Thumb salvage with skin grafted medial femoral corticoperiosteal free flap

Abstract

A 23-year-old man suffered a severe crush injury with fracture of his left thumb base phalanx and destruction of his extensor pollicis longus tendon. Immediate plate stabilisation and soft tissue coverage was performed; however, a recalcitrant pseudarthrosis developed in this compliant non-smoker despite three revisions with avascular iliac crest grafts for interphalangeal joint arthrodesis, corticocancellous bone application and hardware exchange. An attempt to improve thumb vascularity and soft tissue cover with a pedicled Foucher flap as well as through extracorporeal shock wave therapy failed. Bone healing and subsequent thumb salvage were finally achieved with a free vascularised medial femoral condyle (MFC) bone flap, which was covered directly with a full-thickness skin graft. Both bony and soft tissue healing went well and after 3 months the patient returned to work. This case demonstrates that skin grafting the periosteal surface of the MFC flap is safe and results in a thin skin-bone compositae transplant which also might be very useful for indications other than hand surgery.