Knee Donor Site Morbidity Following Harvest of Medial Femoral Trochlea Osteochondral Flaps for Carpal Reconstruction

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.

Free vascularized bone graft from the lateral epicondylar region of the humerus for treatment of scaphoid nonunion

BACKGROUND

Free vascularized bone grafting (FVBG) has become one of the essential methods for treating scaphoid nonunion complicated by avascular necrosis. However, commonly used bone graft, including the medial femoral condyle bone graft and iliac crest bone graft, still present challenges such as a high rate of donor site complications and variations of vascular pedicle. In this study, we have introduced a novel bone graft-the lateral humeral condyle bone graft with the posterior branch of the radial collateral artery (PBRCA) as the vascular pedicle-as an alternative option, with the aim of overcoming some of the limitations of previously described FVBG procedures.

METHODS

Nine patients who had a nonunion of the scaphoid that had been present for an average of 16.8 months (range 9-35 months) were managed with use of a free vascularized bone graft obtained from the lateral humeral epicondylar region. Avascularity of the scaphoid, as assessed on preoperative magnetic resonance imaging and intraoperative bone marrow puncture test. Postoperatively, regular X-ray and CT scans examinations were conducted to assess the progress of fracture healing. Active motion of the wrist, and grip strength recovery were measured periodically. Wrist pain was graded using the Visual Analogue Scale (VAS), while wrist joint functionality was evaluated using the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) questionnaire and the Patient-Rated Wrist Evaluation (PRWE) scale. The elbow functional outcome was evaluated by the Mayo Elbow Performance Score (MEPS).

RESULTS

All of nine lateral humeral epicondylar bone grafts were successfully harvested. The blood supply of the graft during surgery was excellent in six cases and good in three cases. The size of the bone grafts ranges from 1.0 cm × 0.5 cm × 0.5 cm to 2.0 cm × 1.0 cm × 0.5 cm. The average vascular pedicle length was 3.4 cm (range 2.0-6.0 cm). There were no early complications in either the donor or recipient areas after surgery. Union was successfully achieved in all nine patients, with an average time to union of 14.3 weeks (range 11-20 weeks) after surgery. The average follow-up period was 31.2 months (range 26-40 months). At the final follow-up, the average palmar flexion, dorsal extension, radial deviation, and ulnar deviation angles of the injured wrist joint were 56.1° (range 45°-70°), 56.1° (range 40°-80°), 10.6° (range 5°-20°), and 22.2° (range 15°-35°), respectively, which reached 79.0%, 82.1%, 59.4%, and 72.8% of the average activity of the contralateral normal side. The average grip strength of the injured side was 35.2 kg (range 22-51 kg), which was equivalent to 81.3% of the average grip strength of the contralateral side. The average VAS score for wrist joint pain was 1.0 point (range 0-2 points); the Quick-DASH score was 9.2 points (range 6-18 points); and the PRWE score was 13.1 points (range 9-16 points), the Mayo Elbow Performance Index was 100 points (range 100-100 points). One patient reported a feeling of friction during movement but no pain. One patient reported numbness in the donor site. One patient complained of pain when applying force to the scar in the donor area. During the follow-up period, these complications showed improvement without any treatment.

CONCLUSION

The FVBG technique has been considered an effective method for treating scaphoid nonunion with avascular necrosis. Compared to traditional FVBG, the lateral humeral epicondylar bone graft exhibits a higher union rate, fewer complications, and easier accessibility, making it a favorable choice.

Vascularized Origami Medial Femoral Condyle Flap for Finger Joint Reconstruction

SUMMARY

Total finger joint reconstruction is challenging. Vascularized toe joint transfer is currently used for reconstruction, but it is difficult to perform, fails to achieve maximal joint flexibility, and is associated with donor-site complications. As an alternative, the authors developed a vascularized medial femoral condyle flap technique, wherein the vascularized corticoperiosteum is shaped via origami, with the donor tissue folded to fit the recipient site. In this article, the authors describe the use of this method for reconstruction of interphalangeal and metacarpophalangeal joints with a reduced range of motion. The mean age of the patients (three men and four women) was 51 years (range, 36 to 68 years), and the mean follow-up period was 3 years 1 month (range, 4 months to 5 years). In the reconstructed joints, the mean range of motion; Disabilities of the Arm, Shoulder, and Hand score; and pinch strength of the unaffected side were 55 degrees (range, 24 to 90 degrees), 2.3 (range, 0 to 6), and 98% (range, 70% to 38%), respectively. No donor-site morbidities were observed. Radiography and computed tomography scans revealed joint-like grafted tissue remodeling. The study findings suggest that the origami medial femoral condyle flap is useful for functional finger joint reconstruction. The procedure requires fabrication before grafting, but tissue harvest is relatively easy.

