PMC4811065_01
Preoperative radiographs showing an unconsolidated distal femoral shaft fracture with the rupture of one of the distal screws.
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fig1
The radiographic examination showed a hypertrophic nonunion of the distal femur (Figure 1), refractory to the conservative treatment, which has been given an indication for surgical treatment.
Grafting of the corticoperiosteal flap. Black arrow: femoral artery; blue arrow: descending genicular artery (drawing by G. Ferri).
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fig2
The vastus medialis was reflected anteriorly, whereas the tendon of the adductor longus was retracted posteriorly, exposing the medial femoral condyle and its periosteal blood supply (Figure 2). Then, using an osteotome or an oscillating saw, the outer cortex was cut and lifted, hammering slightly from the periphery towards the center (Figures 2 and 3).
Intraoperative image of the corticoperiosteal graft.
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fig3
Then, using an osteotome or an oscillating saw, the outer cortex was cut and lifted, hammering slightly from the periphery towards the center (Figures 2 and 3).
Overturning of the corticoperiosteal flap (drawing by G. Ferri).
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fig4
The fracture was reduced and the osteosynthesis was performed by an anterograde intramedullary nail; the graft was overturned and wrapped around the nonunion and fixed with transbone stitches (Figure 4).
The femoral shaft fracture was stabilized with retrograde intramedullary nailing and the bone loss was restored with a corticoperiosteal pedicled flap. The X-ray shows less radiopacity of the flap (dotted line).
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fig5
A radiograph was performed at the end of the procedure (Figure 5).
At 20 months of follow-up, the radiographic examination showed the complete healing of the femoral shaft nonunion.
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The radiographs showed complete union of the distal femur (Figure 6).