Medial femoral trochlea flap reconstruction: Clinical outcomes and perspectives

The Medial Femoral Trochlea Osteochondral Flap for Scaphoid Reconstruction: A Systematic Review

BACKGROUND

The medial femoral trochlea flap has been used to resurface scaphoids with recalcitrant proximal pole fractures or avascular necrosis, providing vascularized osteochondral tissue with similar morphological characteristics. This article aims to review the contemporary literature on its use for scaphoid reconstruction.

METHODS

A systematic review of Embase, PubMed, Cochrane Central Register of Controlled Trials, and MEDLINE assessed the use of medial femoral trochlea flaps in scaphoids.

RESULTS

Eight studies were included, with 76 patients at a mean age of 26 years. Forty-three patients underwent clinical review, and 10 patients underwent radiographic evaluation, at a mean 23.3 months of follow-up. Flaps were generally performed for proximal pole fractures, avascular necrosis, nonunion, or failure of prior fixation; 94.4% of the flaps united. No marked change in sagittal plane motion was noted; reductions were seen in axial and coronal plane motion. The Disabilities of the Arm, Shoulder, and Hand scores improved from a mean of 25.2 to 11.5. Radiographic markers also improved. A total of 12.3% of patients had unplanned return to theater. Three patients required early revision for vascular thrombosis, and 1 patient suffered a volar carpal dislocation. Three patients underwent salvage procedures for ongoing pain.

CONCLUSIONS

Although technically demanding, promising early-term to medium-term results are noted with the use of medial femoral trochlea flaps in the scaphoid.

Rib osteochondral graft for scaphoid proximal pole reconstruction

BACKGROUND

An irreparable scaphoid proximal pole is challenging to treat because of the fragment size and limited blood supply. Salvage surgery, such as partial wrist fusion or proximal row carpectomy, may be performed but is not ideal for young patients. There are few reports of proximal scaphoid reconstruction using rib osteochondral grafts.

METHODS

Four patients were treated with rib osteochondral graft for reconstruction of the scaphoid proximal pole. The patients had a mean postoperative follow-up of 24 months. The mean age at the time of surgery was 30 years. Outcome measurements included total active range of wrist motion arc, grip strength, and wrist function score. We also evaluated the progression of osteoarthritis and changes in carpal height.

RESULTS

No complications occurred at the donor site. The range of motion improved from 82° to 95° before and after surgery. Grip strength improved from 22 kg to 33 kg before and after surgery. There was a remarkable improvement in the modified wrist function scores of Green and O'Brien from 40 points to 70 points before and after surgery. No progression of arthrosis was seen on the radiographs of all the patients. There was no significant difference in the carpal height ratio before and after surgery.

CONCLUSIONS

Proximal scaphoid fractures may require reconstruction of the articular surfaces of the radius, capitate, and lunate. Reconstruction with a rib osteochondral graft is flexible, easy to fabricate, and can reconstruct the three articular surfaces.

Vascularized Bone Grafts in Orthopaedic Surgery: A Review of Options and Indications

Vascularized bone grafts have demonstrated increased perfusion, structural integrity, and ability to achieve good outcomes in challenging clinical situations when compared with nonvascularized grafts. These grafts may be pedicled or free, and bring perfused, viable bone into areas of impaired healing. Although numerous grafts have been described, a few grafts have demonstrated particular usefulness and versatility. Pedicled grafts from the distal radius, medial femoral condyle, ribs, and fibula have improved outcomes in challenging situations without the need for microsurgery. Free grafts from the fibula and medial femoral condyle/trochlea, although they require microsurgical anastomosis, can be transferred to virtually any site in the body and have expanding indications. The capacity of these grafts to achieve favorable outcomes in difficult cases make them a powerful tool for orthopaedic surgeons to have in their armamentarium.