[Possible applications of pedicled vascularized bone transplants of the distal radius]

Medial femoral condyle free flap for carpo-metacarpal instability following hamate comminute fracture

Complete reconstruction of the hamate bone has been reported in the literature mostly following cancer excision or avascular necrosis. For the exiguity of the tissue deficit, bone grafting has usually been used as treatment option for its rapidity and easiness to perform, even if a variable amount of bone resorption may occur. In traumatic cases, microbial contamination may jeopardize the success of a well performed bone graft and vascularised bone grafts may represent a better reconstructive option. Here we describe the first case reported in the literature of a patient underwent complete hamate reconstruction following trauma with an osseous medial femoral condyle free flap as vascularized arthrodesis between the capitate and the 4th MTC base, in order to stabilize the 4th and 5th finger and the ulnar carpo-metacarpal joint.

Platelet-rich plasma and stromal vascular fraction cells for the engineering of axially vascularized osteogenic grafts

Avascular necrosis of bone (AVN) leads to sclerosis and collapse of bone and joints. We have previously shown that axially vascularized osteogenic constructs, engineered by combining human stromal vascular fraction (SVF) cells and a ceramic scaffold, can revitalize necrotic bone of clinically relevant size in a rat model of AVN. For a clinical translation, the fetal bovine serum (FBS) used to generate such grafts should be substituted by a nonxenogeneic culture supplement. Human thrombin-activated platelet-rich plasma (tPRP) was evaluated in this context. SVF cells were cultured inside porous hydroxyapatite scaffolds with a perfusion-based bioreactor system for 5 days. The culture medium was supplemented with either 10% FBS or 10% tPRP. The resulting constructs were inserted into devitalized bovine bone cylinders to mimic the treatment of a necrotic bone. A ligated vascular bundle was inserted into the constructs upon subcutaneous implantation in the groin of nude rats. After 1 and 8 weeks, constructs were harvested, and vascularization, host cell recruitment, and bone formation were analyzed. After 1 week in vivo, constructs were densely vascularized, with no difference between tPRP- and FBS-based ones. After 8 weeks, bone formation and vascularization was found in both tPRP- and FBS-precultured constructs. However, the amount of bone and the vessel density were respectively 2.2- and 1.8-fold higher in the tPRP group. Interestingly, the density of M2, proregenerative macrophages was also significantly higher (6.9-fold) following graft preparation with tPRP than with FBS. Our findings indicate that tPRP is a suitable substitute for FBS to generate vascularized, osteogenic grafts from SVF cells and could thus be implemented in protocols for clinical translation of this strategy towards the treatment of bone loss and AVN.

Comparative meta-analysis on the various vascularized bone flaps used for the treatment of scaphoid nonunion

We did a meta-analysis of the literature in order to clarify which of the vascularized bone flaps (VBF) used for scaphoid non-union treatment has the best outcome with regard to various parameters. We analyzed 54 articles that present nine different types of VBF. The analysis concerned demographical patient information, radiographic parameters, fracture classification, including the presence or non-presence of avascular necrosis of the scaphoid proximal pole (PP AVN), parameters that have to do with the surgery itself and the postoperative protocol, the healing of the nonunion and functional scores. The meta-analysis showed best healing potential for the femoral graft despite the complexity of the operation. On the other hand, the most commonly used 1,2-ICSRA flap makes the procedure more reproducible but showed worse results. The femoral flap was also among the most successful flaps when used for patients with PP AVN. The consolidation rate, in general, was not affected by the time elapsed between the fracture and the operation but by smoking and the presence of PP AVN. The meta-analysis could not reach many significant statistical conclusions because of either the small number of patients in some flap groups or the heterogeneity and lack of documentation in most of the articles. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1076-1085, 2017.

Kienböck Disease: Recent Advances in the Basic Science, Assessment and Treatment

Kienböck disease is a disorder of impaired lunate vascularity which ultimately has the potential to lead to marked degeneration of the wrist and impaired wrist function. The aetiology of the avascular necrosis is uncertain, but theories relate to ulnar variance, variability in lunate vascularity and intraosseous pressures. Clinical symptoms can be subtle and variable, requiring a high index of suspicion for the diagnosis. The Lichtmann classification has historically been used to guide management. We present a review of Kienböck disease, with a focus on the recent advances in assessment and treatment. Based on our understanding thus far of the pathoanatomy of Kienböck's disease, we are proposing a pathological staging system founded on the vascularity, osseous and chondral health of the lunate. We also propose an articular-based approach to treatment, with an arthroscopic grading system to guide management.

