Medial Femoral Condyle Free Flap Reconstruction of Complex Foot and Ankle Pathology

Stranix, John T.; Piper, Merisa; Azoury, Saïd C.; Kozak, Geoffrey M.; Ben‐Amotz, Oded; Wapner, Keith L.; Levin, L. Scott

doi:10.1177/2473011419884269

Cited by 7 publications

(15 citation statements)

References 32 publications

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“…The MFC flap is known as a versatile flap that can be mobilized for small bony defects where more superficial flaps would not provide adequate coverage, including in the foot and ankle. 29 MFC flap for TAA salvage was successful in 2 of 3 patients in this cohort. The senior authors, therefore, recommend that reconstructive surgeons consider use of the MFC in TAA salvage when an osteocutaneous flap is indicated.…”

Section: Discussionmentioning

confidence: 72%

Soft-Tissue Reconstruction of Complicated Total Ankle Arthroplasty

Othman

Colen

Azoury

et al. 2020

Foot & Ankle Specialist

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Background Total ankle arthroplasty (TAA) is a popular modality to treat end-stage arthritis or internal ankle derangement. Unfortunately, failure rates remain undesirably high, with severe complications, including prosthesis failure, ankle fusion, and amputation. The importance of a stable soft-tissue envelope for coverage of implant compromise has been previously described, but the predictive factors for successful salvage of complicated TAA remain poorly understood. Methods A retrospective review was conducted of patients requiring soft-tissue reconstruction following TAA wound complications. Patient demographics, history, microbiological data, reconstructive approach, and outcomes data were collected. Statistical analysis was used to abstract factors associated with unsuccessful prosthetic salvage. Results In all, 13 patients met inclusion criteria: 8 (61.5%) achieved prosthetic salvage, and 5 (38.5%) failed. The majority (90.9%) of patients presented with infected joints. Reconstructive techniques included skin grafts, dermal substitutes, locoregional flaps, and free tissue transfer. Successful prosthetic salvage was associated with shorter time intervals between wound diagnosis and index reconstructive surgical intervention (median: 20 days for salvage vs 804 days for failure; P = .014). Additionally, salvage was associated with reduced time from the index orthopaedic/podiatric surgical intervention to the index reconstructive surgery procedure (12 vs 727 days; P = .027). Conclusion The prognosis of complicated TAA requiring soft-tissue reconstruction remains poor, especially in patients who present with infected joints. Several reconstructive techniques, ranging from simple skin grafts to complex free tissue transfers, can be used successfully. Early intervention to achieve soft-tissue coverage is crucial in maximizing salvage rates in the setting of complicated and infected TAA. Level of Evidence Level IV

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Section: Discussionmentioning

confidence: 72%

Soft-Tissue Reconstruction of Complicated Total Ankle Arthroplasty

Othman

Colen

Azoury

et al. 2020

Foot & Ankle Specialist

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“…The MFC free flap should, therefore, be reserved for patients with significant infection or soft tissue defects. 19,45…”

Section: Discussionmentioning

confidence: 99%

“…19 In particular, the medial femoral condyle (MFC) free flap has recently emerged as a popular source of vascularized periosteum, corticocancellous bone, and skin for complex reconstruction of the foot and ankle. 38,45…”

Section: Introductionmentioning

confidence: 99%

Biologic Augmentation of Tibiotalocalcaneal Arthrodesis With Allogeneic Bone Block Is Associated With High Rates of Fusion

et al. 2021

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Background: The orthopedic conditions and systemic comorbidities that occur in patients who require bone block tibiotalocalcaneal (TTC) arthrodesis have made this procedure associated with a higher-than-normal risk of nonunion, graft collapse, hardware failure, and amputation. Here, we present a novel approach to bone block TTC arthrodesis using adjunctive osteoinductive agents and a prolonged course of protected weightbearing to assess if we could improve on historical outcomes. We also evaluated the efficacy of a vascularized medial femoral condyle (MFC) free flap to augment TTC arthrodesis. Methods: Fourteen adult patients underwent bone block TTC arthrodesis biologically augmented with fresh-frozen femoral head allograft, bone marrow aspirate concentrate, and demineralized bone matrix cortical fibers. Three patients with soft tissue defects underwent vascularized reconstruction with an MFC free flap. Radiographic union, the Foot Function Index (FFI), and PROMIS pain interference (PI), and physical function (PF) scores were assessed at follow-up. Results: TTC fusion was documented on plain radiograph in 13 of 14 patients (92.9%) and CT in 10 of 11 patients (90.9%). Mean time to fusion was 183.2 ± 83.2 days. One patient (7.1%) experienced nonunion and persistent infection requiring amputation. Patients who underwent vascularized bone grafting had significantly shorter time to fusion (112.3 ± 31.7 days vs 204.4 ± 82.7 days, P = .05). Patient-reported outcomes revealed mild to moderate pain and dysfunction after 1 year (mean FFI = 41.0% ± 23.1%, PROMIS PI = 58.3 ± 1.8, PROMIS PF = 39.0 ± 2.2). Conclusion: In this relatively small series, the biologic augmentation of bone block TTC arthrodesis with osteoinductive agents and protective weightbearing resulted in excellent rates of fusion, modest pain, and preserved function of the lower extremity in almost all those treated. Osseous healing appears to be enhanced and accelerated with application of an MFC flap. We believe that this approach offers a viable salvage option for these challenging clinical problems. Level of Evidence: Level IV, case series.

