Download PDF
J Reconstr Microsurg 2023; 39(07): 502-507
DOI: 10.1055/a-2004-2364
Original Article

Correlation between Risk Factors and Healing Times in Long Bone Nonunions Treated with Corticoperiosteal Flap from the Medial Femoral Condyle

Matteo Guzzini
1   Orthopaedic and Trauma Surgery Unit, A.O.U. Sant'Andrea, La Sapienza University of Rome, Rome, Italy
,
Davide Ciclamini
2   Hand Surgery and Reconstructive Microsurgery Department, CTO Hospital, A.O.U. Città della Salute e della Scienza, Turin, Italy
,
Leopoldo Arioli
1   Orthopaedic and Trauma Surgery Unit, A.O.U. Sant'Andrea, La Sapienza University of Rome, Rome, Italy
,
Paolo Titolo
2   Hand Surgery and Reconstructive Microsurgery Department, CTO Hospital, A.O.U. Città della Salute e della Scienza, Turin, Italy
,
Alessandro Carrozzo 
1   Orthopaedic and Trauma Surgery Unit, A.O.U. Sant'Andrea, La Sapienza University of Rome, Rome, Italy
,
Francesca Latini
1   Orthopaedic and Trauma Surgery Unit, A.O.U. Sant'Andrea, La Sapienza University of Rome, Rome, Italy
,
Bruno Battiston
2   Hand Surgery and Reconstructive Microsurgery Department, CTO Hospital, A.O.U. Città della Salute e della Scienza, Turin, Italy
,
Andrea Ferretti
1   Orthopaedic and Trauma Surgery Unit, A.O.U. Sant'Andrea, La Sapienza University of Rome, Rome, Italy
› Author Affiliations Funding The authors received no financial support for the research, authorship, and/or publication of this article.
› Further Information
Also available at
    Permissions and Reprints

Abstract

Background The rate of fracture nonunion varies depending on the anatomical site. Numerous procedures have been proposed to treat recalcitrant nonunions. The vascularized medial femoral condyle corticoperiosteal free flap (MFCCFF) is increasingly used in nonunions with small bone loss.

The percentage of success of the MFCCFF is high but the factors involved in delayed bone healing or failure of this technique or the contraindications are not described in the literature.

This multicentric study aims to identify and report the different factors involved in determining the time of bone healing in the treatment of atrophic nonunion of long bones with the vascularized medial MFCCFF.

Methods All patients who underwent vascularized medial MFCCFF from January 2011 to December 2020 for the treatment of recalcitrant atrophic nonunions of long bones. Patients were reviewed at 2 and 6 weeks, and 3, 6, and 12 months postoperatively and evaluated by physical and radiographic examinations and patient-reported outcome measures.

Results The final study population comprised 59 patients with a mean follow-up of 26.2 ± 7.6 months, a rate of bone healing of 94.9% with a mean radiographic bone healing time of 4.1 ± 1.3 months, and low morbidity of the donor site. Diabetes mellitus, a body mass index (BMI) ≥30 kg/m2, and ≥2 previous surgeries on the fracture site were factors predicting timing for bone healing at the multivariate analysis.

Conclusion This study demonstrates the MFCCFF as an effective and safe procedure for the treatment of the recalcitrant atrophic nonunion of long bones. An association was found between the lengthening of bone healing time and a high BMI, presence of ≥2 previous surgical interventions, and diabetes mellitus, indicating these comorbidities as risk factors (not absolute contraindications) for this microsurgical treatment. So, to our knowledge, the MFCCFF could be the first-choice treatment for atrophic nonunion of long bones.

Keywords

nonunion - surgery - corticoperiosteal flap

Authors' Contributions

M.G., D.C., and P.T. were responsible for recruiting patients and collecting data. L.A. and F.L. have interpreted the data and drafted the work. A.F. and M.G. made substantial contributions to the conception of the work. M.G., D.C., and B.B. have substantively revised the article. A.C. and L.A. were responsible for statistical analysis and interpretation of data. All authors also substantively revised the work and approved the submitted version. All authors read and approved the final manuscript.


