matched with the corresponding volume. Four hundred and seventy-three respondents were included in final analysis across 14 surgical specialties. Since SARS-CoV-2 pandemic, application of telematic consultations (4.1% vs. 21.6%; p < 0.0001) and diagnostic evaluations (16.4% vs. 42.2%; p < 0.0001) increased. Elective surgical activities significantly reduced and surgeons opted more frequently for conservative management with a possible indication for elective (26.3% vs. 35.7%; p < 0.0001) or urgent (20.4% vs. 38.5%; p < 0.0001) surgery. All new COVID-related measures are perceived to be maintained in the future. Surgeons' personal education online increased from 12.6% (pre-COVID) to 86.6% (post-COVID; p < 0.0001). Online educational activities are considered a beneficial effect from COVID pandemic (56.4%). COVID-19 had a great impact on surgical specialties, with significant reduction of operation volume. However, some forced changes turned out to be benefits. Isolation measures pushed the use of telemedicine and telemetric devices for outpatient practice and favored communication for educational purposes and surgeon-patient/family communication. From the Italian surgeons' perspective, COVID-related measures will continue to influence future surgical clinical practice

Bilobed Skin Paddle Fibula Flap for Large Oromandibular Defects

Although the fibula free flap (FFF) is a useful choice for mandible reconstruction, its application for large oromandibular defects is still debated upon. We report the use of FFF with a bilobed perforator-based skin paddle for combined hemiglossectomy, floor-of-the-mouth, tonsillar pillar, and mandibular body defect. A case of an 84-year-old woman with a 2.5 +/- 3.5-cm exophytic ulcerated mass on the right side of the tongue, extended to omolateral gengival fornix, tonsillar pillar, and mandibular body, is reported. An osteocutaneus FFF with a 7-cm bone strut and a 17 +/- 10-cm bilobed shaped skin paddle was performed. The longer lobe was used to restore tongue shape, whereas the smaller lobe was used to line the pelvic floor, gingival, and tonsillar pillar. The postoperative period was uneventful. The patient was capable to protrude her neotongue beyond the virtual incisors line and to touch the hard palate at different degrees of mouth opening. The bilobed perforator-based skin paddle FFF is felt to be a sound option for large compound oromandibular defects offering the possibility to safely base the skin component on a single peroneal perforator while achieving effective tongue mobility preservation

The Mushroom-Shaped Anterolateral Thigh Perforator Flap for Subtotal Tongue Reconstruction

Background: Reconstruction of a functional tongue with proper motility and sensation after subtotal resection is a demanding procedure. The authors describe the reinnervated mushroom-shaped anterolateral thigh perforator flap for subtotal tongue reconstruction. Methods: Thirteen patients (mean age, 54.8 years; range, 49 to 71 years) diagnosed with T3 and T4 squamous cell carcinomas were allocated prospectively to anterior total mobile (n = 7) or subtotal tongue resection (n = 6). All patients received the mushroom-shaped anterolateral thigh perforator flap. A Likert scale ranging from 1 to 4 was used to assess speech intelligibility, swallowing function, and cosmetic results. Epicritic and proprioceptive sensitivity testing was performed with the Pressure-Specified Sensory Device on the tip of the tongue preoperatively, on the neotongue at the donor site preoperatively, and at the recipient site 12 months postoperatively; protopathic thermoreceptor and nociceptors were clinically investigated. Outcomes were analyzed, and values of p < 0.05 were considered significant. Results: All flaps healed uneventfully (mean follow-up, 18 months). Six patients (46.2 percent) recovered a nearly natural deglutition, whereas seven (53.8 percent) had mild impairment (p = 0.274). Normal intelligible speech was achieved in seven cases (53.8 percent), and acceptable intelligible speech was achieved in six (46.2 percent) (p = 0.286). Aesthetic results were excellent in eight patients (61.5 percent) and good in five (38.5 percent) (p = 0.592). All patients recovered epicritic, proprioceptive, and protopathic sensitivity; cortical upgrading phenomena of the recipient nerve were observed. Conclusion: The reinnervated mushroom-shaped anterolateral thigh perforator flap was found to be an innovative and effective option for subtotal tongue reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV

Sagittal Split Osteotomy of the Fibula for Modeling the New Mandibular Angle

Fibula modeling techniques for mandible reconstruction carry a high risk of bone perfusion impairment and low predictability of osteotomy angles. To restore the parabolic shape of the mandible, the number of osteotomies should be as small as possible to preserve both periosteal and endosteal perfusion. We report our approach with sagittal split osteotomy (SSO) technique for mandibular angle reconstruction. Obwegeser-Dal Pont SSO of fibula flaps was performed on 10 patients who underwent mandibular angle reconstruction. Bone segments were tilted according to stereolithographic template and fixed with 3 bicortical screws in triangular fashion. Fibula-gonial angle at 15 days and 6 months from surgery was compared with the contralateral-mandibular-gonial angle using Kruskal-Wallis test with a P 0.05) between fibula-gonial angle at 15 days (mean, 122.88 +/- 0.55 degrees; range, 122.49-123.27 degrees) and 6 months (mean, 123.36 +/- 0.88 degrees; range, 122.73-123.99 degrees) and contralateral-mandibular-gonial angle (mean, 123.20 +/- 0.80 degrees; range, 122.62-123.77 degrees) were observed. Fibula SSO allows for new-mandible angle shaping, reducing risk of pedicle and endosteal vascular impairment. Triangular bone fixation thereby emerges as a reliable technique, enhancing functional and aesthetic long-term outcomes