Corticoperiosteal flap in the treatment of nonunions and small bone gaps: technical details and expanding possibilities.

The corticoperiosteal flap from the medial femoral condyle (CP) has proved to be highly reliable in the management of persistent, recurrent nonunion. However, much of the related literature has focussed on the flap aspects of the procedure and not so much on bone work-up. We present a series of 25 patients with nonunions and small bone gaps irresponsive to conventional therapy that were successfully treated with a CP with/without the addition of non-vascularised bone graft from the iliac crest. Different technical options of bone reconstruction are possible and discussed: CP plus non-structural bone chips, CP plus structural bi/tricortical struts or CP plus vascularised cancellous bone from the femoral condyle. A stable internal fixation was performed in all cases. Clinical and radiological evidence of healing was obtained in all the patients. Donor-site complications were few and transient (suture intolerance, seroma and numbness in the saphenous territory). No fracture of the femur, knee instability or stiffness has been observed. The corticoperiosteal flap from the femoral condyle is an excellent source of vascularisation and osteogenic stimulus to the nonunion site and highly effective in the management of persistent nonunions and small bone gaps. When needed, a structural corticocancellous strut from the iliac crest (along with a stable internal fixation) provides the greatest stability and the possibility of a prompt rehabilitation and functional recovery. The corticoperiosteal flap has succeeded in revascularising these highly demanding grafts and in allowing a 100% union rate.