Vascularized medial femoral trochlea osteocartilaginous flap reconstruction of proximal pole scaphoid nonunions

Proximal Hamate Reconstruction of Proximal Pole Scaphoid Nonunion: A Case Series and Analysis of Clinical Outcomes

BACKGROUND

Small proximal pole scaphoid nonunions present a clinical challenge influenced by fragment size, vascular compromise, deforming forces exerted through the scapholunate interosseous ligament (SLIL), and potential articular fragmentation. Osteochondral autograft options for proximal pole reconstruction include the medial femoral trochlea, costochondral rib, or proximal hamate. This study reports the clinical outcomes of patients treated with proximal hamate osteochondral autograft reconstruction.

METHODS

A retrospective review identified patients treated with this surgery from 2 institutions with a minimum 6-month follow-up. Clinical outcomes included the Visual Analog Dcale pain score, 12-item Short-Form survey, abbreviated Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, wrist and forearm range of motion (ROM), radiographic assessment, and complications. We reviewed and compared these outcomes with those of the current published literature.

RESULTS

Four patients (mean age: 24 years, 75% men) with a 12.8-month average follow-up (range: 6-20 months) were included. Radiographic union was identified in all cases by 12 weeks (range, 10-12). The average wrist ROM was 67.5% flexion/extension and 100% pronation/supination compared with the contralateral side at the final follow-up. The mean QuickDASH score was 17.6 (SD, 13). No complications were identified.

CONCLUSIONS

Proximal pole scaphoid nonunion reconstruction using autologous proximal hamate osteochondral graft demonstrated encouraging clinical and radiographic outcomes. Proximal hamate harvest involves minimal donor site morbidity without a distant operative site, uses an osteochondral graft with similar morphology to the proximal scaphoid, requires no microsurgical technique, and permits reconstruction of the SLIL using the volar capitohamate ligament.

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.

A Comparison of Rib Osteochondral Graft to Medial Femoral Trochlear Osteocartilaginous Graft for the Salvage of the Fragmented Scaphoid Proximal Pole: A Single-Center Experience with Minimum 2-Year Follow-Up

Purpose  Fragmented fractures of the proximal pole of the scaphoid that cannot be internally fixed may be salvaged by four-corner arthrodesis or proximal row carpectomy. Replacement of the proximal scaphoid with costal-osteochondral graft (COG) or the medial femoral trochlea (MFT) graft are two alternative solutions for this clinical presentation. The purpose of this study was to compare the clinical and radiographic results of the COG and the MFT graft with a minimum 2-year follow-up from a single centre. Methods  A retrospective study was performed to investigate the outcome of COG and MFT with a minimum 2 year follow up. Demographic data and clinical assessment including wrist range of motion and grip strength measurements and Oxford Knee score were collected. Patients completed the outcome measures of Disabilities of Arm, Shoulder, and Hand (DASH), the Patient-Rated Wrist Evaluation (PRWE), and a ten-point visual analogue score for pain (VAS). Radiological examination was performed on all wrists at follow-up. Results  The visual analogue score, DASH and PRWE were similar between the two groups. There was radiographic evidence of arthritis between the radial styloid and distal scaphoid in all patients that underwent COG but no evidence in those that underwent MFT graft reconstruction. There were different complications in each group. Thirty percent of patients that underwent MFT reconstruction had persistent knee pain at follow up. Conclusion  Though there are notable differences in the follow-up period, patients undergoing MFT risk developing knee pain, while those undergoing COG risk radiographic progression of wrist arthritis. Level of Evidence  III - Comparative study.

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.

Total Nasal Reconstruction: Advances in Free Tissue Transfer for Internal Lining and Structural Support

Total nasal reconstruction is a complex challenge due to the need to establish new internal lining, internal structural support, and external skin covering that is both functional and esthetic. The medial femoral condyle corticoperiosteal free flap represents an innovative option for restoration internal structure and internal nasal lining. When used in conjunction with a paramedian forehead flap, acceptable results in both function and esthetics can be achieved.

Idiopathic Avascular Necrosis of the Capitate Treated with a Medial Femoral Trochlea Vascularized Osteochondral Flap: A Case Report

CASE

Capitate avascular necrosis should be entertained in a differential diagnosis of young, active adults with midcarpal wrist pain. We present a case study of a 30-year-old laborer who developed avascular necrosis (AVN) of his right proximal capitate. Grip strength and wrist motion were limited on examination, with advanced imaging confirming AVN. A diagnostic arthroscopy confirmed the pathology. Treatment was completed with a medial femoral trochlea vascularized flap for cartilaginous resurfacing. At 10-month follow-up, the patient's capitate was healed with stable fixation, and he is working full-time as a laborer without restrictions.

CONCLUSION

AVN of the capitate is a unique and challenging articular pathology that requires a thoughtful preoperative evaluation and meticulous surgical technique to reconstruct. The medial femoral trochlea (MFT) vascularized bone transfer with cartilaginous resurfacing is 1 available treatment option. This flap is harvested from the medial femur using microsurgical techniques, based on the descending genicular artery. Using a 2-surgeon approach, simultaneous dissection of the AVN is completed at the wrist. This flap is a vascularized option that can be used for both AVN and nonunion with structural deformity before salvage surgeries.

Medial Femoral Condyle Free Flap: A Systematic Review and Proportional Meta-analysis of Applications and Surgical Outcomes

Background

Recalcitrant bone nonunion and osseous defect treatment is challenging and often requires vascularized bone transfer. The medial femoral condyle flap has become an increasingly popular option for reconstruction. The study aims at reviewing its different applications and synthesizing its surgical outcomes.

Method

A systematic review including all studies assessing surgical outcomes of free medial femoral condyle flap for bone reconstruction in adults was conducted on January 31, 2023. Flap failure and postoperative complications were synthesized with a proportional meta-analysis.

Results

Forty articles describing bony reconstruction in the head and neck, upper limb, and lower limb areas were selected. Indications ranged from bony nonunion and bone defects to avascular bone necrosis. Multiple flaps were raised as either pure periosteal, cortico-periosteal, cortico-cancellous-periosteal, or cortico-chondro-periosteal. A minority of composite flaps were reported. Overall failure rate was 1% [95% confidence interval (CI), 0.00-0.08] in head & neck applications, 4% in the lower limb (95% CI, 0.00-0.16), 2% in the upper limb (95% CI, 0.00-0.06), and 1% in articles analyzing various locations simultaneously (95% CI, 0.00-0.04). Overall donor site complication rate was 4% (95% CI, 0.01-0.06). Major reported complications were: femoral fractures (n = 3), superficial femoral artery injury (n = 1), medial collateral ligament injury (n = 1), and septic shock due to pace-maker colonization (n = 1).