Availability of Data and Materials

The database generated during and/or analyzed during the current study is not publicly available but is available from the corresponding author on reasonable request.


Ethical Approval and Consent to Participate

All patients gave valid, written consent to be enrolled in the study.




Publication History

Received: 13 March 2022

Accepted: 30 November 2022

Accepted Manuscript online:
28 December 2022

Article published online:
19 January 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Zura R, Braid-Forbes MJ, Jeray K. et al. Bone fracture nonunion rate decreases with increasing age: a prospective inception cohort study. Bone 2017; 95: 26-32
    CrossrefPubMedSearch in Google Scholar
  • 2 Zura R, Watson JT, Einhorn T. et al. An inception cohort analysis to predict nonunion in tibia and 17 other fracture locations. Injury 2017; 48 (06) 1194-1203
    CrossrefPubMedSearch in Google Scholar
  • 3 Bell A, Templeman D, Weinlein JC. Nonunion of the femur and tibia: an update. Orthop Clin North Am 2016; 47 (02) 365-375
    CrossrefPubMedSearch in Google Scholar
  • 4 Ciclamini D, Tos P, Guzzini M, Soldati A, Crosio A, Battiston B. The medial femoral condyle free corticoperiosteal flap versus traditional bone graft for treatment of nonunions of long bones: a retrospective comparative cohort study. Injury 2019; 50 (Suppl 5): S54-S58
    CrossrefPubMedSearch in Google Scholar
  • 5 Guzzini M, Lupariello D, Argento G, Arioli L, Ferretti A. Vascular and bone regeneration of the donor site after corticoperiosteal flap from the medial femoral condyle. Hand (N Y) 2022; 17 (02) 366-372
    CrossrefPubMedSearch in Google Scholar
  • 6 Guzzini M, Arioli L, Rugiero C, Rossini M, Argento G, Ferretti A. Donorsite defect of medial femoral condyle corticoperiostal flap in the treatment of lower limb infected nonunions. Handchir Mikrochir Plast Chir 2021; 53 (04) 376-382
    Thieme ConnectPubMedSearch in Google Scholar
  • 7 Fei W, Danmou X, Dong R. et al. Free vascularized medial femoral condyle corticocancellous flap for treatment of challenging upper extremity nonunions. J Reconstr Microsurg 2015; 31 (02) 124-131
    Thieme ConnectPubMedSearch in Google Scholar
  • 8 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 (05) 291-294
    Thieme ConnectPubMedSearch in Google Scholar
  • 9 Calori GM, Albisetti W, Agus A, Iori S, Tagliabue L. Risk factors contributing to fracture non-unions. Injury 2007; 38 (Suppl 2): S11-S18
    CrossrefPubMedSearch in Google Scholar
  • 10 Bishop JA, Palanca AA, Bellino MJ, Lowenberg DW. Assessment of compromised fracture healing. J Am Acad Orthop Surg 2012; 20 (05) 273-282
    CrossrefPubMedSearch in Google Scholar
  • 11 Hernigou J, Schuind F. Smoking as a predictor of negative outcome in diaphyseal fracture healing. Int Orthop 2013; 37 (05) 883-887
    CrossrefPubMedSearch in Google Scholar
  • 12 Robinson CM, Court-Brown CM, McQueen MM, Wakefield AE. Estimating the risk of nonunion following nonoperative treatment of a clavicular fracture. J Bone Joint Surg Am 2004; 86 (07) 1359-1365
    CrossrefPubMedSearch in Google Scholar
  • 13 Duckworth AD, Bennet SJ, Aderinto J, Keating JF. Fixation of intracapsular fractures of the femoral neck in young patients: risk factors for failure. J Bone Joint Surg Br 2011; 93 (06) 811-816
