The use of osteochondral flaps in the treatment of carpal disorders

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.

Metacarpophalangeal Joint Reconstruction of a Complex Hand Injury with a Vascularized Lateral Femoral Condyle Flap Using an Individualized 3D Printed Model-A Case Report

This case report describes the surgical management of a patient with a complex hand trauma. This injury included tendon, vascular, and nerve injuries, a partial amputation of the index finger, fractures of the third proximal phalanx, and destruction of the metacarpophalangeal joint of the fifth finger. Firstly, the acute treatment of a complex hand injury is described. Secondly, the planning and execution of a joint reconstruction using a vascularized lateral femoral condylar flap, assisted by an individual 3D model, is illustrated. Precise reconstruction of the affected structures resulted in good revascularization as well as an anatomical bone consolidation. Intensive physical therapy, including autonomous proprioceptive range-of-motion exercises by the patient, resulted in significant functional improvement of the hand in daily life. Overall, we report on the successful reconstruction of a metacarpophalangeal joint by using a vascularized flap from the lateral femoral condyle. Furthermore, this case report highlights the efficacy of integrating individualized 3D printing technology to plan complex reconstructions, opening up promising opportunities for personalized and optimized interventions.

Vascularized Bone Grafts from the Lateral Femoral Condyle for the Treatment of Avascular Lunate Necrosis (Kienböck's)

Background

Avascular necrosis of the lunate (Kienböck's disease) is rare and one of the main causes of progressive painful arthritis, requiring surgical intervention. Various approaches have shown benefits in treating Kienbock's disease but with limitations. The article aims to analyze the functional outcome using lateral femoral condyle free vascularized bone grafts (VBGs) as the first choice of treatment for Kienböck`s.

Materials and methods

This was a retrospective analysis of 31 patients with Kienbock's who had microsurgical revascularization or reconstruction of the lunate between 2016 and 2021 using either corticocancellous or osteochondral VBGs from the lateral femoral condyle. The characteristics of lunate necrosis, choice of VBG and postoperative functional outcome were reviewed.

Results

Corticocancellous VBGs were used in 20 patients (64.5%), while osteochondral VBGs in 11 patients (35.4%). The lunate was reconstructed in 11 patients, revascularized in 19 patients, and one patient received augmentation of a luno-capitate arthrodesis with a corticocancellous graft. We noted postoperative irritation of the median nerve (n = 3) and screw loosening requiring removal (n = 1) as minor complications. All patients had complete graft healing at eight-month follow-up and acceptable functional outcomes.

Conclusions

Free VBG from the lateral femoral condyle represent a reliable method of lunate revascularisation or reconstruction in advanced Kienböck's. Their main advantages are the constant vascular anatomy, straightforward graft harvesting technique and possibility to harvest several graft types according to the requirements at the donor site. Postoperatively, the patients become pain-free and have an acceptable functional outcome.

Magnetic Resonance Imaging to Investigate the Clinical Applicability of the Medial Femoral Trochlea Osteochondral Flap Within the Wrist

BACKGROUND

The medial femoral trochlea (MFT) osteochondral flap is employed for reconstruction of unsalvageable scaphoid proximal pole nonunions. The convex surface of the cartilage-bearing proximal trochlea is used to replace the similarly contoured proximal scaphoid and articulate with the concave scaphoid fossa of the radius. A magnetic resonance imaging (MRI) comparison of the shape of the MFT as it relates to the native proximal scaphoid has not been previously performed. Our study aimed to quantifiably compare the shape of the MFT, proximal scaphoid, and scaphoid fossa.

METHODS

Using imaging processing software, we measured radius of curvature of the articular segments in MRI scans of 10 healthy subjects' wrists and knees.

RESULTS

Compared with the scaphoid fossa, average ratio of the radius of circumference of the proximal scaphoid was 0.79 and 0.78 in the coronal and sagittal planes, respectively. Compared with the scaphoid fossa, average ratio of the radius of circumference of the MFT was 0.98 and 1.31 in the coronal and sagittal planes, respectively. The radius of curvature of the MFT was larger than the proximal scaphoid, in the coronal and sagittal planes. In the coronal plane, the MFT radius of curvature is nearly identical to the scaphoid fossa, a closer match than the scaphoid itself. In the sagittal plane, the radius of curvature of the MFT was larger than the radius of curvature of the scaphoid fossa.

CONCLUSIONS

Our data suggest that the radius of curvature, in the sagittal and coronal planes, of the MFT and proximal scaphoid is disparate.

