Medial Femoral Trochlea Osteochondral Flap

Medial Femoral Trochlea Osteochondral Flap Reconstruction of the Previously Unsalvageable Kienbock-Associated Lunate With a Coronal Split

PURPOSE

Patients with Kienbock disease can present with coronal fracture and collapse of the proximal lunate (Unified B2/Bain grade 1, 2B). Traditionally, this was considered unsalvageable. However, medial femoral trochlea (MFT) osteochondral reconstruction, used to recreate the proximal lunate surface, can be paired with reduction and repair of the coronal plane fracture, thus restoring midcarpal congruity. The purpose of this study was to report radiographic and clinical outcomes following lunate coronal fracture fixation at the time of MFT osteochondral reconstruction.

METHODS

This was a retrospective study performed at a single institution. We identified patients with Kienbock disease who underwent MFT osteochondral reconstruction from 2014 to 2023. Patients were included if they had a coronal fracture of the lunate distal articular surface fixed at the time of surgery. Radiographic and clinical parameters were evaluated, including carpal height ratio, union rate, presence of heterotopic ossification, need for revision surgery, and patient-reported outcome measures.

RESULTS

Thirty-three patients were included, with a mean age of 27.5 years (range: 15-41); 19 (58%) were women. Mean radiographic follow-up time was 5.8 months, and mean clinical follow-up time was 22.6 months. Union was achieved in 30/33 patients (91%). Carpal height ratio improved from 1.32 to 1.4. Two patients (6%) required reoperation, one for removal of heterotopic ossification and another for conversion to proximal row carpectomy. Patients demonstrated meaningful improvement in brief Michigan Hand Questionnaire and Patient-Reported Outcomes Measurement Information Upper Extremity scores. Range of motion before and after surgery was similar.

CONCLUSIONS

Lunate coronal fracture fixation with MFT osteochondral reconstruction represents an additional management option in select patients with Kienbock disease. This technique restores the midcarpal joint during lunate reconstruction and may allow patients to avoid salvage procedures. Early radiographic and clinical outcomes are promising.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Lateral Femoral Trochlea Osteochondral Flap Reconstruction of Proximal Pole Scaphoid Nonunions

PURPOSE

The medial femoral trochlea flap has been described as a method of scaphoid proximal pole nonunion reconstruction when the proximal pole is deemed nonsalvageable. The lateral femoral trochlea (LFT) is an alternative donor site providing a comparable vascularized convex osteochondral flap. We describe the technique and outcomes of our first 17 cases of LFT flap reconstruction of the proximal scaphoid pole with a minimum follow-up of 14 months.

METHODS

Seventeen of the first 24 patients who underwent LFT scaphoid reconstruction at 3 institutions were able to be contacted for clinical follow-up and chart reviews. We recorded patient age and sex, duration of nonunion, number of previous surgical procedures, details of surgical technique, achievement of osseous union, complications, additional postoperative procedures, preoperative and postoperative pain, and range of motion. Preoperative and postoperative scapholunate and radiolunate angles were analyzed on x-rays and achievement of osseous union on computerized tomography scans.

RESULTS

The average age of patients included was 35 years (range, 16-55 years). Follow-up data were recorded at an average of 33 months (range, 14-62 months). Ten patients had previous procedures (average, 1; range, 0-2). Median duration from trauma to LFT was 3.4 years (range, 8 months-12 years) among patients who had a recognized date of injury. Osseous healing was achieved in 16 of 17 patients and confirmed by computerized tomograpy scan. Twelve patients reported complete pain relief, while 5 reported partial pain relief. Final postoperative range of motion was 59°extension (range, 30°-85°) and 50° flexion (range, 10°-80°), which was comparable to preoperative values. Preoperative (59°) and postoperative (55°) scapholunate angles were similar to normal wrists.

