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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

An Algorithmic Approach to the Treatment of Kienböck Disease

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

Vascularized Bone Flaps for the Treatment of Kienböck Disease

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

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.

Arthroscopic Lunate Excision Provides Excellent Outcomes for Low-Demand Patients with Advanced Kienböck's Disease

Purpose

To examine the clinical outcomes of arthroscopic lunate excisions for advanced Kienböck's disease.

Methods

Fifteen patients (six men and nine women; mean age: 65 years; range: 48-83 years) with advanced Kienböck's disease, who underwent arthroscopic lunate resection between April 2008 and March 2016, were reviewed clinically and radiographically after a follow-up of >2 years (mean: 29 months; range: 24-60 months). Clinical parameters, such as wrist range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and patient-rated wrist evaluation (PRWE) score were evaluated. Radiographic parameters included radioscaphoid angle, scaphocapitate angle, carpal height ratio, ulnar-triquetrum distance, and the scaphoid-triquetrum distance. Wilcoxon's signed-rank test was used to compare measurement results.

Results

During the final follow-up, patients exhibited significant improvements, such as 42.9° in wrist range of motion (P = .009), 24.5% of the contralateral side in grip strength (P = .001), 26.2 points in DASH score (P = .002), and 37.8 points in PRWE score (P < .001), compared with the preoperative values. The radioscaphoid and scaphocapitate angles significantly increased by 4.8° (P = .0027) and 3.7° (P = .0012), respectively. The carpal height ratio, ulnar-triquetrum distance, and scaphoid-triquetrum distance significantly decreased by 0.05 (P < .001), 2.6 mm (P < .001), and 1.3 mm (P = .0012), respectively.

Conclusions

Our results suggest that arthroscopic lunate excisions provided excellent postoperative pain relief and functional recovery within 2 years of follow-up. Changes in carpal alignment and stress concentration on the radial side of the carpal bones could occur in the long term; however, arthroscopic lunate excision can be a good surgical option for treating low-demand patients with advanced Kienböck's disease.

Level of Evidence

Level IV, therapeutic case series.

Matching Kienböck's Treatment Options to Specific Features of Each Case

Kienböck's disease is best understood as a continuous interaction between compromised perfusion and structural deterioration that transitions from an early phase to a late phase. Existing literature has failed to identify any one superior treatment for Kienböck's; many studies even demonstrate no advantage for surgery compared with the natural history. Surgical interventions for early and transitional Kienböck's are designed to preserve or reconstruct the lunate. However, in most studies, the only tool used to assess the lunate itself has been plain radiography that neither reveals critical architectural details (demonstrated by computed tomographic scan) nor the vascular status (demonstrated by magnetic resonance imaging). Most articles, therefore, do not adequately define the preoperative status of the lunate or its alteration through surgical intervention. Critical preoperative features that are best demonstrated by these advanced imaging studies have specific anatomic and physiologic relationships that better correspond with certain surgical interventions, which also pair better with specific patient characteristics. This review explains how to identify, analyze, and strategically match these variables with the treatment interventions available for Kienböck's patients through the early, transitional, and late phases of the disease.

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.