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Introduction: Dorsal hand skin flaps have been described in order to avoid digit skin grafting in syndactyly release. Although these skin-graftless techniques present a lower rate of long term complications, they result in unsightly dorsal scarring and worse patient satisfaction. We describe a novel technique using an intermetacarpal palmar flap by performing an anatomic study and clinical application., Materials and Methods: Ten colored-latex-injected fresh upper limbs were used to study the palmar cutaneous perforators to second to fourth intermetacarpal space skin flaps designed elliptical, its width extending from the center of each involved ray and measuring 40%-50% the length of the palm., Results: The anatomical study revealed a mean 2.77 (range 1 to 4) cutaneous perforators originating from either the common or proper digital vessels for every intermetacarpal space and measuring 0.4 mm (range 0.3 to 0.5 mm) in diameter., Clinical Application: This flap, measuring a mean of 21.5 mm (range 20 to 23 mm) in length and 9.5 mm (range 9 to 10 mm) in width, was used to release simple syndactylies in three patients of mean age 24 months (range = 18-30 months). After skin incision, cutaneous septa to the digital canal were released to permit flap advancement to the web space. Cutaneous perforators were not dissected. Intra-operative palmar-flap advancement provided commissure coverage in all children with no skin grafts needed. Over a mean follow-up of 15 months, no complications occurred, mean palm scar VSS was 2.4 (range 2 to 3) while it was 3 (range 3 to 3) for the commissure scars., Conclusions: Skin-graftless syndactyly release using a palmar intermetacarpal flap seems both reliable and easy-to-perform., Level of Evidence: Therapeutic IV., (© 2023 Wiley Periodicals LLC.)

Introduction: Attaining active glenohumeral external rotation (aGHER), whether via primary reconstruction or spontaneous recovery, is infrequent in patients with neonatal brachial plexus palsy (NBPI). We evaluated the effectiveness of triceps-to-teres minor motor branch transfers to restore this function, both performed primarily (i.e., in conjunction with microsurgical plexus reconstruction) or secondarily (after primary surgery has failed to restore aGHER)., Patients and Methods: This was a retrospective study of 12 children with NBPI undergoing triceps-to-teres minor motor branch transfer via an axillary approach, six undergoing primary surgery and six secondary. The primary outcome was post-operative restoration of aGHER in abduction. The primary-surgery group consisted of six children of mean age 8 months (range 5-11) with partial injuries ranging from C5-C6 to C5-C8. The secondary-surgery group included six patients with C5-C6 injuries of mean age 43 months (range 23-120), undergoing re-operation a mean 40 months (range 18-116) after their primary surgery., Results: No complications occurred after surgery. At a mean follow-up of 22 months (range 14-30), aGHER in abduction only was restored in one patient in the primary group while in the secondary group, aGHER in abduction was restored in all patients to a mean 73° (range 70-80) after a mean follow-up of 16 months (range 6-26)., Conclusions: Triceps-to-teres minor motor branch transfer is not indicated as primary surgery for NBPI. However, they can be effective in children in whom primary surgery has failed to restore aGHER, even if the spinal accessory nerve is unavailable for transfer to the infraspinatus motor branch., (© 2022 Wiley Periodicals LLC.)

Introduction: Congenital pseudarthrosis of the tibia (CPT) is one of the most challenging orthopedic disorders. The use of a vascularized tibial periosteal grafts has been recently reported as a powerful tool to obtain bone union. We report its use in CPT., Patients and Methods: Retrospective short-term study of 29 children (18 male/11 female, 15 right-sided/14 left-sided) of mean age 45 months (range 11-144 months), operated upon after October 2014. Nonunion site was debrided, and the periosteum of the involved limb was excised. A vascularized tibial periosteal graft (mean length 10.7 cm (range 9-15 cm) with a monitoring skin island (mean length 4.1 cm (range 3-5 cm) and based on the anterior tibial vessels, was obtained from the contralateral tibia. Anterior tibial vessels were always the recipient vessels. Most cases were stabilized with an LCP plate. The rate of and time to bone union were analyzed. Charts only were evaluated through the first 3 months after bone union was achieved., Results: The flap survived and bone union was obtained in all cases, through a periosteal callus, in a mean time of 5.1 weeks (range 3-6 weeks). Mean follow-up was 8.3 months (range 7-19 months). No union failures occurred 3 months after resuming unprotected weight bearing., Conclusions: Our novel technique produced a consistent, rapid capacity for CPT union, superior to previously-reported techniques. However, it cannot be recommended as a standard method of treatment until consistent, long-term, refracture-free follow-up is documented., (© 2022 Wiley Periodicals LLC.)

