Treatment of Recalcitrant Distal Tibial Nonunion Using the Descending Genicular Corticoperiosteal Free Flap

Abstract

Background: Recalcitrant nonunions of the distal tibia without bone defect are severe problems whose treatment is difficult. Stable internal fixation and osteogenetic enhancement are required. The thin corticoperiosteal flap based on the descending genicular artery has been previously described to treat nonunions in the upper extremity without bone defect. The use of this flap to treat distal tibial nonunions is reported in the present article. Methods: Twenty-five patients with recalcitrant nonunion of the distal tibial metaphysis without segmental bone defect or evidence of infection were treated with revision of the internal fixation and a corticoperiosteal free flap from the medial condyle of the femur. The number of previous surgical procedures was two to five. The flaps were compound, including muscle or fat, for wound coverage in seven cases. Results: All compound flaps survived. Bony union was achieved in all cases, with bone formation at the nonunion site by the fourth month in all cases but one. In this case bone union took 7 months. Donor morbidity was negligible. Two tibiotalar arthrodeses were performed secondarily for posttraumatic osteoarthritis. Conclusions: Treatment of recalcitrant distal tibial nonunions without bone defect with removal of previous hardware, stable internal fixation, and free corticoperiosteal flap transfer is safe and effective in noninfected cases.