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 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.

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.

Medial femoral trochlea flap reconstruction versus proximal row carpectomy for Kienböck's disease: a morphometric comparison

Surgical options for advanced Kienböck's disease include proximal row carpectomy or lunate reconstruction with a medial femoral trochlea osteochondral flap. This study compares morphology of the proximal capitate and the medial femoral trochlear surfaces to the proximal lunate using three-dimensional geometric morphometric analysis. Virtual articular surfaces were extracted from MRI studies of ten healthy volunteers. Distances between corresponding points on the proximal lunate and proximal capitate or medial femoral trochlear surfaces were measured. In seven subjects, mean inter-surface distance for the medial femoral trochlea-proximal lunate pair was significantly lower than the proximal capitate-proximal lunate pairing. In three subjects, mean proximal capitate-proximal lunate distance was significantly lower. We conclude that the medial femoral trochlear flap was anatomically closer to the shape of the proximal lunate in the majority of the examined subjects. However, we found that in three out of ten cases, the proximal capitate was a better match.

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.

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.

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.

The Medial Femoral Condyle Flap in the Pediatric Patient

BACKGROUND

The use of free flaps from the medial femoral condyle has grown in popularity and is now a workhorse in the reconstruction of skeletal defects. The utility of this technique has not yet been described for the pediatric patient population. The authors present their series of pediatric patients who underwent surgery using a medial femoral condyle free flap or a variant thereof in skeletal reconstruction and demonstrate the efficacy of this technique in this population.

METHODS

A multi-institutional retrospective review of patients aged 18 years or younger who required a medial femoral condyle flap for skeletal reconstruction was undertaken. Operative technique, radiographs, and clinical outcomes were recorded. A novel technique (Innocenti) was used to avoid the distal femoral physis in which a Kirschner wire was placed under fluoroscopic guidance just proximal to the growth plate.

RESULTS

Thirteen patients met inclusion criteria, with an average age of 14.7 years (range, 7 to 18 years) and mean follow-up of 28 months (range, 3 to 120 months). Six were skeletally immature at the time of medial femoral condyle harvest, with the last patient having organic bone disease, putting her at risk for pathologic fracture. All 13 patients achieved bony union, and no patients suffered pathologic fractures or physeal injuries; no patients developed length discrepancies.

CONCLUSIONS

The authors present the first series of corticocancellous medial femoral condyle free flaps in the pediatric population along with a novel technique to avoid injury to the physis in skeletally immature patients. This technique is effective for a variety of skeletal defects or nonunions and is safe for growing patients without causing physeal arrest or growth disturbance.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

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.

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.

Corticoperiosteal medial femoral condyle flap for recalcitrant nonunion in ankle and foot: Outcomes and radiological evaluation of donor site morbidity

BACKGROUND

The aim of this study was to evaluate the effectiveness and safety of free corticoperiosteal medial femoral condyle (MFC) flap for ankle, hindfoot and midfoot reconstruction in patients with recalcitrant nonunion.

METHODS

Patients who underwent ankle and foot reconstruction using the MFC flap at our clinic were recruited for assessment of the union rate, time to union and functional outcome. Furthermore, a clinical and radiological examination of the donor knee was performed using both computed tomography and magnetic resonance imaging.

RESULTS

Thirteen patients with a mean follow-up time of 2.5 years were included; 10 of them had a previously failed ankle and foot arthrodesis. Union was achieved in 11 patients in an average time of 10 months after MFC flap surgery. Donor site morbidity was minor with no radiological evidence for soft tissue or bone complication.

CONCLUSION

MFC flaps are a useful and safe reconstructive tool and may be considered after failed ankle and foot arthrodesis.