Conclusion

The medial femoral condyle flap is a versatile option for bone reconstruction with high success rates and low donor site morbidity.

Biomechanics of Proximal Hamate Autograft in Scaphoid Nonunion

Purpose  Treatment of proximal scaphoid fractures remains a challenge with a risk of nonunions and avascular necrosis due to its retrograde blood supply. The ipsilateral proximal hamate has been described as a viable autograft option for osteochondral reconstruction of the proximal scaphoid. Our study evaluated the changes in the contact area and pressure of the radioscaphoid joint after proximal hamate autograft reconstruction. Methods  Thin sensors (Tekscan Inc., Boston, MA) were placed in the radiocarpal joints of six fresh-frozen cadaveric forearms. Each specimen's tendons were loaded to 150 N in neutral, 45-degree flexion/extension positions through five cycles. Through a dorsal wrist approach, the proximal 10 mm of the scaphoid and hamate was excised. The proximal hamate autograft was affixed to the scaphoid with K-wires. Peak contact pressures and areas at the scaphoid facet were determined and averaged across loading cycles. Results  At the radioscaphoid facet, peak contact pressures were equivalent, although an increasing trend in the neutral and extended wrist position was seen. At the radiolunate facet, contact pressure had an increasing trend in the hamate reconstructed wrists in all wrist positions. Contact areas had a decreasing trend and were nonequivalent at the radioscaphoid facet in the hamate reconstructed wrist. Conclusion  After hamate autograft, the contact areas were not equivalent between the native and reconstructed wrists but contact pressures were equivalent in the facets. The proximal hamate has a more pointed morphology compared with the proximal scaphoid, which would explain the change in contact area in the hamate autografted wrist. Our study suggests hamate autograft may present a viable reconstruction for the proximal pole of the scaphoid without significantly altering peak contact pressures at the radioscaphoid facet.

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.

Rethinking Scaphoid Fixation

Scaphoid fixation, whether for acute injuries or nonunion, is made challenging by the small and intra-articular nature of the most commonly fractured carpal bone. The purpose of this article is to review the techniques to simplify scaphoid fixation and to optimize healing and early return to activity.

Does Proximal Hamate Graft for Proximal Scaphoid Reconstruction Restore Native Wrist Kinematics?

BACKGROUND

The objective of this study was to determine whether reconstruction of the proximal pole of the scaphoid with a proximal hamate graft restores native carpal kinematics.

METHODS

A cadaveric study was designed assessing wrist kinematic after proximal hamate graft for proximal pole of the scaphoid nonunion. Wireless sensors were mounted to the carpus using a custom pin and suture anchor system to 8 cadavers. A wrist simulator was used to move the wrist through a cyclical motion about the flexion/extension and radial/ulnar deviation axes. Each specimen was tested under a series of 3 conditions: (1) a native state, "Intact"; (2) fractured scaphoid proximal pole, "Fracture"; and (3) post-reconstruction of the proximal pole of the scaphoid using a proximal hamate graft, "Graft."

RESULTS

The fracture condition resulted in a statistically significant change in scapholunate kinematics across the entire arc of motion relative to the intact condition. Reconstruction with proximal hamate grafts restored scapholunate kinematics close to the intact state in both flexion/extension and radial/ulnar deviation axes. The lunocapitate flexion during wrist flexion was significantly different after the hamate graft reconstruction.

CONCLUSIONS

Proximal hamate to scaphoid transfer resulted in restoration of near normal carpal kinematics to the intact state.

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.

Lateral Femoral Trochlea Flap Reconstruction of the Proximal Capitate: An Assessment of Congruity and Description of Technique

PURPOSE

We examined morphologic similarities of the medial lateral femoral trochlea (MFT) and lateral femoral trochlea (LFT) osteochondral flaps for reconstruction of the proximal capitate.

METHODS

Magnetic resonance imaging scans of the wrists and ipsilateral knees of 10 young healthy volunteers were obtained. Three morphologic parameters were investigated, comparing the MFT and LFT harvest sites to the capitate proximal pole. The correspondingly relevant surgical planes were compared. The coronal plane radius of curvature (ROC) of the capitate was compared with the sagittal planes of the MFT and LFT. The sagittal plane ROC of the capitate was compared to the axial planes of the MFT and LFT. The angular relationship between the dorsal cortical surface of the capitate and the proximal pole cartilage (proximal dorsal capitate pitch) was compared to the corresponding angles between the cortical bone and convex cartilage on the LFT and MFT.

RESULTS

The average ratios of ROC for the coronal planes of the capitate to the MFT (0.61) and LFT (0.58) were similar. The average ratios of ROC for the sagittal planes of the capitate to the MFT (0.57) and LFT (0.86) were also similar. The proximal dorsal capitate pitch demonstrated greater similarity to the corresponding shape of the LFT (angular ratio, 1.01) than to that of the MFT (angular ratio, 0.74).

CONCLUSIONS

The LFT and MFT demonstrate similar congruity to the proximal capitate in the sagittal and coronal planes of the wrist. The LFT dorsal pitch closely approximates the relationship of the proximal capitate pole to its dorsal cortical surface.

CLINICAL RELEVANCE

In capitate fracture, fracture nonunion, or avascular necrosis, both the MFT and LFT demonstrate similarity to the proximal convex capitate morphology. The relationship between the cortical and chondral surfaces of the LFT is morphologically very similar to that of the proximal capitate.

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 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.

Vascularized osteochondral free flaps from the femoral trochlea as versatile procedure for reconstruction of osteochondral lesions of the talus

BACKGROUND

Osteochondral lesions of the talus (OLT) are defects affecting the articular cartilage as well as the subchondral bone, on the lateral shoulder possibly associated with trauma. This study presents the results of reconstructing OLT using vascularized osteochondral flaps from the femoral trochlea.

METHODS

We treated 19 patients with osteochondral talar shoulder defects, using osteochondral flaps from the medial (MFT) or lateral (LFT) femoral trochlea. Functional outcome was evaluated by clinical investigation, visual analogue scale (VAS, 0-10), American Orthopaedic Foot and Ankle Society-Ankle and Hindfoot Scale (AOFAS, 0-100) and The Foot and Ankle Disability Index (FADI, 0-104). Radiographic postoperative follow-up was done by anterior-posterior and lateral X-rays and union of the transferred osteochondral flaps was documented by CT scans.

RESULTS

The osteochondral flaps fused in all of the 19 cases. After a median follow-up of 45.5 months, the patients showed an average FADI of 94.9 and AOFAS-Ankle and Hindfoot Scale of 91.2. All of them were walking free and normal. Subjective median satisfaction was 1.3 in a scale from 1 to 5.