CONCLUSION

Vascularized LFT flaps provide an alternative donor site for vascularized osteochondral reconstruction of proximal pole scaphoid nonunion. Rate of union, range of motion, and pain relief are similar to reported results with medial femoral trochlea flap reconstruction.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The Role of Microsurgery in Coverage of Defects of the Hand

Soft tissue defects of the hand may result from trauma, infection, vascular disease, and after resection of tumors. Microsurgery has evolved to a stage where it is relatively commonplace today but procedures such as free flaps still incur significant time, manpower, cost, and material resources. The aim of this article is to articulate the specific situations in hand reconstruction when microsurgery is superior to nonmicrosurgical reconstructive options. The benefits of microsurgical reconstruction include a variety of important metrics, such as improved function, better tissue match, less donor site morbidity, and reduced downtime for the patient.

Metacarpophalangeal Joint Reconstruction of a Complex Hand Injury with a Vascularized Lateral Femoral Condyle Flap Using an Individualized 3D Printed Model-A Case Report

This case report describes the surgical management of a patient with a complex hand trauma. This injury included tendon, vascular, and nerve injuries, a partial amputation of the index finger, fractures of the third proximal phalanx, and destruction of the metacarpophalangeal joint of the fifth finger. Firstly, the acute treatment of a complex hand injury is described. Secondly, the planning and execution of a joint reconstruction using a vascularized lateral femoral condylar flap, assisted by an individual 3D model, is illustrated. Precise reconstruction of the affected structures resulted in good revascularization as well as an anatomical bone consolidation. Intensive physical therapy, including autonomous proprioceptive range-of-motion exercises by the patient, resulted in significant functional improvement of the hand in daily life. Overall, we report on the successful reconstruction of a metacarpophalangeal joint by using a vascularized flap from the lateral femoral condyle. Furthermore, this case report highlights the efficacy of integrating individualized 3D printing technology to plan complex reconstructions, opening up promising opportunities for personalized and optimized interventions.

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.

Vascularized Bone Graft Reconstruction for Upper Extremity Defects: A Review

Upper extremity reconstruction may pose clinical challenges for surgeons due to the often-critical, complex functional demands of the damaged and/or missing structures. The advent of vascularized bone grafts (VBGs) has aided in reconstruction of upper extremity (UE) defects due to their superior regenerative properties compared with nonvascularized bone grafts, ability to reconstruct large bony defects, and multiple donor site options. VBGs may be pedicled or free transfers and have the potential for composite tissue transfers when bone and soft tissue are needed. This article provides a comprehensive up-to-date review of VBGs, the commonly reported donor sites, and their indications for the treatment of specific UE defects.

Knochenrekonstruktion an der oberen Extremität mittels eines freien vaskularisierten Knochentransplantates aus der medialen Femurkondyle ohne Berücksichtigung des Skaphoids

Ziel Diese Studie untersucht, ob das vaskularisierte Knochentransplantat aus der medialen Femurkondyle (MFC) auch erfolgreich bei kleinen (< 4 cm) Knochendefekten an der oberen Extremität eingesetzt werden kann, die nicht das Skaphoid betreffen.

Patienten und Methoden Achtmal wurde bei 7 Patienten mit einem Alter zwischen 28 und 66 Jahren ein vaskularisiertes Knochentransplantat aus der MFC zur Rekonstruktion von Knochendefekten, die nicht das Kahnbein betrafen, an der oberen Extremität eingesetzt. Knochenheilung, Komplikationen, Hebemorbidität und die Patientenzufriedenheit wurden erfasst. Die Nachuntersuchungszeit betrug 3 bis 40 Monate. Die Indikationen für die Rekonstruktion mittels freier MFC waren 2 trotz mehrerer Voroperationen nicht geheilte distale Radiusfrakturen, ein ossärer Defekt am distalen Radius nach Fraktur mit radioskaphoidaler Arthrose, ein akutes, komplexes Trauma mit Verlust von Anteilen des Karpus und des distalen Radius bei Explosionsverletzung, eine Rekonstruktion des ersten Mittelhandknochens (MHK) nach Resektion eines Riesenzelltumors und 3 Arthrodesen zwischen dem 1. und 2. MHK als Rettungsoperation nach mehrfachen Operationen bei Daumensattelgelenksarthrose.

