A Composite Osteomusculocutaneous Free Flap from the Medial Femoral Condyle for Reconstruction of Complex Defects

ABSTRACT

This combined anatomic and clinical study illustrates the first experiences of an osteomyocutaneous flap from the medial femoral condyle for reconstruction of composite tissue defects. We analyzed the anatomic consistency and the vascular distribution of this flap and showed that muscle tissue can easily be added as a composite flap. Twenty-one flaps were harvested from fresh adult cadavers with careful identification of the origin and the course of the three different branches of the descending genicular artery. The corresponding skin areas and muscle portion were identified. The clinical application of this flap was described for closure of complex calcaneal defects. The cadaveric study presented a constant pedicle length and diameter of the arteries, combined with a constant venous drainage. Furthermore, the medial condyle provided a corticocancellous segment and separate vascularity for skin and muscle portions. In the case reports, satisfying results of bone union and soft tissue contouring were achieved. The medial femur condyle region is a reliable donor site for composite flaps, providing a good corticocancellous bony structure and a separate skin paddle, as well as a muscle portion. Its vascular distribution shows anatomic consistency. Despite long-term atrophy of muscle transplants, we believe the additional muscle tissue improves the reconstruction results and provides better soft tissue contouring.

Medial femoral condyle - osteomusculocutaneous flap - composite free flap

REFERENCES

• 1 Weiland A J. Current concepts review: vascularized free bone transplants.  J Bone Joint Surg Am. 1981;  63 166-169
• 2 Nusbickel F R, Dell P C, McAndrew M P, Moore M M. Vascularized autografts for reconstruction of skeletal defects following lower extremity trauma. A review.  Clin Orthop Relat Res. 1989;  (243) 65-70
• 3 Tu Y K, Yen C Y. Role of vascularized bone grafts in lower extremity osteomyelitis.  Orthop Clin North Am. 2007;  38 37-49
• 4 Cannon C P, Lin P P, Lewis V O, Yasko A W. Management of radiation-associated fractures.  J Am Acad Orthop Surg. 2008;  16 541-549
• 5 Han C S, Wood M B, Bishop A T, Cooney III W P. Vascularized bone transfer.  J Bone Joint Surg Am. 1992;  74 1441-1449
• 6 Arata M A, Wood M B, Cooney III W P. Revascularized segmental diaphyseal bone transfers in the canine. An analysis of viability.  J Reconstr Microsurg. 1984;  1 11-19
• 7 Cutting C B, McCarthy J G. Comparison of residual osseous mass between vascularized and nonvascularized onlay bone transfers.  Plast Reconstr Surg. 1983;  72 672-675
• 8 Goldberg V M, Shaffer J W, Field G, Davy D T. Biology of vascularized bone grafts.  Orthop Clin North Am. 1987;  18 197-205
• 9 Choudry U H, Bakri K, Moran S L, Karacor Z, Shin A Y. The vascularized medial femoral condyle periosteal bone flap for the treatment of recalcitrant bony nonunions.  Ann Plast Surg. 2008;  60 174-180
• 10 Doi K, Hattori Y. Vascularized bone graft from the supracondylar region of the femur.  Microsurgery. 2009;  29 379-384
• 11 Doi K, Sakai K. Vascularized periosteal bone graft from the supracondylar region of the femur.  Microsurgery. 1994;  15 305-315
• 12 Hertel R, Masquelet A C. The reverse flow medial knee osteoperiosteal flap for skeletal reconstruction of the leg. Description and anatomical basis.  Surg Radiol Anat. 1989;  11 257-262
• 13 Sammer D M, Bishop A T, Shin A Y. Vascularized medial femoral condyle graft for thumb metacarpal reconstruction: case report.  J Hand Surg Am. 2009;  34 715-718
• 14 Penteado C V, Masquelet A C, Romana M C, Chevrel J P. Periosteal flaps: anatomical bases of sites of elevation.  Surg Radiol Anat. 1990;  12 3-7
• 15 Acland R D, Schusterman M, Godina M, Eder E, Taylor G I, Carlisle I. The saphenous neurovascular free flap.  Plast Reconstr Surg. 1981;  67 763-774
• 16 Hong G X, Zhu T B, Wang F B et al.. Medial flap of the shank—anatomical study and clinical application.  J Tongji Med Univ. 1986;  6 246-250
• 17 Koski A, Kuokkanen H, Tukiainen E. Postoperative wound complications after internal fixation of closed calcaneal fractures: a retrospective analysis of 126 consecutive patients with 148 fractures.  Scand J Surg. 2005;  94 243-245
• 18 Benirschke S K, Kramer P A. Wound healing complications in closed and open calcaneal fractures.  J Orthop Trauma. 2004;  18 1-6
• 19 Martin D, Bitonti-Grillo C, De Biscop 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
• 20 Grant I, Berger A C, Ireland D C. 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
• 21 Sakai K, Doi K, Kawai S. Free vascularized thin corticoperiosteal graft.  Plast Reconstr Surg. 1991;  87 290-298
• 22 Larson A N, Bishop A T, Shin A Y. 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
• 23 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
• 24 Del Piñal F, García-Bernal F J, 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 Eur Vol. 2007;  32 135-142
• 25 Fuchs B, Steinmann S P, Bishop A T. Free vascularized corticoperiosteal bone graft for the treatment of persistent nonunion of the clavicle.  J Shoulder Elbow Surg. 2005;  14 264-268
• 26 Masquelet A C, Romana M C, Penteado C V, Carlioz H. Vascularized periosteal grafts. Anatomic description, experimental study, preliminary report of clinical experience.  Rev Chir Orthop Repar Appar Mot. 1988;  74 (Suppl 2) 240-243