CONCLUSION

Vascularized transfer of osteochondral flaps from the femoral trochlea is a reliable treatment option for symptomatic OLT of the medial and lateral talar edge.

LEVEL OF CLINICAL EVIDENCE

Therapeutic IV.

Utilization of a Chimeric Medial Femoral Condyle Free Flap for Mandibular Osteoradionecrosis

BACKGROUND

Primary options for oromandibular reconstruction with osteocutaneous free flaps are the vascularized fibula and iliac crest. Complications of mandible reconstruction are not uncommon and include osteomyelitis, malunion, and osteoradionecrosis (ORN) after radiation therapy. The medial femoral condyle (MFC) free flap is an established salvage option for carpal reconstruction in hand surgery, frequently used for scaphoid nonunion and avascular necrosis. We hypothesize that the MFC flap can be utilized to restore blood supply and reverse the negative effects of radiotherapy in patients who require mandibular reconstruction due to ORN.

METHODS

A retrospective chart review was conducted at Beaumont Health System, Royal Oak, for patients who underwent MFC free flap reconstruction for mandibular ORN between the years 2012 and 2018. Demographic data, operative details, complications, medical comorbidities, and patient outcomes were retrospectively gathered.

RESULTS

A total of four patients were isolated. Four patients developed ORN after resection of squamous cell carcinoma and adjuvant radiotherapy. No patients experienced donor site deficits. Revisions after MFC reconstruction were dependent on individual aesthetics and involvement of neighboring tissue. All four patients continue to be followed with no current issues to the osseous component of the MFC flap.

CONCLUSION

Utilization of the MFC periosteal flap is a viable option in selected patients to salvage nonunion/resorption of mandible reconstruction and ORN of the mandible. Our experience found that the MFC is able to provide pain resolution and healing of intraoral soft tissue defects, and may halt the progression of ORN of the mandible.

Arthroscopic bone graft and fixation for proximal scaphoid nonunions

AIMS

This study aims to report the outcomes in the treatment of unstable proximal third scaphoid nonunions with arthroscopic curettage, non-vascularized bone grafting, and percutaneous fixation.

METHODS

This was a retrospective analysis of 20 patients. All cases were delayed presentations (n = 15) or failed nonoperatively managed scaphoid fractures (n = 5). Surgery was performed at a mean duration of 27 months (7 to 120) following injury with arthroscopic debridement and arthroscopic iliac crest autograft. Fracture fixation was performed percutaneously with Kirschner (K)-wires in 12 wrists, a headless screw in six, and a combination of a headless screw and single K-wire in two. Clinical outcomes were assessed using grip strength, patient-reported outcome measures, and wrist range of motion (ROM) measurements.

RESULTS

Intraoperatively, established avascular necrosis of the proximal fragment was identified in ten scaphoids. All fractures united within 16 weeks, confirmed by CT. At a mean follow-up of 31 months (12 to 64), there were significant improvements in the Patient-Rated Wrist Evaluation, Mayo Wrist Score, abbreviated Disabilities of the Arm, Shoulder and Hand score, wrist ROM, grip strength, and the patients' subjective pain score. No peri- or postoperative complications were encountered.

CONCLUSION

Our data indicate that arthroscopic bone grafting and fixation with cancellous autograft is a viable method in the treatment of proximal third scaphoid nonunions, regardless of the vascularity of the proximal fragment. Cite this article: Bone Joint J 2022;104-B(8):946-952.

Treatment of proximal scaphoid waist nonunions with vascularized bone graft from the distal radius or medial femoral condyle

Fractures of the proximal scaphoid waist are more prone to nonunion than distal scaphoid fractures. Thirty-nine patients (five females, 34 males; mean age 31 years) who had operation for proximal scaphoid waist nonunion between 2017 and 2020 were retrospectively analysed. Patients received a free vascularized medial femoral condyle graft (Group 1: 18 patients) or distal radial bone graft based on a 1,2 intercompartmental supraretinacular artery pedicle (Group 2: 21 patients). In Group 1, union was achieved in 17 of 18 cases, with mean time to union of 13 weeks and mean operation time was 221 minutes. In Group 2, union was achieved in 19 of 21 cases, with mean time to union of 15 weeks and mean operation time was 100 minutes. The radiological and functional results of both groups were similar. We recommend a distal radial bone graft based on the 1,2 intercompartmental supraretinacular artery pedicle for proximal scaphoid waist nonunions since the operation is shorter, technically more manageable and requires less microsurgical experience.Level of evidence: III.

CMC Mimickers: Differential Diagnosis and Work-Up for Radial-Sided Wrist Pain

In patients with radial-sided wrist pain, a myriad of possible etiologies exists and as such, a detailed history, examination, and, where indicated, imaging is obtained to try and aid with its diagnosis. The purpose of this article is to provide an overview of radial-sided wrist pain, diagnostic modalities and discuss current treatment options. More detailed information is out-of-scope for this article and if needed, we would guide the reader to seek out other selected texts, as indicated.

Management of type 3 Kienbock's disease in manual workers by scaphocapitate fusion with minimum 7-year follow-up

BACKGROUND

Kienbock's disease results in altered wrist biomechanics producing debilitating pain at the wrist. The disease is staged according to radiological and clinical findings and the stage guides the treatment. Various treatment options have been described for stage 3, however, there is a lack of consensus over these treatment methods. Scaphocapitate fusion is the preferred surgical option for advanced Kienbock's disease. Previous studies had heterogeneous cohorts with a short duration of follow-up and a lack of uniform surgical technique. The purpose of the study was to show the long-term functional and radiological outcome of scaphocapitate arthrodesis (SCA) by using Herbert screw for the treatment of Kienbock's disease in manual workers.

METHODS

For this single-centre, retrospective study, all consecutive patients who were manual workers and managed by SCA between January 2010 and Jan 2014 for Lichtman stage IIIA and IIIB with at least 7 years of follow-up were included. Patients were assessed using clinical and radiological parameters preoperatively and in the follow-up period. Disabilities of the Arm, Shoulder, and Hand (DASH), Patient-Related Wrist Evaluation (PRWE), and VAS for pain were assessed.

RESULTS

Out of 27 patients, 4 lost to follow-up, therefore, 23 patients (14 women and 9 men) with 30 years of median age at the time of the surgery were included. DASH scores, PRWE scores, and VAS for pain significantly improved (p < 0.5) after surgery. Wrist range of motion and grip strength also improved significantly (p < 0.5). Postoperative radiological parameters were found to be within a normal range.

CONCLUSION

Scaphocapitate fusion by Herbert screws gives good functional, clinical, and radiological outcomes, in stage 3 of Kienbock's disease with excellent rates of fusion with low complications. Even, in manual workers, scaphocapitate fusion can reliably provide good outcomes and this is maintained in the mid to long-term follow-up. Therefore, it should be considered as one of the procedures of choice.