Temporomandibular joint reconstruction with medial femoral condyle osseocartilaginous flap: a case series

Reconstruction for large-scale temporomandibular joint (TMJ) defects can be challenging. We have used the medial femoral condyle (MFC) osseocartilaginous flap for repair of TMJ defects. The aim of this paper was to describe our technique and to present the preliminary results. The MFC osseocartilaginous flap was used as a free vascularized graft for TMJ defect in four patients who had undergone resection for benign tumor of the TMJ region (n = 2) or TMJ ankylosis (n=2). A computer-assisted technique was used in all cases. Symmetry of the mandible was objectively evaluated by postoperative computed tomography. Complications were recorded during follow-up visits. Lower extremity functional status was assessed by the Lower Extremity Functional Scale (LEFC) questionnaire. The MFC osseocartilaginous flap success rate was 100%; bony union was obtained in all four patients, and normal occlusion was achieved within 6-11 months after surgery. No flap-related complications occurred. All patients were satisfied with their postoperative facial symmetry and oral function. The LEFC score ranged from 72 to 80, indicating normal lower extremity function. Vascularized MFC osseocartilaginous flap appears to be a reliable option for reconstruction of large-scale TMJ defects.

Preliminary Clinical, Radiographic, and Patient-Reported Outcomes of the Medial Femoral Trochlea Osteochondral Free Flap for Lunate Reconstruction in Advanced Kienböck Disease

PURPOSE

We aimed to describe the radiographic, functional, and patient-reported outcomes (PROs) of medial femoral trochlea osteochondral free flap reconstruction of the proximal lunate in stage IIIA and IIIB Kienböck disease.

METHODS

Eighteen adult patients underwent medial femoral trochlea reconstruction of the proximal lunate for advanced Kienböck disease by a single surgeon. Eight of these patients returned for clinical examination, radiographs, and completion of PRO questionnaires. An additional 4 patients completed PRO questionnaires remotely.

RESULTS

The mean patient age was 28.4 years. The mean radiographic and physical examination follow-up was 1.4 and 2.2 years, respectively. The mean PRO follow-up was 2.1 years. Radiographic measurements (carpal height ratio, radioscaphoid angle) demonstrated that carpal collapse was halted, and carpal alignment was maintained, after surgery. Wrist flexion (38.3°) and extension (37.3°) were unchanged by this operation, and postoperative pinch and grip strength were 90% and 68% of the uninjured side, respectively. The mean postoperative Disabilities of the Arm, Shoulder, and Hand score was 10.8, and the Patient-Rated Wrist Evaluation score was 18.1. Knee Injury and Osteoarthritis Outcomes Score subscales, International Knee Documentation Committee, and Kujala lower extremity PRO scores ranged from 83.1 to 96.8. The Patient-Reported Outcomes Measurement Information System Global Health, Physical Function, Pain Intensity, Pain Interference, and Pain Behavior scores reflected good postoperative patient health and function and low pain levels.

CONCLUSIONS

Following medial femoral trochlea reconstruction of the proximal lunate for advanced Kienböck disease, we observed a cessation of radiocarpal collapse. After surgery, patients demonstrated acceptable levels of function, pain, and wrist range of motion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

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.

The medial femoral condyle free flap: An excellent option for difficult cases: case series

The use of the medial femoral condyle free flap is a versatile option for the treatment of upper extremity non unions and reconstructive procedures associated with bone loss or osteonecrosis. The benefit of this type of flap is the viability of the bone which favors primary ossification and increases bone density. Vascularized free bone flaps are especially useful for the treatment of recalcitrant nonunions, or nonunions that have failed three or more treatments to obtain consolidation. We present a case series of three patients treated with medial femoral condyle free flap for reconstruction of the upper extremity of different etiologies at the level of the distal humerus, distal radius and distal phalanx of the thumb.

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.

Carpal Collapse After Scaphoid Nonunion: A Novel Combined Approach to the 1,2 Intercompartmental Supraretinacular Artery Radial Flap

Purpose

Scaphoid nonunion remains a major problem in hand surgery. The 1,2 intercompartmental supraretinacular artery flap (1,2 ICSRA), as first described by Zaidemberg et al, is widely used with reported union rates of approximately 80%. However, its use is limited in the case of associated carpal collapse as in dorsal intercalated segmental instability (DISI) and humpback deformity. In this study, we present a novel approach to this flap enabling the correction of associated carpal collapse.