Vascularized periosteal flaps have been reported as very effective for treating biologically complex bone nonunion in pediatric patients, owing to their high angiogenic and osteogenic potentials. The purpose of this article is to report a case of a 6-year-old patient with nonunion involving both forearms and a very limited bone flap donor site in the context of prior bilateral transfemoral amputation due to meningococcal sepsis. Two free vascularized iliac periosteal flaps (VIPF), supplied by the deep circumflex iliac vessels, were used in two stages to reconstruct the forearms. In the first stage, the left forearm, which had a diaphyseal bone defect of 5 cm diameter in the ulna and 4 cm in the radius, was combined with an iliac-crest bone allograft, fixed with two longitudinal 1.8 mm Kirschner wires and surrounded with a free VIPF of 24 cm 2 . Consolidation was achieved 3 months after left forearm surgery, while complete allograft revascularization and remodeling was observed at 12 months. In the second stage, the right forearm, which had a diaphyseal bone defect of 3 cm diameter in the ulna and 1 cm in the radius, was fixed the radius with a 2.7 mm plate and surrounded with a free VIPF of 24 cm 2 . The radius nonunion healed 6 weeks after surgery. There were no postoperative complications. Two years postoperatively, the patient had again resumed his arm gait painlessly and without a splint. VIPF may be considered a valuable and reliable surgical option for nonunion reconstruction in complex clinical scenarios in children., (© 2021 Wiley Periodicals LLC.)

Introduction: In the last years, limb salvage has become the gold standard treatment over amputation. Today, 90% of extremity osteogenic sarcomas can be treated with limb salvage surgery. However, these reconstructions are not exempt from complications. Massive allografts have been associated to high risk of nonunion (12-57%), fracture (7-30%) and infection (5-21%). Association of vascularized periosteum flap to a massive bone allograft (MBA) has shown to halve the average time of allograft union in clinical series, even compared to vascularized fibular flap. Creeping substitution process has been reported in massive allograft when periosteum flap was associated. However, we have little data about whether it results into allograft revitalization. We hypothesize that the association of a periosteum flap to a bone isograft promotes isograft revitalization, defined as the colonization of the devitalized bone by new-form vessels and viable osteocytes, turning it vital., Materials and Methods: Forty-four New Zealand white male rabbits underwent a 10 mm segmental radial bone defect. In 24 rabbits the bone excision included the periosteum (controls); in 20 rabbits (periosteum group) bone excision was performed carefully detaching periosteum in order to preserve it. Cryopreserved bone isograft from another rabbit was trimmed and placed to the defect gap and was fixed with a retrograde intramedullar 0.6 mm Kirschner wire. Rabbits were randomized and distributed in 3 subgroups depending on the follow-up (control group: 5 rabbits in 5-week follow up group, 8 rabbits in 10-week follow-up group, 7 rabbits in 20-week follow-up group; periosteum group: 5 rabbits in 5-week follow up group, 7 rabbits in 10-week follow-up group, 7 rabbits in 20-week follow-up group). Fluoroscopic images of rabbit forelimb were taken after sacrifice to address union. Each specimen was blindly evaluated in optical microscope (magnification, ×4) after hematoxylin and eosin staining to qualitative record: presence of new vessels and osteocytes in bone graft lacunae (yes/no) to address revitalization, presence of callus (yes/no) and woven bone and cartilage tissue area (mm 2 ) to address remodeling (osteoclast resorption of old bone and substitution by osteoblastic new bone formation)., Results: No isograft revitalization occurred in any group, but it was observed bone graft resorption and substitution by new-formed bone in periosteum group. This phenomenon was accelerated in 5-week periosteum group (control group: 49.5 ± 9.6 mm 2 vs. periosteum group: 34.9 ± 10.4 mm 2 ; p = .07). Remodeled lamellar bone was observed in both 20-week groups (control group: 6.1 ± 6.3 mm 2 vs. periosteum group: 5.8 ± 3.0 mm 2 , p = .67). Periosteum group showed complete integration and graft substitution, whereas devitalized osteons were still observed in 20-week controls. All periosteum group samples showed radiographic union through a bone callus, whereas controls showed nonunion in eight specimens (Union rate: control group 60% vs. periosteum group 100%, p = .003)., Conclusions: Association of vascularized periosteum to a massive bone isograft has shown to accelerate bone graft substitution into a newly formed bone, thus, no bone graft revitalization occurs., (© 2020 Wiley Periodicals LLC.)