LEVEL OF EVIDENCE

Retrospective, Level 4.

Arthroscopic Treatment of Scaphoid Nonunion With Olecranon Bone Graft and Screw Fixation Leads to Union and Improved Outcomes

PURPOSE

To evaluate the outcomes of arthroscopic treatment of scaphoid nonunion using olecranon bone graft and screw fixation and to analyze the outcomes in accordance with variations in the chronicity, location, and severity of nonunion.

METHODS

Between March 2012 and December 2020, patients with diagnoses of scaphoid delayed nonunion and nonunion with substantial bone resorption (Slade and Dodds grade IV-VI) underwent arthroscopic-assisted olecranon bone graft and screw fixation. Preoperative and postoperative measurements included the visual analog scale score for pain; range of motion; grip strength; the Modified Mayo Wrist Score; the Disabilities of the Arm, Shoulder and Hand (DASH) score; and the minimal clinically important difference for the DASH score. Union rate and duration were also evaluated. The outcomes between groups of patients with different conditions were analyzed.

RESULTS

Twenty-two patients were included. The average follow-up period was 32.5 months. The visual analog scale pain score, range of motion, grip strength, Modified Mayo Wrist Score, and DASH score were significantly improved after surgery (P < .001). The minimal clinically important difference threshold for the DASH score was reached by 100% of patients. At final follow-up, all patients had united scaphoid with no complications. The average time to union was 15.3 weeks. Group analysis showed significant improvements in mean grip strength between patients with delayed union (3-6 months) and those with chronic nonunion (> 1 year) (17.75 kg vs 12.25 kg, P = .032), between grade IV nonunion and grade V nonunion (14.86 kg vs 10.43 kg, P = .035), and between grade V nonunion and grade VI nonunion (10.43 kg vs 15.63 kg, P = .013). Patients with grade VI nonunion achieved union at 17.8 weeks postoperatively, a significantly longer period than that for patients with grade IV nonunion (11.4 weeks, P = .014).

CONCLUSIONS

Arthroscopic treatment of scaphoid nonunion using olecranon bone graft and screw fixation provided satisfactory outcomes regardless of the chronicity, location, and severity of nonunion.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Supine harvest of vascularised scapular bone grafts-Anatomical study and clinical application

BACKGROUND

We report our findings from an anatomical study on harvest of a vascularized scapular bone graft from a supine position. A clinical case is presented to illustrate the operative approach.

METHODS

Twenty cadaveric hemibody specimens were dissected in the supine position. Outcomes of interest included the characterization of anatomical variants and measurements of pedicle length. Specific measurements included distance from the origin of the subscapular artery (at the axillary artery) to the branch point of the angular artery from the thoracodorsal artery or serratus branch and the length of the angular branch proper.

RESULTS

There are five reported anatomic variations regarding the origin of the angular branch of the thoracodorsal artery. In our cadaveric cohort only four known types were seen, and an entirely new variant was encountered. Six cadaveric dissections exhibited a type 3 configuration, six were type 1, four were type 2, three were type 4, and one was a previously unreported variant we termed a type 6, with multiple angular artery branches originating from the posterior branch of the thoracodorsal. The mean distance between the origin of the subscapular artery and the takeoff of the angular branch was 6.3 ± 2.0 cm. The mean length of the angular branch was 3.7 ± 1.4 cm.

CONCLUSIONS

Supine positioning for harvest of a vascularized bone graft obviates the need for an intraoperative position change and allows reconstruction of bone defects in the hand and upper extremity within a single surgical field.

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.

Free Medial Femoral Condyle Flap for Reconstruction of Scaphoid Nonunion: A Systematic Review

BACKGROUND

 The free medial femoral condyle (MFC) bone flap is an attractive option for reconstruction of scaphoid nonunion utilizing vascularized bone to augment bony healing, especially in cases of failed prior treatment or osteonecrosis. This review aims to determine the role and reliability of the free MFC flap for treatment of scaphoid nonunion.

METHODS

 A search of electronic databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles examining free MFC bone flaps for treatment of scaphoid nonunion were included for analysis. Outcomes of interest included flap failure, postoperative union rate, time to union, carpal indices, functional outcomes, and complications.

RESULTS

 Twelve articles met the inclusion criteria. A total of 262 patients underwent free MFC flaps for treatment of scaphoid nonunion. The most common site of nonunion was the proximal pole of the scaphoid with 47% of patients receiving prior attempts at operative management. Overall bony union rate was 93.4% with a mean time to union of 15.6 weeks. There were no flap failures reported. Improvements in carpal indices including scapholunate (p < 0.0004), radiolunate (p < 0.004), lateral interscaphoid angles (p < 0.035), and revised carpal ratio height (p < 0.024) were seen postoperatively. Visual analog scale improved postoperatively from 6.5 to 2.3 (p < 0.015). Postoperative complications were observed in 69 cases (26.3%), with 27 patients (10.3%) requiring further operative intervention. However, no major donor or recipient site morbidity was appreciated.

CONCLUSION

 MFC flaps provide a highly versatile and reliable option for reconstruction of scaphoid nonunion with excellent bony union rates and acceptable complication rates. The present literature suggests that MFC reconstruction of scaphoid nonunion restores radiocarpal anatomy and improves wrist function without causing significant donor or recipient site morbidity.

The free vascularized lateral femoral trochlea osteochondral graft: a reliable alternative for Stage III Kienböck's disease

Lunate reconstruction using a lateral femoral trochlea osteochondral graft was carried out in 27 patients with Stage III Kienböck's disease from 2012 to 2019. Twenty-three of these patients could be followed-up in this retrospective study. Ten were women and 13 men. Nine were Lichtman Stage IIIA, seven Stage IIIB and seven Stage IIIC. The mean follow-up was 39 months (range 12-86). Bony consolidation was found in 18 of the 23 patients, with no graft loss. The mean Disabilities of the Arm, Shoulder and Hand score (DASH score) was 11 and the Modified Mayo Wrist Score was 83. There were only two radiological deteriorations, with the same or improved Lichtman classifications in the other patients and a significant reduction in pain. Postoperative extension of the wrist (52°) and flexion (48°) were comparable with preoperative values and, respectively, 81% and 72% of the contralateral side. Grip strength and pinch grip were 32 kg and 12 kg, 88% and 94% of the other hand, respectively, and an insignificant increase compared with the preoperative values. The vascularized lateral femoral trochlea osteochondral graft yields good short- and mid-term results in Grade III Kienböck's disease.Level of evidence: IV.