Methods

Between 2006 and 2015, 9 patients with scaphoid nonunion or delayed union with carpal collapse were treated with a vascularized bone flap based on the 1,2 ICSRA using a combined volar and dorsal approach. Immobilization in a short-arm cast was applied for 8 weeks. Union rates, correction of DISI and humpback deformity, as well as clinical end points were noted. In addition, scapholunate (SL) angles were measured using 2 accepted radiological techniques, employing either the scaphoid midline axis or its proximal radiological landmarks as a reference.

Results

All cases united and a median time to bone consolidation of 4 months (range, 2–5 months) was observed. Preoperative DISI deformities (n = 4) were corrected in all patients. Humpback deformities (n = 5) were also corrected. Two patients had repeat surgery: one for K-wire removal after bony consolidation and the other for neuropathic pain.

Conclusions

The 1,2 ICSRA bone flap is a reliable treatment for scaphoid nonunion associated with carpal collapse. This combined volar and dorsal approach permits the correction of DISI and humpback deformity without compromising the scaphoid vascular supply, which eliminates the need to use free bone flaps from other sites. In this series, we observed a 100% union rate. Two patients required reoperation for symptomatic hardware and dorsal wrist pain linked to superficial neuritis.

Type of study/level of evidence

Therapeutic IV.

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.

Outcomes of the Medial Femoral Trochlea Osteochondral Free Flap for Proximal Scaphoid Reconstruction

PURPOSE

To describe the radiographic, functional, and patient-reported outcomes (PROs) of medial femoral trochlea (MFT) osteochondral free flap reconstruction of the proximal scaphoid at approximately 2 years follow-up.

METHODS

Eleven patients who underwent MFT reconstruction of the proximal scaphoid returned for clinical examination, radiographs, and completion of PROs questionnaires. For another 10 patients who were unable to return, data were gathered remotely or from the medical record.

RESULTS

Mean radiographic follow-up was 2.0 years and mean examination follow-up ranged from 2.6 to 2.8 years. Mean follow-up for several PROs ranged from 2.8 to 2.9 years. On average, carpal collapse did not progress, and radiolunate angle was significantly improved by 9.5°. Wrist flexion (41.6°; -6%) and extension (43.8°; -7%) were only slightly changed, and dominance-corrected postoperative pinch and grip strength were 77% and 72% of the uninjured side, respectively. Mean postoperative Disabilities of the Arm, Shoulder, and Hand (DASH) score was 10.7. In patients with both pre- and postoperative scores available, DASH significantly improved by 15 points. Knee donor-site morbidity was measured on the Knee Injury and Osteoarthritis Outcome Score (KOOS)-Sports and Recreation and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scales. The Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health, Physical Function, Pain Intensity, Pain Interference, and Pain Behavior scores reflected good postoperative patient health and function and low pain levels. Higher body mass index (BMI) was found to be predictive of inferior lower extremity and global PROs.

CONCLUSIONS

An MFT reconstruction of proximal scaphoid nonunion has the potential to restore normal functional radiocarpal anatomy, improve function, and relieve pain without causing wrist stiffness or weakness. Donor-site morbidity has been further delineated in this study. Caution is warranted when considering this procedure in patients with elevated BMI because they may be at increased risk for donor-site morbidity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Scaphoid Reconstruction

Surgical strategies for scaphoid nonunions become more complex based on time from injury to treatment. The decision-making process, however, can follow a logical sequence. Scaphoid nonunions less than 1 year after trauma and no carpal malalignment can be treated with percutaneous screw fixation under fluoroscopic and/or arthroscopic guidance. Reinterventions or patients with avascular proximal poles that do not need substantial grafts are reliably treated with pedicle vascularized bone grafts. Resection of the distal pole of the scaphoid is a good option in old nonunions or after a failed scaphoid procedures. When there are radioscaphoid degenerative changes, salvage procedures such as proximal row carpectomy (PRC) should be considered.