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“…43 In patients with complex hindfoot pathology, the MFC facilitates osseous healing in greater than 90% of cases. 42 The fibula bone flap based on the peroneal artery has been used extensively because of its size of up to 18 to 26 cm in length, predictable dissection, and acceptable donor site morbidity. It is the most commonly used bone flap for femur and tibia reconstruction given its strength, ability to hypertrophy, and long cylindrical shape.…”

Section: Vascularized Bone Flaps For Lower Extremity Reconstructionmentioning

confidence: 99%

“…It has been used for larger bone grafting procedures and for osseous defects measuring up to 4 cm in largest dimension. 42 The MFC flap has been used to treat recalcitrant nonunions of the femur, tibia, and foot/ankle. 43 In patients with complex hindfoot pathology, the MFC facilitates osseous healing in greater than 90% of cases.…”

Section: Vascularized Bone Flaps For Lower Extremity Reconstructionmentioning

confidence: 99%

Reconstruction Options for Lower Extremity Traumatic Wounds

Azoury

Kovach

Levin

2022

J Am Acad Orthop Surg

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The senior author first coined the "orthoplastic" approach to traumatic lower extremity reconstruction, by which multidisciplinary surgeons and specialists work together for optimal patient success. The goals of lower extremity salvage are to optimize limb appearance, restore unrestricted pain-free ambulation, and improve quality of life. Composite traumatic defects require an organized approach, and the reconstructive ladder is used for strategies of varying complexity for repair of soft-tissue wounds. The lower rungs of the ladder include simpler reconstructive options such as the use of skin grafts and local flaps, and the higher rungs represent complex techniques such as free tissue transfer. Although there is no notable difference between muscle and fasciocutaneous/perforator flaps in reconstructive outcomes, there has been a trend toward perforator flaps to minimize donor site morbidity.T rauma is one of the most common antecedent etiologies for lower extremity wounds, both acute and chronic. The care of traumatized lower extremity patients necessitates an orthoplastic approach, first coined by the senior author (L.S.L.), by which multidisciplinary surgeons and specialists all work together to ensure optimal patient success. 1 Early treatment of a patient sustaining severe lower extremity trauma at a specialized orthoplastic limb salvage center should be the standard of care, and the lower extremity guidelines for salvage should be widely embraced to expedite referrals. [2][3][4] The goals of limb salvage are to optimize limb appearance, restore unrestricted pain-free ambulation, and improve quality of life. Our algorithm for the management of composite defects of the lower extremity below the knee has been previously described (Figure 1). 5,6 Blood flow should be restored, devitalized tissue débrided, bony defects or fractures stabilized, and missing soft-tissue implants replaced. When deciding the optimal tissue type for coverage, the reconstructive ladder is used: the lower rungs of the ladder include options such as skin grafts and local flaps and the higher rungs represent complex techniques such as microvascular free tissue transfer. The ladder is also expanding with options for the lower extremity amputee patient, including osseointegration, targeted muscle reinnervation, Saı ¨d C. Azoury, MD

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Medial Femoral Condyle Free Flap Reconstruction of Complex Foot and Ankle Pathology

Cited by 7 publications

References 32 publications

Soft-Tissue Reconstruction of Complicated Total Ankle Arthroplasty

Soft-Tissue Reconstruction of Complicated Total Ankle Arthroplasty

Biologic Augmentation of Tibiotalocalcaneal Arthrodesis With Allogeneic Bone Block Is Associated With High Rates of Fusion

Reconstruction Options for Lower Extremity Traumatic Wounds

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