Proximal scaphoid arthroplasty using the medial femoral trochlea flap

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.

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.

Bone Morphogenetic Protein in Scaphoid Nonunion: A Systematic Review

Background  Scaphoid nonunion can lead to carpal collapse and osteoarthritis, a painfully debilitating problem. Bone morphogenetic protein (BMP) has been successfully implemented to augment bone healing in other circumstances, but its use in scaphoid nonunion has yielded conflicting results. Case Description  The purpose of this study is to assess the outcomes and complications of scaphoid nonunion treated surgically with BMP. Literature Review  A literature review of all available journal articles citing the use of BMP in scaphoid nonunion surgery from 2002 to 2019 was conducted. We included studies that used BMP as an adjunct to surgical treatment for scaphoid nonunions in both the primary and revision settings with computed tomography determination of union. Demographic information, dose of BMP, tobacco use, outcomes, and complications were recorded. A total of 21 cases were included from four different studies meeting inclusion criteria. Clinical Relevance  The union rates were 90.5% overall, 100% for primary surgeries, and 77.8% for revision surgeries. Five patients (24%) experienced 11 complications, including four cases (19%) of heterotrophic ossification. Use of BMP in scaphoid nonunion surgery resulted in a 90.5% overall union rate but was also associated with complications such as heterotopic ossification. All included studies used BMP to augment bone graft, screw or wire fixation, or a combination of methods. The efficacy of BMP in scaphoid nonunion is unclear, and a sufficiently powered, randomized controlled trial is needed to determine optimal fixation methods, dosing, and morbidity of the use of BMP. Level of Evidence  This is a Level IC, therapeutic interventional study.

[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.

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.

Osteochondral Autograft Transplantation for Hand and Wrist Articular Problems

Management of hand and wrist avascular necrosis with osteochondral fragmentation or focal arthritis can be a challenging problem with a variety procedures described for its treatment. Osteochondral autograft transplantation systems have been utilized in various focal defects of the knee, ankle, elbow, and wrist. The same principle for the treatment of focal defects of the proximal scaphoid, proximal capitate as well as metacarpal head as an alternative treatment is described. The main indication for this treatment is to address focal or partial osteochondral defects where the size of the defect is smaller than the isthmus of the involved bone to accommodate a cylindrical osteochondral graft that can be press fit. Larger and complete defects are contraindications to this treatment. We discuss the surgical technique as well as its main indications and expected outcomes.

Scapholunate Ligament Injury and the Effect of Scaphoid Lengthening

Objective  We hypothesized that lengthening the scaphoid in a model of scapholunate ligament injury (SLI) will result in correction of radiographic markers of dorsal intercalated segment instability (DISI) deformity. Materials and Methods  An SLI with DISI deformity was created by sectioning the SL ligament, the palmar radiocarpal ligaments, and scapho-trapezio-trapezoid ligaments of a cadaveric upper extremity ( n  = 5). The wrist was radiographed in both anteroposterior and lateral planes to confirm creation of SLI and DISI. The scaphoid was then osteotomized at its waist. A series of grafts (1-8 mm) were then placed at the osteotomy site. Radiographs were completed at each length. The main outcome measures were scapholunate interval (SL, mm), scapholunate angle (SLA, degrees), and radiolunate angle (RLA, degrees). These values, measured following the insertion of varying graft lengths, were compared with baseline measurements taken "post-injury" status. Results  The ability to create an SLI with DISI was confirmed in the postinjury group with a statistically significant change in RLA, SLA, and SL compared with preinjury. With osteotomy and progressive insertion of spacers, the values improved into the accepted normal ranges for RLA (6 mm) and SLA (4 mm) with scaphoid lengthening. Conclusions  In this cadaveric model of SL injury, radiographic markers of DISI were returned to within normal ranges with scaphoid osteotomy and lengthening. Clinical Relevance  The results of this study add insight into wrist kinematics in our injury model and may represent a potential future direction for surgical treatment of SLI.

Clinical and radiological results of the vascularized medial femoral condyle graft for scaphoid non-union

INTRODUCTION

This study evaluated the use of a free vascularized bone graft with and without cartilage from the medial femoral condyle (MFC) in patients with recalcitrant scaphoid non-union, with a special focus on union rates and the osteochondral graft for proximal pole destruction.

