Periosteal Flaps Enhance Prefabricated Engineered Bone Reparative Potential

The clinical translation of bone tissue engineering for reconstructing large bone defects has not advanced without hurdles. The in vivo bioreactor (IVB) concept may therefore bridge between bone tissue engineering and reconstructive surgery by employing the patient body for prefabricating new prevascularized tissues. Ideally, IVB should minimize the need for exogenous growth factors/cells. Periosteal tissues are promising for IVB approaches to prefabricate tissue-engineered bone (TEB) flaps. However, the significance of preserving the periosteal vascular supply has not been adequately investigated. This study assessed muscle IVB with and without periosteal/pericranial grafts and flaps for prefabricating TEB flaps to reconstruct mandibular defects in sheep. The sheep ( n = 14) were allocated into 4 groups: muscle IVB (M group; nM = 3), muscle + periosteal graft (MP group; nMP = 4), muscle + periosteal flap (MVP group; nMVP = 4), and control group ( nControl = 3). In the first surgery, alloplastic bone blocks were implanted in the brachiocephalic muscle (M) with a periosteal graft (MP) or with a vascularized periosteal flap (MVP). After 9 wk, the prefabricated TEB flaps were transplanted to reconstruct a mandibular angle defect. In the control group, the defects were reconstructed by non-prevascularized bone blocks. Computed tomography (CT) scans were performed after 13 wk and after 23 wk at termination, followed by micro-CT (µCT) and histological analyses. Both CT and µCT analysis revealed enhanced new bone formation and decreased residual biomaterial volume in the MVP group compared with control and MP groups, while the M group showed less new bone formation and more residual biomaterial. The histological analysis showed that most of the newly formed bone emerged from defect edges, but larger areas of new bone islands were found in MP and MVP groups. The MVP group showed enhanced vascularization and higher biomaterial remodeling rates. The periosteal flaps boosted the reconstructive potential of the prefabricated TEB flaps. The regenerative potential of the periosteum was manifested after the transplantation into the mechanically stimulated bony defect microenvironment.

Distal fibular periosteal flap for superior peroneal retinaculum reconstruction

Peroneal tendon instability is a common injury that occurs in physically active individuals, often as a result of trauma and in the context of an anatomically shallow distal fibular groove. Subluxation of these tendons over the lateral malleolus is accompanied by superior peroneal retinaculum injury. Several techniques have been described in the literature, including fibular groove deepening and retinaculum repair, but few reconstruction techniques are available for cases with insufficient residual retinaculum. We report the case of a 53-year-old man, without a history of trauma, who presented with chronic peroneal instability with a completely obliterated, unsalvageable retinaculum which we treated with a combination of fibular groove deepening and fibular periosteal flap to reconstruct the superior peroneal retinaculum. Level of Evidence V; Case Report; Expert Opinion.

Modified perichondrial-periosteal flaps to camouflage nasal dorsum in rhinoplasty

Background The smooth and straight nasal dorsum is a goal after nasal hump reduction as dorsal irregularities are unexpectable and inevitable complications. The aim of this study is to evaluate modified perichondrial-periosteal flaps functionally and aesthetically to camouflage nasal dorsal irregularities. A total of 115 patients with nasal humps were enrolled in the study. The perichondrium over the upper lateral cartilages is divided in the midline and dissected forming two laterally based flaps while the periosteum over the nasal bones is dissected superiorly. After completion of all rhinoplasty steps, the flaps were repositioned and sutured as a separate layer. Follow-up for 2 years with an assessment of irregularities of the nasal dorsum, collapse of the upper lateral cartilage, and nasal breathing. Results Aesthetically, no nasal dorsal irregularities were noticed. Also, no patients complained of nasal obstruction. Conclusion The modified perichondrial-periosteal flap is a successful technique, functionally and aesthetically. It avoids the appearance of dorsal irregularities.

Arthroscopic modified Broström operation versus open reconstruction with local periosteal flap in chronic ankle instability

Introduction The modified Broström operation (MBO) has found widespread use in the therapy of lateral chronic ankle instability (CAI). However, alternative surgical techniques like the open reconstruction using a periosteal flap (RPF) are still an important part of the surgical treatment of lateral CAI. Both procedures differ in terms of the reconstruction material used and the surgical procedure. Comparative studies on the surgical therapy of CAI are limited and generally refer to similar surgical procedures. Aim of this study was to compare the arthroscopic MBO and the RPF. Materials and methods We retrospectively analysed 25 patients with lateral CAI after a tear of the anterior talofibular ligament (ATFL). 14 patients received arthroscopic MBO and 11 patients received RPF. We compared the postoperative outcome between both groups with respect to subjective instability, the number of ankle sprains, pain, complications and follow-up operations as well as the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. Results Both surgical procedures resulted in a significant improvement in pain, in subjective instability, in the reduction in the frequency of ankle sprains and improvement in the AOFAS ankle-hindfoot score one year postoperatively. Three months postoperatively, the values for pain and instability of the MBO group were significantly better compared to the RPF. One year after the operation, these differences were evened out. Also in terms of complications and follow-up operations, no significant difference was found between the two procedures. Conclusions Both surgical procedures give very good results one year postoperatively in terms of pain, instability, function and complication rate. With significantly better results regarding pain and instability three months postoperatively, the MBO allows a faster recovery in patients operated with this technique.

Costal osteochondral graft for a postoperative cartilage defect in a patient with polydactyly

We present a case of a postoperative cartilage defect in a patient with polydactyly who was treated with a costal osteochondral graft. Excision of the radial digit and ligamentous periosteal flap with longitudinal osteotomy were performed when the patient was 1 year old. The alignment of the interphalangeal joint was straight after surgery, but the deviation gradually developed. A revision surgery using a costal osteochondral graft was performed when the patient was 3 years old. A satisfactory outcome was obtained at the 3-year follow-up. The authors suggest that a costal osteochondral graft may be a reasonable option for revision surgery for a postoperative cartilage defect.

The Use of Fascia Lata Free Graft for Lateral Canthus Reconstruction Following Mohs Lower Lid Surgery

We present a case of a 75-year-old patient who underwent reconstruction of the lower eyelid and lateral canthus following removal of 80% of the lower eyelid due to basal cell carcinoma. A Hughes transconjunctival eyelid-sharing flap was used to form the posterior lamella, and a free skin graft from the ipsilateral upper lid was used to recreate the anterior lamella. The lateral canthal ligament was reconstructed using a free fascia lata graft. A periosteal flap was not used due to local scarring that was the result of previous multiple lateral canthal surgeries. Skin preservation in the lateral canthal area and additional horizontal support for the lower eyelid were achieved by using a local advancement flap. This two-stage surgery produced excellent functional and cosmetic effects. Fascia lata free graft can be an alternative to the periosteal flap for reconstruction of the lateral canthal ligament when use of the lateral orbital periosteum is not feasible.