Can headless screw used in fixation of the scaphoid proximal pole fracture be broken after wrist trauma? An unreported complication of scaphoid surgery

The post-traumatic impairment of blood supply of the scaphoid bones' proximal pole is the subject of controversy in the surgical techniques which would heal this fracture. In a surgery performed with a dorsal approach, the main goal is to make a strong fixation with a small incision and a good implant without disturbing the blood supply of the bone. To date, complications related to surgical treatment of scaphoid proximal pole fractures have been reported in detail. However, there is no other study which presents headless screw failure which placed for the scaphoid proximal pole fracture surgery. Although implant technologies have been developed nowadays, our case report highlights that the endurance of these implants has not been carried out in such proximal pole fractures of the scaphoid, yet. Herein, we present the explanation of a broken headless screw which was placed into the proximal pole fracture of scaphoid, avoiding to affect bone stock of the scaphoid surgical technique. We believe that this surgical technique would be helpful to manage similar difficult situations for orthopedic surgeons.

Comparison of the functional and radiological outcomes of vascularized and non-vascularized bone graft options in the treatment of scaphoid nonunion

OBJECTIVES

This study aims to compare the functional and radiological outcomes of the patients with scaphoid waist nonunion treated with non-vascularized bone graft and vascularized bone graft options.

PATIENTS AND METHODS

Between January 2016 and February 2020, a total of 24 patients (22 males, 2 females; mean age: 30.6±9.4 years; range, 18 to 66 years) with scaphoid waist nonunion who were treated with vascularized or non-vascularized bone graft were retrospectively analyzed. Of these patients, eight were treated with iliac crest non-vascularized bone graft (IC-NBG), seven with vascularized free medial femoral condyle (MFC) graft, and nine with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft (1,2-ICSRA-VBG). The grip strength, flexion, extension, radial deviation, ulnar deviation angles were measured and compared to the contralateral hand for functional outcomes. Union rates, the scaphoid height-to-length ratio, the lateral intrascaphoid angle (LISA) were evaluated for radiological outcomes. The Mayo Wrist Score, Visual Analog Scale (VAS) score, and Quick Disability of the Arm, Shoulder and Hand (Q-DASH) Questionnaire score were calculated.

RESULTS

Union was observed in seven (87.5%) patients after IC-NBG, in six (85.7%) patients after MFC bone graft and nine (100%) patients in the treatment group with 1,2-ICSRA-VBG. There were no statistically significant differences among the IC-NBG, MFC and 1,2-ICSRA-VBG groups in terms of the union rates, the scaphoid height-to-length ratio, VAS score, Q-DASH score, grip strength and flexion, ulnar deviation, radial deviation angles after surgery (p>0.05). However, extension was statistically lower in the MFC group than IC-NBG and 1,2-ICSRA-VBG groups after surgery. The Mayo score was better in the IC-NBG group than MFC and 1,2-ICSRA-VBG, indicating a statistically significant difference (p<0.05).

CONCLUSION

Based on our study results, we suggest to use IC-NBG for scaphoid waist nonunion as the primary procedure, as the union rates are comparable with the MFC and 1,2-ICSRA-VBG techniques and it has advantages such as shorter operation time, easier technique, no special experience requirement, and better functional outcomes.

Autologous Osteoligamentous Reconstruction of Scaphoid Proximal Pole With Metatarsal Head and Collateral Ligament: Cadaver Anatomic Description of Novel Surgical Technique

Background: Historically, scaphoid nonunion has been surgically treated with vascularized bone graft taken from multiple different anatomic sites. However, none of these grafts fully recapitulate the unique osteoligamentous anatomy of the proximal pole of the scaphoid and the attachment of the scapholunate ligament (SLIL). We studied the anatomy of the vascularized second metatarsal head with its lateral collateral ligament as a potential novel treatment of proximal pole scaphoid nonunion with collapse. Methods: Scaphoids and second metatarsal heads were harvested from bilateral upper and lower extremities of 18 fresh frozen cadavers (10 male, 8 female) for a total of 36 scaphoids and 36 second metatarsal heads. The ipsilateral second metatarsal head was harvested with its lateral collateral ligament and its blood supply from the second dorsal metatarsal artery (SDMA). Measurements of the scaphoid, the SLIL, the second metatarsal head, and lateral collateral ligaments were compared to matched limbs from the same cadaver. Results: The anatomic dimensions of the second metatarsal head with its lateral collateral ligament are similar to the scaphoid proximal pole and the SLIL in matched cadaveric specimen. Conclusions: This anatomic cadaver study reveals that the second metatarsal head with its associated lateral collateral ligament is a well-matched donor to reconstruct the proximal pole of the scaphoid and SLIL. This anatomic similarity may be well suited to treat nonunion of the scaphoid proximal pole with or without avascular necrosis with simultaneous reconstruction of the SLIL. The authors describe a technique of vascularized reconstruction of the osteoligamentous proximal pole of the scaphoid with its attached SLIL utilizing autologous second metatarsal head with its attached lateral collateral ligament. Based on this cadaver study, this technique merits consideration.

Donor site morbidity after the harvest of microvascular flaps from the medial and lateral femoral condyle region: Objective, radiologic, and patient-reported outcome of a multi-center trial

BACKGROUND

With the experience-based hypothesis of low donor site morbidity (DSM) for free flaps from the distal femur, this cohort study aimed to evaluate the DSM according to objective and reproducible criteria.

METHODS

One hundred and fifty-six patients who had a flap harvest from either the medial or lateral femoral condyle region between 2005 and 2017 were included. A retrospective chart review was performed for all patients. In total, 97 patients were available for a follow-up examination. Outcomes were assessed according to objective (Knee Society Score; Larson Knee Score; OAK Score; 0-100 points), patient-reported (IKDC Score; KOOS Score; 0-100 points), and radiologic criteria (Kellgren and Lawrence Score; MRI Osteoarthritis Knee Score).

RESULTS

The median follow-up time was 1,529 days (range: 248-4,810). The mean Knee Society Score (94.8 ± 10.1), Larson Knee Score (94.5 ± 10.1), and OAK Score (95.5 ± 6.6) showed nearly unimpaired knee function. The overall patient-reported DSM was low (IKDC Score: 86.7 ± 17.4; KOOS Score: 89.3 ± 17.1). Osteochondral (OC) flaps had a significantly higher DSM, regardless of the donor site. Bone flaps did not show any relevant radiologic morbidity in the Kellgren and Lawrence Score. Besides the procedure-associated cartilage lesions at the OC donor sites, MRI Osteoarthritis Knee Score did not show any significant presence of further knee pathologies in the bilateral MRI Scans. The obvious cartilage lesions did not have a relevant impact on the knee function of most patients.

CONCLUSION

The DSM for bone and soft-tissue flaps from the femoral condyle region is negligible. OC flaps are associated with a significantly higher DSM, although a clinically relevant impact on knee function was not evident in the majority of patients.