MATERIALS AND METHODS

Thirty-eight avascular scaphoid non-unions in 37 patients who were treated with a free osteoperiosteal or osteochondral MFC graft were retrospectively evaluated (mean follow-up 16 months). Bone union, the scapholunate and the radiolunate angles were evaluated on X-ray images. The range of motion, grip strength, VAS, DASH and PRWE scores were evaluated clinically.

RESULTS

The overall union rate was 95%. Bone union was achieved in 27 out of 29 (93%) scaphoids treated with a free osteoperiosteal MFC grafts and in 9 out of 9 (100%) scaphoids treated with a free osteochondral MFC graft. The range of motion remained almost unchanged, while grip strength increased significantly (34 kg vs. 44 kg) and the VAS (22-5), DASH (59-19) and PRWE (62-30) score decreased significantly. The scapholunate (71°-65°) and radiolunate (28°-18°) angle decreased. No major donor site morbidity was observed. Postoperative complications were observed in eight cases (21%).

CONCLUSIONS

The vascularized medial femoral bone graft leads to a good functional outcome in the treatment of scaphoid non-unions. The graft provides adequate blood supply and structural stability to the scaphoid. A proximal pole destruction can be replaced using an osteochondral graft with promising short-term results preventing carpal osteoarthritis and collapse.

Vascularized Osteochondral Grafts: Histologic Evaluation of Chondrocyte Viability with Viable Hyaline Nonfibrous Cartilage

Vascularized osteochondral flaps are used for challenging arthroplasties of the upper extremity. Little has been described regarding the biological outcomes of these flaps, specifically regarding the structure of the cartilage. The authors present a case of a 31-year-old patient undergoing medial femoral trochlea flap for proximal scaphoid arthroplasty in the setting of proximal pole avascular necrosis. The patient sustained a fracture that was treated by a headless compression screw and demonstrated provisional radiographic healing, but at late follow-up he had new fragmentation of the proximal pole. The medial femoral trochlea flap that comprised the proximal pole of the reconstructed scaphoid was found to have viable chondrocytes and regularly oriented hyaline cartilage on pathologic analysis 1 year postoperatively. The patient initially had relief of wrist pain and return to work but ultimately developed intractable pain requiring scaphoidectomy and midcarpal arthrodesis. Despite the failure of the procedure, the presence of histologically normal cartilage and viable chondrocytes in a vascularized osteochondral flap offers encouragement that this technique may provide a durable long-term solution for articular reconstruction.

[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.

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 Medial Femoral Condyle Corticoperiosteal Free Flap for Frontal Sinus Reconstruction

Although the medial femoral condyle has been used for reconstruction in various areas of the body, to the authors' knowledge it has not been used for frontal sinus reconstruction. The authors describe a novel approach to a complex patient using the medial femoral condyle cortiocoperiosteal free flap to reconstruct an anterior frontal sinus defect in conjunction with a recalcitrant mucocele.

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.

Management of Scaphoid Fractures

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Understand the epidemiology, classification, and anatomy pertinent to the scaphoid. 2. Appropriately evaluate a patient with suspected scaphoid fracture, including appropriate imaging. 3. Understand the indications for operative treatment of scaphoid fractures, and be familiar with the various surgical approaches. 4. Describe the treatment options for scaphoid nonunion and avascular necrosis of the proximal pole.

SUMMARY

The goal of this continuing medical education module is to present the preoperative assessment and the formation and execution of a surgical treatment plan for acute fractures of the scaphoid. In addition, secondary surgical options for treatment of scaphoid nonunion and avascular necrosis are discussed.

Scaphoid Nonunion With Poor Prognostic Factors: The Role of the Free Medial Femoral Condyle Vascularized Bone Graft