Background: Vascularized periosteal graft have demonstrated a tremendous bone healing capacity in children. The objective is to report outcomes on the use of vascularized tibial periosteal graft (VTPG) during bone reconstruction in a series of children with complex bone healing problems., Patients and Methods: Cases were collected retrospectively since May 2013 to May 2019, excluding cases of congenital pseudarthrosis of the tibia. Mean age at surgery was 12.8 (range 11-18) years. Indications included treatment of recalcitrant bone nonunion and the prevention of bone allograft-host junction nonunion in seven and three patients, respectively. The periosteal flap, based on the anterior tibial vessels, was harvested as a free flap in six instances and as a pedicled flap in four., Results: Mean follow-up was 25.2 months (range 8-36). The flap showed a 13.6 cm (range 9-16) and mean width 3.4 cm (range 2.7-3.9). Early bone union was achieved, initially through periosteal callus, followed by cortical union at mean times of 2 and 4 months, respectively, in nine cases. The flap was not successful in a patient with severe comorbidities. No donor site complications were registered., Conclusions: VTPG was fast and high effective for the treatment complex bone nonunion or the prevention of allograft nonunion in children., (© 2020 Wiley Periodicals LLC.)

Purpose: Through an anatomical review, the primary aim of this study was to delineate the dorsal thumb metacarpal (TM) periosteal branches of the radial artery (RA). In addition, we report here the clinical utility of a vascularized TM periosteal pedicled flap (VTMPF), supplied by the first dorsal metacarpal artery (FDMA), in a complex case of scaphoid nonunion., Methods: Ten latex-colored upper limbs from fresh human cadavers were used. Branches of the RA were dissected under 3x loupe magnification, noting the periosteal branches arising from the FDMA. The VTMPF was measured for both length (cm) and width (cm)., Results: The FDMA provided a mean 12 periosteal branches (range 9 to 15), with a mean distance between branches of 0.5 cm (range 0.2-1.1), allowing for the design of a VTMPF which measured a mean 4 cm in length and 1.2 cm in width. We used a VTMPF to treat recalcitrant scaphoid nonunion, with a volar defect of 0.7 cm, in a 16-year-old boy. No bone graft was used. The patient experienced no postoperative complications. Successful consolidation was achieved three months after surgery, confirming the flap's survival. At 14-months of postoperative follow-up, the patient's VAS pain rating was 0 out of 100, and his DASH questionnaire score was 5. The patient had painless range that was 95% that of the contralateral limb. The patient's pinch and grip strengths were 6.5 kg and 28 kg, respectively (95% of unaffected side)., Conclusions: VTMPF may be considered a valuable and reliable surgical option for scaphoid nonunion in complex clinical scenarios., (© 2017 Wiley Periodicals, Inc.)

Purpose: Through an anatomical review, the aim of this study is to define the ulnar periosteal branches of the posterior interosseous vessels (PIV). In addition, we report the clinical utility of a vascularized ulnar periosteal pedicled flap (VUPPF), supplied by the investigated PIV, in a complex case of radial nonunion., Methods: Ten upper limbs latex colored from fresh human cadavers were used. Branches of the PIV were dissected under 2.5× loupe magnification, noting the periosteal, muscular, and cutaneous branches arising distal to the interosseous recurrent artery. The VUPPF was measured in length (cm) and width (cm)., Results: The PIV provided a mean 12.8 periosteal branches to the ulna distributed along the most distal 15 cm, with a mean distance between branches of 1 cm, allowing for the design of a VUPPF which measured a mean 12 cm in length and 1.7 cm in width. We used a VUPPF of 7.8 cm in length and 2 cm in width to treat extensive nonvascularized bone graft nonunion with a defect of 2 cm of the left radius in a 6-year-old girl, secondary to previous Ewing's Sarcoma reconstruction. Successfully consolidation was achieved 6-months after surgery. The patient did not present postoperative complications. At 2-years of follow-up after surgery, active supination was 80° and pronation 0° (due an incomplete interosseous ossification); grip strength was 80% that of the opposite hand. The patient had resumed all her daily activities., Conclusions: VUPPF may be considered a valuable and reliable surgical option for forearm reconstruction in complex clinical scenarios., (© 2017 Wiley Periodicals, Inc.)

