Pedicled medial femoral condyle corticoperiosteal flap for resistant nonunion of the distal half of the femur

Abstract

Abstract Introduction: Resistant nonunion of the distal half of the femur is considered a major challenge for both the patient and the treating surgeon. Resistant bone nonunion is defined as impairment of the biological potential at the fracture bony ends due to diminished vascularity and loss of osteogenic cells at the bony ends, thus nonvascularized bone grafts will have a low chance of achieving union. Resistant nonunion includes septic nonunion, atrophic nonunion with failed nonvascularized graft and nonunion of recycled bony segments. Vascularized bone grafts include vascularized fibular flap and medial femoral condyle periosteal flap and others.1Vascularized fibular flap is suitable for gap nonunion with large gaps more than 5 centimeters. In resistant nonunion with minimal gapping in the lower limb, medial femoral condyle periosteal flap is more suitable. Medial femoral condyle periosteal flap is harvested from the distal medial aspect of the femur, and can be transferred as a free flap for distal site nonunion. In the distal half of the femur, the medial femoral condyle periosteal flap can be pedicled and transferred to the nonunion site at any point in the distal half of the femur.2–5 Methods we included three patients with resistant nonunion of the distal half of the femur. We calculated the transposition ratio for every patient by measuring the distance between the medial femoral epicondyle and the nonunion site (DMEB) and divided it by the distance between the medial femoral epicondyle and the apex of the lesser trochanter (DMELT). Patients with transposition ratio more than 0.5 were excluded from the study and other surgical options were done. Adequate rigid fixation was done in the three patients. The pedicled medial femoral condyle periosteal flap was harvested from the medial aspect of the distal femur.And was rotated to cover the nonunion site and was augmented by iliac crest graft to fill any gap. Bony union was followed up by monthly X ray and CT topography. All the three cases united (union rate 100%) with average duration of union was 6.7 months .We concluded that pedicled medial femoral condyle periosteal flap is a suitable surgical option for resistant nonunion of the distal half of the femur in addition to adequate rigid fixation.