Vascularized Bone Graft Reconstruction for Upper Extremity Defects: A Review

Upper extremity reconstruction may pose clinical challenges for surgeons due to the often-critical, complex functional demands of the damaged and/or missing structures. The advent of vascularized bone grafts (VBGs) has aided in reconstruction of upper extremity (UE) defects due to their superior regenerative properties compared with nonvascularized bone grafts, ability to reconstruct large bony defects, and multiple donor site options. VBGs may be pedicled or free transfers and have the potential for composite tissue transfers when bone and soft tissue are needed. This article provides a comprehensive up-to-date review of VBGs, the commonly reported donor sites, and their indications for the treatment of specific UE defects.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

The condylar capping for microvascular temporomandibular joint reconstruction: A preliminary study

BACKGROUND

Defects of the temporomandibular joint (TMJ) are often difficult to be reconstructed in the correct dimensions and function. This preliminary study aims to describe a novel technique of condylar reconstruction with a microvascular flap in case of deforming arthrosis of the TMJ: condylar capping.

PATIENTS AND METHODS

Four patients between 22 and 62 years old-three females and one male-with severe unilateral arthrosis of the TMJ underwent condylar capping. All patients had already had a failed conservative treatment, followed by arthroscopy with lysis and lavage and later open surgery with total or subtotal diskectomy combined with a condylar arthroplasty. Nevertheless, their pain was still at level six or more on a visual analogue scale. Moreover, they could eat only soft food. At this stage, they underwent condylar capping using an osteochondral lateral femoral condyle (LFC) flap. The surgical technique and the postoperative management are described in detail. Crucially the attachment of the lateral pterygoid muscle to the condylar neck was preserved in all cases. The patients were followed up clinically and by CT scan preoperatively, 6, and 12 months postoperatively.

RESULTS

The mean height of the reconstructed neo-condyle was 6.0 mm, the mean width 16.2 mm, and the mean sagittal length 9.8 mm. The follow-up period ranged from 14 to 64 months. The procedures were uneventful for all patients, and the donor site morbidity was negligible. Twelve months later, the patients were all pain-free and able to have a regular diet. The TMJ and the knee had a normal range of movement and power. Postoperative imaging demonstrated bone healing and stable and anatomically correct condyle reconstruction.

CONCLUSIONS

Based on the author's experience, the condylar capping with the LFC appears promising for reconstructing the condylar head in cases of severe osteoarthritis. Preserving the attachment of the lateral pterygoid muscle allows a complete restoration of the physiologic range of movement, including protrusion and laterotrusion of the mandible.

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 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.

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

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

Dorsal capsular-based vascularized distal radius graft for proximal pole scaphoid nonunion with avascular necrosis

BACKGROUND

Scaphoid nonunion involving the proximal pole with the presence of avascular necrosis is difficult to reconstruct. We aimed to determine the efficacy of surgical treatment of proximal pole scaphoid nonunion with avascular necrosis using a dorsal capsular-based vascularized distal radius graft.

METHODS

Between 2000 and 2018, 64 patients with established proximal pole scaphoid nonunion with avascular necrosis were treated using a dorsal capsular-based vascularized distal radius graft. This graft was harvested from the dorsal aspect of the distal radius with its dorsal wrist capsule attachment. Fixation of the scaphoid nonunion was performed with a small cannulated screw, followed by insertion of the vascularized graft into the dorsal trough at the scaphoid nonunion site. In the last 47 patients of this series, a micro suture anchor was placed into the scaphoid to augment graft fixation.

RESULTS

Union rate was 86% (55 of 64 scaphoid nonunions with avascular necrosis) at a mean time of 12 weeks. Persistent non-union was noted in eight patients and fibrous union in one patient. No patients developed donor site morbidity. No graft dislodgment was noted. There was significant improvement of the wrist functional outcomes at the final follow up.

CONCLUSIONS

The dorsal capsular-based vascularized distal radius graft is a safe and effective treatment in patients with scaphoid nonunion with avascular necrosis of the proximal pole. This pedicle vascularized bone graft is derived from a location that can easily reach the proximal third of the scaphoid avoiding microsurgical dissection or anastomosis.

Volar rerouting of the 1,2 intercompartmental supraretinacular artery vascularized bone graft for middle and distal scaphoid nonunions

BACKGROUND

The bone graft vascularized by the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) placed on the scaphoid by a dorsal approach is a technique used to treat scaphoid nonunions with avascular necrosis of the proximal pole and without significant bone loss or carpus collapse. We present the results of patients treated with a volar rerouting of the 1,2 ICSRA graft under the tendons of the first extensor compartment to treat more distal scaphoid nonunions than the proximal pole. The aim of this study was to assess the clinical and radiological outcomes of patients operated with this technique with the hypothesis that it would allow to treat more distal nonunions than those of the proximal pole.