Reconstruction of proximal pole scaphoid non-union with avascular necrosis using proximal hamate: A four-case series

Union of proximal pole scaphoid fracture is challenging because the vascular supply is limited. The avascular necrosis accompanying non-union and progressive fragmentation make surgical reconstruction difficult. The present study aimed to report short-term results of reconstruction with proximal hamate in proximal pole scaphoid non-union with avascular necrosis. Four patients (3 male, 1 female) were assessed for non-union following proximal pole scaphoid fracture. Mean age was 25.7 years (range, 22-35 years). Mean interval between injury and reconstruction was 7.5 years (range, 5-9 years). In 3 patients, no treatment was given following the fracture and in the other internal fixation was performed following cast immobilization. The non-united avascular proximal scaphoid was resected and reconstructed with proximal hamate autograft. Mean follow-up was 14.0 months (range, 9-22 months) after reconstruction. At the last control, cases were evaluated in terms of clinical and functional status, and radiologic union was determined on CT scan. Three patients reported subjective decrease in pain. Mean grip strength proportionally to the unaffected side was 24% (range, 8-51%), mean flexion-extension was 55.3% (range, 21-60%), and radial-ulnar deviation was 63.6% (range, 25-100%). Mean QuickDASH score was 32.3 (range, 13.6-52.2). Union was observed in all patients. Proximal hamate reconstruction provided union and pain relief, but only moderate objective functional results. It can be used as an alternative technique in proximal pole scaphoid non-union with avascular necrosis.

A Morphometric Analysis of Hamate Autograft for Proximal Scaphoid Reconstruction

Objective  Recently, authors have investigated using the proximal hamate as osteochondral autograft for proximal pole scaphoid reconstruction in the case of nonunion with avascular necrosis. The aim of our study was to analyze the morphology and anatomic fit of the proximal hamate compared with the proximal pole of the scaphoid using cadaveric specimens. Materials and Methods  Ten cadaver specimens (five males and five females) were dissected. Scaphoid and proximal hamate bones were measured by two independent investigators using electronic calipers and radius of curvature gauges. After measurements were determined to have good correlation, the average value of the two observers' measurements were used for further analysis. Sagittal radius of curvature (ROC), coronal ROC, depth, width, and maximum graft length were compared. Results  The average depth of the scaphoid proximal pole was 12.3 mm (standard deviation [SD] = 1.12) compared with 11.3 mm (SD = 1.24) for the proximal hamate ( p  = 0.36). The average width was 7.8 mm (SD = 1.00) in the scaphoids compared with 8.6 (SD = 1.05) in the hamates ( p  = 0.09). There was also no significant difference in the sagittal ROC between hamates (9.1 mm, SD = 1.13) and scaphoids (9.5 mm, SD = 0.84; p  = 0.36). All of these average measurements were within 1 mm. There was a significant difference between the coronal ROC of the hamate (23.4 mm) and scaphoid (21.1 mm) bones in our samples ( p  = 0.03). Females were on average smaller than their males, but there was no significant difference in fit based on sex alone. Conclusion  The proximal pole of the hamate has similar morphology and size as the scaphoid, with similar depth, width, and sagittal ROC. It has potential as an osteochondral autograft for proximal pole scaphoid reconstruction.

Management of Proximal Pole Scaphoid Nonunions: A Critical Analysis Review

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Optimal management of nonunions of the proximal pole of the scaphoid is controversial and dependent on many patient and pathophysiologic considerations.

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If the proximal pole subchondral bone support is sufficient, options include open reduction and internal fixation, either alone or in combination with autologous nonvascularized or vascularized bone graft.

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If the proximal pole is not salvageable, replacement with osteochondral autografts or osteochondral flaps is the only option for reconstruction of the native anatomy.

Vascularized Bone Flaps for Carpal Reconstruction

Within the field of hand and upper extremity surgery, reconstruction of the bony carpus remains a perplexing task and is a field undergoing rapid evolution. Among the eight bones of the carpus, the scaphoid and lunate are most frequently affected by traumatic and avascular processes which render their articular surfaces degenerated and painful. These conditions include scaphoid waist fracture, scaphoid proximal pole fracture, and Kienböck's disease of the lunate. While traditional salvage operations with limited functional outcomes have historically been employed for management of these unsolved problems, advances in microsurgical understanding and capability are changing the treatment algorithm at our center. This paradigm shift centers in large part around the introduction of new techniques for vascularized bone and cartilage transfer for carpal reconstruction.

Reconstruction of the Proximal Scaphoid With a Medial Femoral Trochlea Osteochondral Graft: Minimum 2-Year Results

PURPOSE

To report the clinical and radiological outcomes after medial femoral trochlear (MFT) osteochondral graft for the salvage of proximal scaphoid fractures with a minimum 2-year follow-up.

METHODS

A retrospective review was performed of patients with comminuted fractures of the proximal scaphoid treated by excision of the proximal pole and replacement with free vascularized MFT osteochondral graft. Demographic data, objective and radiographic measurements, and patient-reported outcome measures of the upper limb and knee were collected. Pain was assessed by completion of a visual analog scale (VAS).

RESULTS

Between February 2014 and May 2015, 12 MFT osteochondral grafts were performed. Eight patients were available for follow-up at a mean of 34 months (range, 28-39 months). The mean range of wrist flexion was 31° (range, 15°-60°), extension was 34° (range, 5°-60°), radial deviation was 9° (range, 0°-20°), ulnar deviation was 28° (range, 10°-45°) and grip strength was 42 kg (range, 25-53 kg). The median wrist pain, as measured by VAS, was 0.7 (mean, 1.3; range, 0-6). The average follow-up scapholunate, radiolunate, and radioscaphoid angles were 58.9° (range, 44°-93°), 12.9° (range, 0°-30°), and 46.0° (range, 35°-63°), respectively. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 13.9 (range, 3-43) and Patient Rated Wrist Evaluation (PRWE) score was 22.4 (range, 2-68). The mean postoperative Oxford Knee Score was 42 (range, 14-48). One patient suffered notable knee pain at 37-month follow-up. One patient suffered notable pain on the radial side of the wrist and underwent scaphoid excision and 4-corner arthrodesis.