Several types of vascularized periosteal flaps have recently been described for the treatment or prevention of complex non-union in pediatric patients. Among them, a vascularized tibial periosteal graft (VTPG), supplied by the anterior tibial vessels (ATV), has been used successfully as a pedicled flap in a few patients. The purpose of the study is to describe the periosteal branches of the ATV, as well as the cutaneous and muscular branches by means of an anatomical study. In addition, to report on the use of VTPG as a free flap with a monitoring skin island in a clinical case. A mean of 6.5 periosteal branches (range 5-7) were found. In all cases we located a cutaneous perforator branching from one of the periosteal branches located at the midlevel of the leg. We performed a two-stage reconstruction of a recalcitrant non-union and residual shortening of the right tibia in a 17-year-old boy. After nonunion focus distraction, we used a massive bone allograft fixed with a nail and covered by a VTPG as a biological resource. Allograft consolidation was achieved 5.5 months after surgery. At eighteen months after surgery, no complications were observed and the patient had resumed all his daily activities, despite a residual 2-cm limb-length discrepancy. VTPG may be considered as a valuable surgical option for bone reconstruction in complex biological scenarios in the young population. © 2015 Wiley Periodicals, Inc. Microsurgery 37:248-251, 2017., (© 2015 Wiley Periodicals, Inc.)

Purpose: To evaluate femoral head bone viability following free vascularized fibular grafting (FVFG) for osteonecrosis using SPECT/CT imaging., Methods: Ten hips (9 patients) with osteonecrosis of the femoral head (ONFH) undergoing FVFG were prospectively enrolled. Four cases showed ARCO stage II, while six showed ARCO stage III. The mean age at surgery was 15.7 years (range, 13-22 years). Hip Harris Score (HHS) was measured pre- and post-operative. Bone scintigraphy with SPECT/CT was performed at 2 weeks and 6 months following surgery., Results: Mean follow-up was 4.0 years (range, 2-5.9 years). Mean HHS increased from 37.2 to 92.3. SPECT/CT findings revealed a progressive increase of femoral head uptake in all cases, suggesting subchondral graft bone viability. No progressive deformation of the femoral head was evidenced in radiographic evaluation at final follow-up., Conclusions: This study demonstrates FVFG's capacity for revitalizing femoral head subchondral bone grafting in patients with ONFH, surgically treated following Urbaniak's technique. © 2015 Wiley Periodicals, Inc. Microsurgery 36:573-577, 2016., (© 2015 Wiley Periodicals, Inc.)

Bone nonunion in the pediatric population usually occurs in the context of highly unfavorable biological conditions. Recently, the vascularized fibular periosteal flap has been reported as a very effective procedure for treating this condition. Even though a vascularized tibial periosteal graft (VTPG) was described long ago and has been successfully employed in one adult case, there has been no other report published on the use of this technique. We report on the use of VTPG, pedicled in the anterior tibial vessels, for the treatment of two complex pediatric bone nonunion case: a recalcitrant supracondylar femoral pseudarthrosis secondary to an infection in an 11-year-old girl, and a tibial nonunion secondary to a failed bone defect reconstruction in a 12-year-old girl. Rapid healing was obtained in both cases. In the light of the data presented, we consider VTPG as a valuable surgical option for the treatment of complex bone nonunions in children., (© 2014 Wiley Periodicals, Inc.)

Several microsurgical techniques have been described for the treatment of osteonecrosis of the talus (ONT). Recently reported in children, vascularized periosteal grafts showed promising revascularizing properties. We report a novel technique using a pedicled periosteal graft from the first metatarsal bone to treat steroid-induced early Ficat-Arlet stage III ONT in an 11-year-old boy. The patient presented initial favorable clinical and radiological results which were maintained at 34 months during the last follow-up. Through this original technique, and basing on the powerful osteogenic and vasculogenic propreties of periosteal flaps, we could effectively induce bone revascularization and prevent further collapse of the talar dome., (Copyright © 2012 Wiley Periodicals, Inc.)