Topographical Analysis of the Hamate for Proximal Pole Scaphoid Nonunion Reconstruction

PURPOSE

To quantify the similarity of the surface topography of the proximal hamate and proximal pole of the scaphoid for nonunion reconstruction.

METHODS

Using previously acquired computed tomographic scans of the wrist of 10 patients, the 2 bones were segmented and subsequently aligned using both a manual and automated technique. Surface error between corresponding articular surfaces was computed to determine the similarity of the shape of the 2 bones.

RESULTS

The median distance between the 2 articulating surfaces for each patient was 1 mm or less for all cases. Maximum distance varied from 2.7 to 9.7 mm. The automated method improved alignment such that the maximum distance was 4.1 mm. Visual review of the alignment revealed that the maximum error occurred on or around the margin of the articulating surfaces.

CONCLUSIONS

In most cases, the proximal hamate appears to be a suitable donor match to reconstruct proximal pole scaphoid nonunions.

CLINICAL RELEVANCE

This study serves as a guide to practitioners when considering the suitability of the proximal hamate autograft for unsalvageable proximal pole scaphoid nonunions.

The vascularized medial femoral condyle free flap for reconstruction of segmental recalcitrant nonunion of the clavicle

BACKGROUND

Recalcitrant clavicular nonunion is a rare but complicated problem of clavicular fracture fixation. Nonunion is most often treated with clavicular shortening or in extreme cases vascularized bone grafting. Herein we describe our experience using the vascularized medial femoral condyle (MFC) free flap for the reconstruction of segmental defects in cases of recalcitrant clavicular nonunion.

METHODS

A retrospective chart review was conducted of patients with symptomatic recalcitrant nonunion of the clavicle who underwent reconstruction with the vascularized MFC free flap from June 2003 to January 2018. Patients' demographics, time to union, and postoperative complications were collected.

RESULTS

A total of 7 patients (6 women; 39.8 ± 9.01 years old) underwent clavicular reconstruction after an average of 3.7 ± 1.3 previous surgical procedures. Average preoperative visual analog scale score for pain was 4.1. The graft size ranged from 2 to 5 cm in length with approximately 1 cm in width and depth. The average time of total nonunion was 66 ± 48.2 months before surgery. All flaps survived and all clavicles healed with an average time to radiographic union of 15 ± 6.7 months. Patients regained full shoulder motion, and average postoperative visual analog scale score was 1.6 ± 1.8. All patients returned to their preoperative employment status. Donor site morbidity from the knee was minimal.

CONCLUSION

The MFC free flap is a good option for recalcitrant bone nonunion of the clavicle where larger vascularized flaps are not warranted. It is effective and offers minimal donor site morbidity.

[Scaphoid pseudarthrosis : Complex reconstruction using vascularized bone grafts]

The most important goals of scaphoid reconstruction in pseudarthrosis are correction of the humpback deformity, the realignment of the proximal carpal row and the bony union of the scaphoid. Therefore, in most cases bone grafting is required. To increase the healing rate and to improve vascularization, several kinds of vascularized bone grafts have been developed. Pedicled grafts are preferably harvested from the dorsal or palmar side of the distal radius with fusion rates between 27% and 100%. Free microvascular grafts can be obtained from the iliac crest and the medial or lateral femoral condyle with fusion rates between 60% and 100%. For their application microsurgical equipment and skills are required. Up to now osteochondral grafts from the femoral condyle offer the only chance for joint surface replacement by transferring part of the surface of the femoropatellar joint. The use of vascularized grafts is still a matter of controversy, since their superiority is still unproven compared to nonvascularized grafts, which also achieved 100% fusion rates in several series. They are indicated in secondary procedures after failed reconstruction and nonunion with small avascular proximal pole fragments. Since no evidence-based guidelines exist, this article provides an experience-based treatment algorithm for scaphoid nonunion with special consideration to vascularized bone grafts.

Long-Term Outcomes of Vascularized Trochlear Flaps for Scaphoid Proximal Pole Reconstruction

Reconstruction of proximal pole scaphoid nonunion using medial femoral trochlea osteochondral free flap is indicated in young active patients for whom salvage procedures are not ideal. This article reviews the outcomes data available in the literature and provides a brief report of clinical, radiographic, and patient-reported outcomes for the subset of our patients with greater than 3 years postoperative follow-up. The present literature suggests that medial femoral trochlea reconstruction for proximal pole scaphoid nonunion can restore radiocarpal anatomy, prevent progressive carpal collapse, improve function, and relieve pain without causing wrist stiffness, weakness, or excessive donor site morbidity in the short and medium term.