CONCLUSIONS

Replacement of the fragmented proximal scaphoid by MFT graft is an alternative to other salvage options and most patients can expect pain relief and acceptable wrist motion. These results need to be balanced against the potential for donor-site morbidity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Vascularized bone grafts for post-traumatic defects in the upper extremity

Vascularized bone grafts (VBGs) are widely employed to reconstruct upper extremity bone defects. Conventional bone grafting is generally used to treat defects smaller than 5–6 cm, when tissue vascularization is adequate and there is no infection risk. Vascularized fibular grafts (VFGs) are mainly used in the humerus, radius or ulna in cases of persistent non-union where traditional bone grafting has failed or for bone defects larger than 6 cm. Furthermore, VFGs are considered to be the standard treatment for large bone defects located in the radius, ulna and humerus and enable the reconstruction of soft-tissue loss, as VFGs can be harvested as osteocutaneous flaps. VBGs enable one-stage surgical reconstruction and are highly infection-resistant because of their autonomous vascularization. A vascularized medial femoral condyle (VFMC) free flap can be used to treat small defects and non-unions in the upper extremity. Relative contraindications to these procedures are diabetes, immunosuppression, chronic infections, alcohol, tobacco, drug abuse and obesity. The aim of our study was to illustrate the use of VFGs to treat large post-traumatic bone defects and osteomyelitis located in the upper extremity. Moreover, the use of VFMC autografts is presented.

Medial femoral trochlea flap reconstruction: Clinical outcomes and perspectives

INTRODUCTION

We report our experience with use of the medial femoral trochlea (MFT) osteochondral flap for carpal applications.

METHODS

Outcomes of all patients treated with MFT flaps were reviewed. Healing, range of motion, grip strength, carpal alignment, pain, and complication data were collected.

RESULTS

MFT flaps were performed on seven patients with a mean age of 26.1 (range, 17-42) years. Indications included scaphoid proximal pole nonunion (n = 3), Kienböck's disease (n = 3), and Preiser's disease (n = 1). The mean follow-up was 32.3 (range, 5-70) months. Union was achieved in five patients at a mean of 12 (range 6-22) weeks. All five patients had increased grip strength and absence of pain at follow-up. There were two failures due to graft resorption.

CONCLUSIONS

The MFT osteochondral flap is a technically challenging yet powerful tool to replace the loss of both carpal articular cartilage and adjacent bone.

Arthroscopic-assisted reduction, bone grafting and screw fixation across the scapholunate joint for proximal pole scaphoid nonunion

Background

There are some difficulties in treating proximal scaphoid nonunion, mainly including poor vascularity of the proximal scaphoid fragment and limited space for a stable fixation in the proximal scaphoid fragment. This study reports the outcomes of treating proximal scaphoid nonunion with arthroscopic assist for reduction, bone grafting and screw fixation across the scapholunate (SL) joint.

Methods

Between 2008 and 2017, 21 patients were enrolled. Fracture healing and change in the lateral SL angle and SL gap were evaluated. Functional outcomes were evaluated using the Disabilities of the Arm, Shoulder, and Hand (DASH) score, wrist range of motion, grip strength, and the Visual Analog Scale (VAS) for pain.

Results

Nineteen patients achieved fracture healing and their mean follow-up duration was 31.3 months (24–120 months). The average fracture healing time was 16.3 weeks (10 to 28 weeks). From the preoperative to the postoperative final evaluation, there was some significant improvement in wrist function, including wrist flexion from 54.5^o to 67.4^o, wrist extension from 62.3^o to 71.7^o, DASH scores from 52.4 to 21.4, VAS during activity from 4.6 to 2.1, and grip strength from 9.6 kg to 24.7 kg. The lateral SL angle also improved significantly, from 82^o to 66^o. Seventeen patients requested screw removal after fracture healing because of their cultural belief in not leaving hardware in the body. No significant SL gap widening was noted after screw removal in the sequential follow-ups.

Conclusions

Using arthroscopic-assisted reduction, bone grafting and screw fixation across the SL joint in proximal scaphoid nonunion treatment, satisfactory functional and radiographic outcomes can be achieved.

Headless screw fixation through the dorsal rough surface for proximal-pole scaphoid-nonunion: a report of 15 patients

Clinical outcomes of the dorsal-retrograde headless screw-fixation technique in 15 patients with proximal scaphoid nonunion are presented. In this technique, screws are inserted from the dorsal rough surface of the scaphoid, located between the dorsal ridge and scaphoid-trapezium-trapezoid joint. Fifteen patients underwent osteosynthesis with this technique with iliac bone graft. Seven patients required primary surgery, and eight patients with a history of failed operation required revision surgery. Among 15 patients, 13 achieved union and two with persistent nonunion were asymptomatic with average follow-up of 24 months (range 14-57). Mean time to union was 20 weeks (range 12-40). Our experience with the dorsal-retrograde headless screw fixation technique has shown encouraging results for the treatment of proximal-scaphoid nonunion, especially in revision surgery wherein secure fixation of the small proximal fragments can be difficult using conventional anterograde techniques.Level of evidence: IV.

Three-and-a-half to 18 year outcome data for costal osteochondral grafts for salvage of the proximal pole of the scaphoid

Twelve patients who had undergone costal osteochondral graft reconstruction of the proximal pole of scaphoid were evaluated with clinical examination, patient-reported outcome scores and radiographs with an average follow-up of 10 years (range 3.5-18). The range of wrist motion was not significantly changed compared with the preoperative range of motion and functional outcomes scores were acceptable. The patients reported low pain scores despite the universal presence of radiographic changes of reduced carpal height and arthritis of the midcarpal and radiocarpal joints. Costal osteochondral graft reconstruction of the proximal pole of scaphoid offers good long-term pain relief and function.Level of evidence: IV.

[Scaphoid non-union: Experience from more than 280 reconstructions using a medial femur condyle bone graft]

BACKGROUND

Since 2008 we have been using many free vascularized medial femoral condyle grafts for reconstruction of difficult scaphoid non-unions. This article aims to report our results and experiences.

PATIENTS AND METHODS

Until the end of 2019 a total of 287 patients had a microvascular scaphoid reconstruction, 158 with use of a corticocancellous, and 129 using an osseocartilaginous graft. Complete analysis of all of these patients was impossible. This manuscript is based on a retrospective analysis of 28 out of 42 patients with corticocancellous grafts operated on between 2008 and 2010 with a mean follow-up time of 6.1 years as well as another 44 out of 76 patients with an osseocartilaginous graft operated on between 2011 and 2016 with a mean follow-up time of 44 months. Follow-up included clinical parameters, conventional x-rays, a DASH-Score and a modified Mayo wrist score. Additionally, the authors report their personal experiences - necessarily without quantification. In view of this incomplete data-pool statistical analysis was not reasonable.

RESULTS

In the group with corticocancellous reconstructions bony healing was achieved in 69 %, salvage operations were required in 9,5 %. The 28 patients had a mean DASH-Score of 11, a mean modified Mayo wrist score of 83 points, a mean ROM of 86° and a mean grip strength of 89 % of the contralateral side. In the group with osseocartilaginous reconstructions complete bony healing was seen in 80 %, partial healing in 5 %, and salvage procedures were required in 11 %. The remaining 39 patients had a mean DASH-Score of 15, a mean modified Mayo wrist score of 80 points, a mean ROM of 90° and a grip strength of 81 % of the contralateral hand. A specific complication was an ossification of the pedicle, but the main problem was a satisfying reconstruction of the shape of the scaphoid and reestablishment of carpal stability in far advanced cases. We could not identify factors reliable for the persisting non-unions.