PATIENTS AND METHODS

This retrospective study involved patients treated by a volar rerouting of the 1,2 ICSRA graft for nonunions of the middle and distal thirds of the scaphoid. Assessments included clinical outcomes and radiological bone consolidation. QuickDASH and Mayo Wrist scores were computed. Range of motion and grip strength were evaluated for both the operated and the contralateral sides.

RESULTS

Nineteen patients were followed-up for 33 months (range: 6-75). Mean postoperative QuickDASH score was 10 (range: 0-45), and mean Mayo wrist score was 85 (range: 50-100). Flexion and extension, ulnar and radial deviations were statistically different between the affected and healthy sides (p<0,05). Consolidation was achieved in 17 patients (89%).

DISCUSSION

This technical modification allowed good functional outcomes and scaphoid consolidation. It expands the classic indications of the vascularized 1,2 ICSRA bone graft to more distal nonunions than the proximal pole.

LEVEL OF EVIDENCE

IV.

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.

Compound or Specially Designed Flaps in the Lower Extremities

Novel and combined tissue transfers from the lower extremity provide new tools to combat soft tissue defects of the hand, foot, and ankle, or fracture nonunion. Flaps can be designed for special purposes, such as providing a gliding bed for a grafted or repaired tendon or for thumb or finger reconstruction. Propeller flaps can cover soft tissue defects of the leg and foot. In repairing severe bone and soft tissue defects of the lower extremity, combined approaches, including external fixators, one-stage vascularized bone grafting, and skin or muscle flap coverage of the traumatized leg and foot, have become popular.

Vascularized Small-Bone Transfers for Fracture Nonunion and Bony Defects

Vascularized small-bone grafting is an efficient and often necessary surgical approach for nonunion or necrosis of several bones in particular sites of the body, including scaphoid, lunate, distal ulna, and clavicle. The medial femoral condyle is an excellent graft source that can be used in treating scaphoid, ulna, clavicle, or lower-extremity bone defects, including nonunion. Vascularized bone grafting to the small bones, particularly involving reconstruction of damaged cartilage surfaces, should enhance subchondral vascular supply and help prevent cartilage regeneration. Vascularized osteoperiosteal and corticoperiosteal flaps are useful for treating nonunion of long bones.

Major Changes in Lymphatic Microsurgery and Microvascular Surgery in Past 20 Years

This article summarizes the major changes seen in lymphatic microsurgery and microvascular surgery in first 20 years of the 21st century. Lymphatic microsurgery is discussed first, as more advances have been seen in imaging of the lymphatic system, lymphatico-venous anastomosis, and vascularized lymph node transfers. During the past 2 decades, there have been more patient population changes than major technical evolutions in microvascular surgery, although new techniques and modifications emerged and became clinical routines, with the landscape of microvascular surgery evolving in this time period.

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.

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.

Treatment for proximal pole scaphoid nonunion with capsular-based vascularized distal radius graft

PURPOSE

We retrospectively reviewed the results of 89 patients with proximal pole scaphoid nonunion, 58 with avascular necrosis, treated with a capsular-based vascularized distal radius graft.

METHODS

Seventy-one male and eighteen female patients with symptomatic nonunion at the proximal pole of the scaphoid were included in this study. No patient had a humpback deformity. In all patients, the vascularized bone graft was harvested from the dorsum of the distal radius and was attached to a capsular flap of the dorsal wrist capsule. After fixation of the scaphoid with a small cannulated screw, the graft was inserted press-fit into the scaphoid trough in the nonunion site. Supplementary fixation of the graft with a microsuture anchor into the scaphoid was used in 66 patients.

RESULTS

At a mean time of 12.3 weeks (range 6-24) after surgery, solid union was achieved in 76 of 89 patients (49 of 58 with avascular necrosis). Eleven patients had persistent nonunion and two fibrous union as determined by CT scan. Sixty-six of the patients with solid bone union were completely pain free, and ten complained of slight pain with strenuous activities. No donor site morbidity was observed.

CONCLUSIONS

The capsular-based vascularized bone graft from the distal radius is a reliable alternative technique for scaphoid nonunions. It is a simple and expedient harvesting technique without the need for a microsurgical anastomoses. The supplemental fixation with a microsuture anchor eliminates the risk of graft displacement.