Ergebnisse Vier der 8 Knochentransplantate zeigten eine regelrechte Heilung; 3-mal war sie mit 7, 8 und 9 Monaten verzögert. Einmal zeigte sich nur eine partielle Knochenheilung. Zweimal kam es zu einem revisionsbedürftigen Hämatom an der Entnahmestelle. Die Patientenzufriedenheit war mit Schmerzfreiheit in 7 der 8 Fälle in Anbetracht der Komplexität der Fälle zufriedenstellend.

Schlussfolgerung Das freie vaskularisierte Knochentransplantat aus der MFC kann erfolgreich ohne Längenverlust zur Rekonstruktion bei Knochendefekten an der oberen Extremität eingesetzt werden, die nicht das Kahnbein betreffen und kleiner als 4 cm sind.

[Bone Reconstruction in the Upper Extremity other than the Scaphoid with the free vascularized Medial Femoral Condyle]

PURPOSE

To evaluate whether a vascularized bone graft from the medial femur condyle (MFC) can successfully be used to reconstruct small bone defects (< 4 cm) on the upper extremity other than the scaphoid.

PATIENTS AND METHODS

In 7 patients at the age of 28 to 66 years 8 vascularized bone grafts from the MFC were used to reconstruct bone defects on the upper extremity other than the scaphoid. Bone healing, complications, donor side morbidity, and patient´s satisfaction were evaluated. Follow-up was 3 to 40 months. Indications were: two nonunion of the distal radius in spite of several surgical procedures, one defect of the distal radius following a radius fracture with osteoarthritis of the radiocarpal joint, one acute trauma with partial loss of the carpus and radius due to an explosion injury, reconstruction of the first metacarpal (MC) following resection of a giant cell tumour, and three fusions between the 1^st and 2^nd MC as a salvage procedure after several surgical procedures at the saddle joint.

RESULTS

There was a regular bony healing in 4 of the 8 cases; delayed bony healing was seen in three cases after 7, 8, and 9 months. In one case there was only a partial bony healing. Two donor side haematomas required surgical revision. Patient's satisfaction was high with 7 painless cases.

CONCLUSION

Free vascularized bone grafts from the medial femur condyle can successfully be used to reconstruct bone defects up to 4 cm of the upper extremity other than the scaphoid.

An Algorithmic Approach to the Treatment of Kienböck Disease

The algorithm and rationale described is a reflection of our own surgical experience for this challenging disorder and can be compared with other publications. Our algorithm has evolved from treatment of a large volume of patients with Kienböck disease in a referral practice. However, it is limited to the management that we have found logical, effective, and within our scope of experience. The treatment guidelines for our specialty as a whole will evolve as our understanding of the etiology and our ability to quantify efficacy improves.

Vascularized Bone Flaps for the Treatment of Kienböck Disease

Of the many treatments for Kienböck disease, only lunate revascularization procedures provide a direct mechanism for reversing the process of osteonecrosis. Owing to the redundant blood supply of the distal radius and carpus, pedicled flaps are versatile solutions for patients with bone loss but intact cartilage. With the advent of free vascularized flaps, the indications for lunate revascularization procedures are expanding. These flaps can be used when the articular cartilage has been compromised and are suitable options to restore native anatomy in patients previously thought to have unreconstructible disease.

Addressing common orthopaedic calamities with microsurgical solutions

Reconstructive microsurgery has been an essential aspect of orthopaedic surgery and extremity reconstruction since the introduction of the operating microscope in the mid-20^th century. The reconstructive ladder ranges from simple healing by secondary intention to complex procedures such as free tissue transfer and vascularized composite allotransplantation. As orthopaedic surgery has evolved over the past 60 years, so too have the reconstructive microsurgical skills that are often needed to address common orthopaedic surgery problems. In this article, we will discuss a variety of complex orthopaedic surgery scenarios ranging from trauma to infection to tumor resection as well as the spectrum of microsurgical solutions that can aid in their management.

[Reconstruction of defects on the hand]

From a reconstructive viewpoint, injuries of the hand are particularly challenging. They are often associated with exposed tendons, bones, nerves and vessels, whereas little skin and soft tissue reserves are available for coverage. Functional and esthetic requirements necessitate a differentiated approach, depending on the location and extent of the defect. This article gives an overview of reconstruction techniques and flap surgery on the hand for various defect sizes and locations.