CONCLUSIONS

These operations combine great chances for healing with considerable risks for serious complications. So future patients have to be fully informed, so that their decision for such a procedure is based on realistic expectations.

Costo-osteochondral graft (rib graft) reconstruction of the irreparable proximal scaphoid

We present our series of 21 cases in which proximal scaphoid nonunions with fragmentation were treated with costo-osteochondral graft reconstruction (rib graft). The median follow-up was 29 months. Union was achieved in all 21 patients. There were significant improvements in subjective and objective outcome measurements and carpal alignment was well maintained in all patients, as shown by normal postoperative capitolunate angle measurements. No donor site complications were encountered. Rib graft reconstruction offers a reliable and straightforward option for the difficult problem of the irreparable proximal pole of the scaphoid.Level of evidence: IV.

Medial Femoral Trochlea Osteochondral Graft: A Quantitative Anatomic Comparison to the Proximal Pole of the Scaphoid

Background  Treatment of scaphoid proximal pole (SPP) nonunion with a vascularized osteochondral graft from the medial femoral trochlea (MFT) has been described, with positive outcomes thus far. However, our understanding of the congruency between the articular surfaces of these structures is incomplete. Objective  Our purpose was to evaluate the congruency of the MFT and SPP using a quantitative anatomical approach. Methods  The distal femur and ipsilateral scaphoid were dissected from 12 cadavers and scanned with computerized tomography. Three-dimensional models were created and articular surfaces were digitally "dissected." The radius of curvature (RoC) of the radioulnar (RU) and proximodistal (PD) axes of the SPP and MFT, respectively, as well as the orthogonal axes (SPP, anteroposterior [AP]; MFT, mediolateral [ML]) were calculated. The RoC values were compared using the Wilcoxon signed-rank test. Results  The RoC values for the SPP and MFT were not significantly different in the RU-PD plane ( p  = 0.064). However, RoC values for the SPP and MFT were significantly different in the AP-ML plane ( p  = 0.001). Conclusions  For most individuals, the RU curvature of the SPP was similar to the PD curvature of the MFT. For nearly all individuals, the AP curvature of the SPP and the ML curvature of the MFT shared less congruence. Clinical Relevance  Articular surface congruity may not be a critical factor associated with improvements in wrist function following this procedure.

Outcomes of Local Bone Graft and Fixation of Proximal Pole Scaphoid Nascent Nonunions and Nonunions

Background  Fractures of the proximal pole of the scaphoid have an increased risk of nonunion due to its tenuous blood supply. The optimal treatment of proximal pole scaphoid nonunions remains controversial. Objectives  To review a single surgeon's experience with proximal pole scaphoid nascent nonunions (delayed unions) and nonunions that underwent surgical fixation with a cannulated headless compression screw and local autologous bone graft from the distal radius. Patients and Methods  After obtaining Institutional Review Board approval, the electronic medical record of one tertiary care center was queried for patients with the diagnosis of "proximal pole scaphoid fractures" who underwent surgical fixation by a single surgeon over an 11-year period (2006-2017). Fifteen patients met initial query criteria; upon review of records, four patients were excluded due to the acute nature of the fracture, and one was excluded as surgical fixation included a vascularized bone graft. Results  The final study cohort consisted of 10 patients with a total of 10 proximal pole scaphoid nonunions. Almost all of the patients in this study were male (9/10 [90%]), and sporting activities were the most common mechanism of injury (8/10 [80%]). Volumetric measurements of the scaphoid fractures on computed tomography (CT) revealed that the mean total volume of the scaphoid was 2.4 ± 0.48 cm ³ and the mean volume of the proximal pole fragment was 0.38 ± 0.15 cm ³ . Postoperative CT scans were performed at a mean of 12.4 weeks (range: 8-16 weeks), with seven (7/10 [70%]) showing signs of complete union and three (3/10 [30%]) demonstrating partial union. None of the patients required additional procedures and there were no complications. Conclusions  Our results suggest that proximal pole scaphoid fractures with delayed union and nonunion treated with surgical fixation and autologous local bone graft heal without the need for more complex vascularized procedures. The volume of the proximal pole fragment did not correlate with increased risk of ongoing nonunion after the index procedure. Level of Evidence  This is a Level IV, case series study.

Medial Femoral Trochlea Graft for Scaphoid Waist Nonunion: A Case Report and Review of the Literature

The medial femoral trochlea (MFT) of the knee is a donor site for convex osteochondral vascularized bone that has been used for the salvage of fractures of the proximal pole of the scaphoid. Chronic nonunited fractures of the scaphoid may lead to a sequence of degenerative change often referred to as scaphoid nonunion advance collapse. The vascularized MFT osteochondral graft has been reported as a salvage procedure for fractures of the proximal pole of the scaphoid, in situations where fixation is not an option. In this "Special review," we describe the technique of free vascularized MFT graft in a case in which the nonunited scaphoid fracture was associated with segmental loss of the articular surface of the scaphoid waist. Given the likely progression of arthritis, if left untreated, we elected to treat this by replacing the lost articular surface using a vascularized intercalary osteochondral MFT graft between the nonunited scaphoid segments.

The Effect of Proximal Hamate Osteotomy on Carpal Kinematics for Reconstruction of Proximal Pole Scaphoid Nonunion With Avascular Necrosis

Background: The purpose of this study is to determine the effects of proximal hamate transfer for proximal pole scaphoid reconstruction upon carpal kinematics. Methods: Eight fresh-frozen cadaveric wrists underwent evaluation of their radiocarpal and midcarpal motion after proximal hamate osteotomy. A wrist simulator was used to apply cyclical tension to the flexor carpi ulnaris (FCU), flexor carpi radialis (FCR), extensor carpi ulnaris (ECU), and extensor carpi radialis longus and brevis stitched together (ECR). Kinematic motion was captured using Moiré Phase Tracking 3-dimensional motion-tracking sensors (MPT, Metria Innovation, Inc, Milwaukee, Wisconsin) to evaluate the lunocapitate and scapholunate angles for each condition. Results: During wrist flexion-extension and radial-ulnar deviation, there were no statistically significant differences about the lunocapitate or scapholunate axis between the intact and post-hamate osteotomy conditions. Conclusions: The harvest of the proximal hamate for proximal pole scaphoid reconstruction does not appear to adversely affect wrist kinematics.