Donor site morbidity of vascularized bone grafts from the medial femoral condyle for osseous revascularization

BACKGROUND

Vascularized bone grafts from the medial femoral condyle (MFC) are used to gain surgical revascularization of osseous defects. To date objective data regarding the donor site morbidity are limited. This study aims to evaluate the donor site associated outcome after MFC flap harvest.

PATIENTS AND METHODS

From 2008 to 2016, 22 patients who underwent MFC bone flap harvest for osseous revascularization of 9 talus, 8 scaphoids, 2 metacarpals, 1 phalanx, 1 pilon tibiale, and 1 distal femur were included. Outcome analysis was performed for the whole cohort as well as for two subgroups (recipient site upper [group A] and lower extremity [group B]) by the lower extremity functional scale (LEFS), the OAK-score of the Swiss Orthopedic Society and the visual analog scale (VAS). Additionally, a 3D gait analysis was performed for four patients.

RESULTS

The mean flap size was 1 × 1 × 3 cm. No flap loss was observed. One minor surgical revision was performed due to donor site hematoma. Mean follow-up was 35.8 (12-98) months. Mean LEFS-score was 74.9 ± 9.5 (A: 74.3 ± 7.9; B: 75.6 ± 11.2, p > .05) and OAK-score was 92.8 ± 9.4 (A: 93.2 ± 5.8; B: 92.4 ± 12.3, p > .05). At follow-up examination, pain at rest was stated with 0.1 ± 0.2 (A: 0.1 ± 0.3; B 0 ± 0, p > .05) and with activity 0.6 ± 1.4 (A: 1.2 ± 1.8; B: 0 ± 0, p > .05) on VAS. The 3-D gait analysis showed normative walking patterns.

CONCLUSION

After MFC flap harvest knee function and gait pattern were almost unimpaired. Donor site morbidity can be considered as being of minor concern in the decision-making for this microvascular procedure.

Volar Vascularized Strut Graft for Avascular Scaphoid Nonunion Using the 1,2 Intercompartmental Supraretinacular Artery

In this retrospective study, we report the preliminary results of a novel technique for volar vascularized strut grafting to treat avascular scaphoid nonunion by using the 1,2 intercompartmental supraretinacular artery through a single incision. Forty-three of 45 patients with avascular scaphoid nonunion healed at a mean of 13 weeks (range, 3 to 10 mo). Complications consisted of 1 pin tract infection that resolved with oral antibiotics and 4 cases of transient dysesthesia of the radial sensory nerve. In 4 patients with equivocal radiographs, computed tomography scans confirmed bony union. The 2 patients who remained unhealed subsequently underwent proximal row carpectomy. Two other patients had persistent pain with the progression of radiocarpal arthritis. Our technique provides good results for the treatment of avascular scaphoid fracture nonunion. Notable advantages include performance through a single incision, use of an already established vascularized bone graft, volar graft placement, and no requirement for microvascular free graft reconstruction. It also provides the surgeon with the ability to adjust the procedure intraoperatively in the event of unexpected avascularity, without requiring substantially longer operative time or additional equipment.

Donor-Site Morbidity of Vascularized Bone Flaps from the Distal Femur: A Systematic Review

BACKGROUND

Vascularized grafts from the femur, including the medial femoral condyle and medial femoral trochlea, are increasingly being used. It is critical to understand the lower extremity complications from flap harvest.

METHODS

The authors searched available literature reporting on femoral flaps using PubMed, Embase, Cochrane Database, and Web of Science. After article selection, data were collected regarding demographics, procedure details, outcomes, and complications. The authors classified outcomes as good, fair, or poor based on pain, range-of-motion, sensory changes, subjective reporting, patient-reported outcomes, and other donor-site complications, including the need for additional procedures.