    CrossrefPubMedSearch in Google Scholar
  • 14 Day SM, DeHeer DH. Reversal of the detrimental effects of chronic protein malnutrition on long bone fracture healing. J Orthop Trauma 2001; 15 (01) 47-53
    CrossrefPubMedSearch in Google Scholar
  • 15 Lin PP, Boland PJ, Healey JH. Treatment of femoral fractures after irradiation. Clin Orthop Relat Res 1998; (352) 168-178
    PubMedSearch in Google Scholar
  • 16 Brinker MR, O'Connor DP, Monla YT, Earthman TP. Metabolic and endocrine abnormalities in patients with nonunions. J Orthop Trauma 2007; 21 (08) 557-570
    CrossrefPubMedSearch in Google Scholar
  • 17 Calori GM, Giannoudis PV. Enhancement of fracture healing with the diamond concept: the role of the biological chamber. Injury 2011; 42 (11) 1191-1193
    CrossrefPubMedSearch in Google Scholar
  • 18 Gustilo RB, Gruninger RP, Davis T. Classification of type III (severe) open fractures relative to treatment and results. Orthopedics 1987; 10 (12) 1781-1788
    PubMedSearch in Google Scholar
  • 19 Rodriguez-Merchan EC, Forriol F. Nonunion: general principles and experimental data. Clin Orthop Relat Res 2004; (419) 4-12
    CrossrefPubMedSearch in Google Scholar
  • 20 Penteado CV, Masquelet AC, Romana MC, Chevrel JP. Periosteal flaps: anatomical bases of sites of elevation. Surg Radiol Anat 1990; 12 (01) 3-7
    CrossrefPubMedSearch in Google Scholar
  • 21 Romana MC, Masquelet AC. Vascularized periosteum associated with cancellous bone graft: an experimental study. Plast Reconstr Surg 1990; 85 (04) 587-592
    CrossrefPubMedSearch in Google Scholar
  • 22 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 (02) 85-92
    CrossrefPubMedSearch in Google Scholar
  • 23 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 (03) 264-268
    CrossrefPubMedSearch in Google Scholar
  • 24 Guzzini M, Lanzetti RM, Proietti L, Lupariello D, Iorio R, Ferretti A. The role of vascularized flaps in the treatment of proximal pole avascular necrosis in scaphoid non-unions. Acta Biomed 2019; 90 (12-S): 64-68
    PubMedSearch in Google Scholar
  • 25 Zhou KJ, Graham DJ, Stewart D, Lawson RD, Sivakumar BS. Free medial femoral condyle flap for reconstruction of scaphoid nonunion: a systematic review. J Reconstr Microsurg 2022; 38 (08) 593-603
    Thieme ConnectPubMedSearch in Google Scholar
  • 26 Lese I, Biedermann R, Constantinescu M, Grobbelaar AO, Olariu R. Predicting risk factors that lead to free flap failure and vascular compromise: a single unit experience with 565 free tissue transfers. J Plast Reconstr Aesthet Surg 2021; 74 (03) 512-522
    CrossrefPubMedSearch in Google Scholar
  • 27 Sanati-Mehrizy P, Massenburg BB, Rozehnal JM, Ingargiola MJ, Hernandez Rosa J, Taub PJ. Risk factors leading to free flap failure: analysis from the national surgical quality improvement program database. J Craniofac Surg 2016; 27 (08) 1956-1964
    CrossrefPubMedSearch in Google Scholar
  • 28 Chang EI, Nguyen AT, Hughes JK. et al. Optimization of free-flap limb salvage and maximizing function and quality of life following oncologic resection: 12-year experience. Ann Surg Oncol 2016; 23 (03) 1036-1043
    CrossrefPubMedSearch in Google Scholar
  • 29 Houdek MT, Bayne CO, Bishop AT, Shin AY. The outcome and complications of vascularised fibular grafts. Bone Joint J 2017; 99-B (01) 134-138
    CrossrefPubMedSearch in Google Scholar