Surgical Revascularization-An Innovative Approach to the Treatment of Talar Osteonecrosis Dissecans Stages II and III

Talar osteonecrosis dissecans is caused by osseous malperfusion, leading to destruction of the talar bone. The current reference standard for advanced stages lacking arthrosis is core decompression, followed by autologous cancellous bone grafting. However, talar revascularization has not been observed in a subset of patients after this procedure. Microsurgical vascularized bone grafting can improve outcomes by the induction of angiogenesis. We present the 1-year follow-up data from 3 patients with talar osteonecrosis dissecans, who had undergone free vascularized medial femoral condyle autotransplantation. The patients were evaluated preoperatively and 3, 6, and 12 months postoperatively. The active range of motion, pain (visual analog scale [VAS]), and American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, and lower extremity functional scale were used. Osteonecrosis dissecans stage II was seen in patient 1 (aged 27 years) and stage III in patients 2 (aged 18 years) and 3 (aged 41 years). Preoperative pain of the ankle was recorded as VAS score of 3 by patients 1 and 2 and VAS score of 6 by patient 3. At 12 months postoperatively, patients 1 and 2 recorded a VAS score of 2 and patient 3, a VAS score of 0. All patients showed improvement in the lower extremity functional scale and American Orthopaedic Foot and Ankle Society scale scores. After 6 and 12 months, magnetic resonance imaging showed a well-vascularized femoral condyle incorporated into the talus in all the patients. Autotransplantation of vascularized bone grafts from the medial femoral condyle is a promising technique for surgical revascularization of talar osteonecrosis dissecans stage II and III.

Treatment of scaphoid non-unions of the proximal third with conventional bone grafting and mini-Herbert screws: an analysis of clinical and radiological results

This study assessed the clinical and radiological outcomes after treatment of scaphoid non-union of the proximal third by non-vascularised bone grafts and stabilisation by Mini-Herbert Screws from a dorsal approach. Thirty-one patients, one woman and 30 men, were reviewed retrospectively at a mean of 42 (12-77) months. All patients received pre- and postoperative CT scans to assess bone union. In addition to demographic data, the range of motion, grip strength, DASH score, Krimmer score, Mayo wrist score and radiological parameters (carpal height, scapholunate and radiolunate angles) were recorded. Bone union was achieved in 21 patients. The average DASH score in patients with bone union was 12 and that in patients with persistent non-union it was 30. No progression into carpal collapse or increase of scapholunate angles was detected. Our study demonstrates that acceptable union rates can be achieved with non-vascularised bone grafts, and this technique compares favourably with other reports in the literature.

Vascularised bone graft for the treatment of non-union of the scaphoid

A 4/5 compartment pedicled vascularised bone graft from the distal radius combined with internal fixation with a Herbert type cannulated screw was used to treat non-union fractures of the proximal pole of the scaphoid in 13 patients. Non-union was identified on plain radiographs alone. Uneventful clinical and radiological healing was achieved in 11 patients. One patient had progressive signs of failure of the fixation of the screw at the proximal pole; the screw was changed and the fracture was stable at reoperation. One patient had a fall postoperatively, radiographs taken at follow-ups showed only partial healing, and he had a bone graft 12 months later. Twelve patients had clinical and radiological union of the fracture, and one patient fibrous healing alone. The technique may improve healing of non-union of fractures of the proximal pole of the scaphoid, but it is still a technical challenge.

[The reconstruction of scaphoid pseudoarthroses with the operation of Matti-Russe. A retrospective follow-up analysis of 84 patients]

BACKGROUND

In a retrospective study 84 patients were examined who were treated with a Matti-Russe procedure between 1985 and 1997 due to scaphoid non-union. The purpose of this study was to evaluate the long term results after scaphoid reconstruction and to get impressions about subjective feeling of the patients.

PATIENTS AND METHODS

79 patients were male, 5 were female. The average follow-up period was 88 months. Measured parameters were: grip strength and range of motion, pain was evaluated with a visual analog scale (VAS) from 0 to 100. The functional and subjective outcome was evaluated with the DASH-questionnaire.

RESULTS

A bony consolidation could be verified in 82% of the patients. The mean postoperative pain score was 3 (non-stress) and 33 (stress) in patients with scaphoid union. The DASH-score reached 15. Active range of motion and grip strength were 82% and 92% compared to the contralateral side. 81% of the patients have been working in strenuous jobs.

CONCLUSION

The results show the reliability of the Matti-Russe procedure in non-union of fractures of the scaphoid. Alternative treatment options have no advantages in bony union.