RESULTS

Two hundred twenty articles were identified. Forty-five met criteria for review, with data available for 283 patients. No patients had range-of-motion deficits beyond 1 year. Two percent of patients (six of 283) required additional donor-site procedures, with one report of a femur fracture after medial femoral condyle harvest. Only one study on 45 medial femoral trochlea patients presented patient-reported outcomes regarding the knee. Few objective data were presented. Twenty-eight articles presented adequate complication data for 252 patients to be rated as good, fair, or poor. Overall, 89 percent had good outcomes without donor-site complications. Of the 176 medial femoral condyle patients with outcomes reported, 92 percent had good outcomes; and 71 percent of the 48 medial femoral trochlea patients had good outcomes reported.

CONCLUSIONS

Overall, the reported donor-site morbidity from medial femoral condyle and medial femoral trochlea harvest is low. Chronic knee pain and sensory changes are most frequently reported, especially in medial femoral trochlea patients.

Lunate Reconstruction Using Osteochondral Vascularized Graft in Kienböck's Disease

There is a general consensus that the pathogenesis for Kienböck's disease remains uncertain, though it is probably related to nonphysiologic stress transmission across the lunate, acting in concert with one of several possible vascular abnormalities. Most surgical treatments focus on mechanical aspects rather than real physiopathology, but in the recent years several articles have shown the utility of vascularized grafts in the treatment of Kienböck's disease, especially in its early stages. The authors present a case of a successfully reconstruction of a IIIA stage Kienböck's disease with an osteochondral vascularized graft from medial femoral condyle.

The use of osteochondral flaps in the treatment of carpal disorders

Vascularized osteochondral flaps have been described for use in reconstruction of the wrist, providing the benefits of osteochondral grafts in addition to the benefit of osseous and subchondral perfusion via the microvascular pedicle. Various harvest sites have been described including the medial and lateral femoral trochlea and the proximal third metatarsal. The reconstructed surfaces described include the cartilage surfaces of the scaphoid, lunate, capitate and radius. The ability to transfer analogous osteochondral surfaces poses the possibility for new motion-preserving alternatives for difficult articular problems previously treated with salvage procedures. A description of the procedures and reported outcomes are provided, as well as a discussion of the role of these procedures in the future of wrist surgery.

Medial Femoral Condyle Microvascular Bone Transfer as a Treatment for Capitate Avascular Necrosis: Surgical Technique and Case Report

Avascular necrosis (AVN) of the capitate is a rare clinical entity for which a variety of treatment options have been described, ranging from immobilization to microvascular bone transfer. Outcomes following medial femoral condyle corticocancellous free flap reconstruction have not been reported for this specific pathology. We present the case of a 16-year-old girl with posttraumatic capitate AVN who was treated with curettage and medial femoral condyle corticocancellous vascularized bone grafting. At 18 months after surgery, the patient remains pain-free and had resumed all activities including lifeguarding by 6 months after surgery. This microsurgical technique, described previously for AVN of the scaphoid and lunate, may be applied in a similar fashion for the capitate with promising clinical results.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Chondrocyte Viability 3.5 Years Following a Vascularized Medial Femoral Trochlea Osteocartilaginous Free Flap

CASE

A 30-year-old woman underwent arthroscopy for wrist pain 3.5 years following a medial femoral trochlea (MFT) osteocartilaginous free flap for Kienböck disease, which provided the opportunity to examine the transferred cartilage in vivo. Arthroscopy revealed no evidence of chondrolysis, and histologic examination revealed uniformly viable chondrocytes within a matrix consistent with fibrocartilage.

CONCLUSION

To the best of our knowledge, the long-term viability of chondrocytes following an MFT free flap has not been previously documented. This case provides early evidence that free tissue transfer based on the descending genicular artery can provide a durable solution for osteocartilaginous defects.

A Scapholunate Ligament-Sparing Technique Utilizing the Medial Femoral Condyle Corticocancellous Free Flap to Reconstruct Scaphoid Nonunions With Proximal Pole Avascular Necrosis

This article demonstrates a technique for the treatment of scaphoid fracture waist and proximal pole nonunions with avascular necrosis using a free vascularized medial femoral condyle flap. We present our surgical technique and representative case examples in which the scapholunate ligament, a key structure required to preserve carpal kinematics, is spared.