Background: To report on the results of free medial femoral condyle (MFC) vascularized bone graft for scaphoid nonunions with 1 or more poor prognostic factors. Methods: We have used the free MFC vascularized bone graft for scaphoid nonunions that have 1 or more factors associated with a poor prognosis. These were, a delay in presentation of over 5 years, a proximal pole nonunion, the presence of avascular necrosis (AVN), or previous nonunion surgery. We used this technique on 20 patients over a 4.5-year period. Results: Our overall union rate was 88.5% (17 of 19 patients), with 1 patient failing to attend for follow-up. Our mean union time was 7 months (2-18). All patients had at least 1 poor prognostic factor and over half had 2 or more. Of those with AVN with or without other factors, the union rate was 85% (11 of 13). There were 2 donor site complications that required a further procedure and 2 patients with residual wrist pain that required a scapho-trapezio-trapezoid joint fusion and a radial styloidectomy, respectively. Both nonunions were offered further surgery, and 1 elected to undergo successful revision surgery. Conclusions: Overall, this technique showed good results, in a subgroup of patients that typically have poorer outcomes, with a low incidence of donor site morbidity. Our union rate compares favorably with other techniques for this difficult subset of patients with 1 or more poor prognostic factors, although results are clearly not as good as those of studies using the MFC graft for all scaphoid nonunions. We continue to reserve this technique for nonunions with 1 or more poor prognostic factors, and we believe that this technique should at least be considered in these patients.

Vascularized Medial Femoral Condyle Bone Graft for Resistant Nonunion of the Distal Radius

Background: Nonunion involving the metaphyseal region of the distal radius is exceedingly rare, usually involving co-morbidity. Patients that have failed multiple prior conventional surgical interventions represent an even more difficult subset to treat; this investigation examined the utility of a specially designed free vascularized medial femoral condyle flap consisting of a central structural block graft with an extended corticoperiosteal sleeve to wrap around the junctions.

Methods: Six patients (5 males, 1 female) with a mean age of 52 years had failed to achieve union involving the distal radius metaphysis after a mean of 3.7 prior surgeries occurring over a mean period of 24 months. Comorbidities included smoking, alcoholism, chronic nutritional deficiency, and prior osteomyelitis. The unique descending genicular artery medial femoral condyle flap designed to address these patients consisted of a central structural block graft in continuity with an extended corticoperiosteal sleeve. The structural block filled the bone defect, and the corticoperiosteal sleeve wrapped around the bone junctions and the neighboring bone margins. The mean flap size was 5.3 (+/- 1.3) cm long by 4.5 (+/- 0.9) cm wide. Pre-operative to post-operative DASH scores were compared using the paired student’ s t-test, with p < 0.05.

Results: All flaps achieved union at a mean of 6.8 (+/- 2.1) weeks following surgery, using the criteria of bridging trabeculae on all 3 radiographs: coronal, sagittal, and oblique. The mean pre-operative DASH score of 63 (+/- 10) was statistically significantly different compared to the mean post-operative DASH score of 18 (+/- 8).

Conclusions: With few alternative solutions able to address this unique and difficult problem, the structural block of vascularized bone with the extended corticoperiosteal sleeve proved able to achieve a union that had failed multiple previous attempts and able to resist reactivation of infection, in a challenging group of patients with comorbidities.

Free Vascularized Medial Femoral Condyle Structural Flaps for Septic Terminal Digital Bone Loss

A unique clinical problem exists when the majority of distal bone stock in a digit is destroyed by osteomyelitis, leaving a residual soft tissue envelope with tenuous, random perfusion surrounding a nidus of scar tissue. Pulp pinch is lost in the absence of bony support, and limited options exist. Apart from toe transfer or revision amputation with shortening, non-vascularized bone grafting inside the residual soft tissue envelope risks graft resorption and reactivation of infection. The purpose of this investigation was to evaluate the clinical outcomes of free vascularized medial femoral condyle structural bone flaps to restore lost pulp pinch in such cases. Nine patients (8 males, 1 female) with a mean age of 43 years sustained extensive terminal bone loss near digital tips following osteomyelitis. The mean length of bone defect was 28 mm (± 8.4). The patients were reconstructed at a mean of 12 weeks from initial trauma/infection, having undergone a mean of two prior surgeries. A structural block of vascularized bone from the medial femoral condyle replaced the missing bone at the digital tip defect, temporarily fixed with K-wires. The bone flap was encased by the residual soft tissue envelope after removing scar tissue from the prior trauma and infection. All bone flaps incorporated fully, restoring pulp pinch function to the respective digits with a mean time to union of 8.6 (± 2.1) weeks; range 6-11 weeks. With few alternative solutions able to address this unique and difficult problem, the structural block of vascularized bone proved able to resist resorption, nonunion, and reactivation of infection; the problems normally encountered under this scenario.