Vascularized bone grafts for upper limb reconstruction: defects at the distal radius, wrist, and hand

Functional Outcomes of Centralization of the Ulna as a Method of Reconstruction Following Resection of Campanacci Grade 3 Giant Cell Tumor of the Distal Radius

PURPOSE

Wrist reconstruction after distal radial tumor resection poses a challenge to the orthopedic oncologist. We evaluated the functional outcomes of centralization of the ulna with ulnocarpal arthrodesis as a method of reconstruction following resection of distal radius tumors, using impairment measures and patient-reported outcomes.

METHODS

Evaluation of functional outcome was performed using the Musculoskeletal Tumor Society 93 scoring system and Disabilities of the Arm, Shoulder, and Hand questionnaire. We also determined hand grip strength on the affected side, time to radiologic union at the ulnocarpal junction and reduction in wrist circumference. Local complications and oncologic outcomes were recorded.

RESULTS

The study included 26 patients with Campanacci grade 3 giant cell tumor of the distal radius. Mean follow-up period in the study was 32.8 ± 12 months. Mean resection length was 10.3 ± 2.5 cm. Radiologic union at the ulnocarpal junction was achieved in 38.5%, 77% and 96% of the patients by 4, 5, and 6 months respectively. Mean hand grip strength was 74 ± 3.9% of the contralateral side whereas mean reduction in wrist circumference was 16.9 ± 6.4%. A good functional outcome with a mean the Musculoskeletal Tumor Society 93 score of 26 ± 1.4 and mean Disabilities of the Arm, Shoulder, and Hand score of 10.5 ± 6.3 was observed. Fracture of the ulna, hardware loosening, and reflex sympathetic dystrophy were each noted in 1 patient, with an overall complication rate of 10.7% (3/28). No patient had nonunion, infection, or local recurrence.

CONCLUSIONS

This is a simple and effective modality of reconstruction after resection of distal radial tumors. It provides good functional outcome and preservation of good hand grip strength, with low complication rates.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Non-vascularised corticocancellous (tricortical) iliac bone graft longer than 3 cm for non-union after failed surgical treatment

PURPOSE

We hypothesised that traditional iliac tricortical bone grafts (no vascularised) still have a reasonable role in promoting satisfactory bony healing in non-union defects of certain sizes. Here, we report the clinical/radiological outcomes through a retrospective case series.

METHODS

We screened 74 patients with definitive non-union in the long bones of the upper extremities who visited the outpatient department from 2008 to 2018. Among these patients, 25 who met our inclusion/exclusion criteria were investigated.

RESULTS

The mean age was 51.92 years, and there were 12, 9, 1, and 3 lesions of the radius, ulna, clavicle, and humerus, respectively. The tools for primary fixations were plate and intramedullary nails in 24 and 1 patients, respectively. Six patients presented with atrophic non-union. The mean period from a previous surgery was 6.84 months. The mean defective bone sizes were 1.81 and 3.50 cm pre-debridement and post-debridement, respectively. All devices had locking plates longer than the previous plate, and the graft was concurrently fixed by screws in three patients. At a mean of 15.92 weeks after the revision surgery, all patients experienced union. At the final follow-up, the clinical outcomes were satisfactory. No significant differences in clinical outcomes were found according to the lesion, type of non-union, period from the previous surgery, or harvest length of the iliac bone.

CONCLUSIONS

If the proper indications and some technical aspects are considered, a non-vascularised iliac bone graft longer than 3 cm could still be a reasonable option for treating diaphyseal non-union of the upper extremities.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Blood Vessel Injuries of the Fingers: A Clinical Comparison of One- and Two-Arterial Blood Supply

Traumatic finger injuries are very common in emergency medicine. When patients present with finger injuries, there is often damage to the vascular nerve bundles, which requires subsequent reconstruction. It is unknown if repairing a unilaterally injured artery affects patients' recovery in a well-perfused finger. This retrospective cohort study compares the clinical outcomes of 11 patients with one-vessel supply (mean age 48.3 years; 7 males, 4 females) to 14 patients with two-vessel supply (mean age 44.5 years; 8 males, 6 females). The patient outcomes were assessed using patient questionnaires (Disabilities of Arm, Shoulder, and Hand (DASH), European Quality of Life 5 Dimensions 5 Level Version (EQ-5D-5L), and EuroQol visual analog scale (EQ-VAS)) and a clinical examination of hand function and imaging of circulatory efficiency. No significant changes were observed in the DASH, EQ-5D-5L, and EQ-VAS questionnaires. Clinical evaluation of hand function, measured by cold sensitivity, two-point discrimination, pain numerical analog scale, and grip strength also revealed no significant differences between cohorts. Blood flow measurements using thermal imaging revealed no effects on circulation in the affected digit. Collectively, the study finds reconstruction is not absolutely necessary when there is one intact digital artery as it is sufficient for healing and functional outcomes. We recommend finger artery reconstruction when both digital arteries are injured or if an immediate tension-free suture is possible.

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.

The Value of Diversity, Equity, and Inclusion: Race and Ethnicity Affecting Patients

Patient race and ethnicity are important factors in health-care inequity, including care for the patient with hand and upper extremity pathologic condition. Physician diversity has been shown to promote better access, improve health-care quality, and improve satisfaction for underserved populations. Concordance, most often defined as a similarity or shared identity between physician and patient, has been shown to have a positive influence on health-care disparities. Although diversity among Hand surgeons is increasing, it is not matching the diversity of the population as a whole. It is imperative that we work to increase and maintain diversity in order to provide the best care for our patients.

The impact of previous surgery on scaphoid nonunion reconstruction: a retrospective study of 95 cases

We retrospectively compared 64 scaphoid reconstructions in cases that had not undergone previous surgery with 31 cases in which previous surgery had been performed. The characteristics of the groups were similar except that there were more smokers in the group without previous surgery and a more frequent use of vascularized bone grafts in the group with previous surgery. At final follow-up, 66 and 65 months, respectively, after reconstruction, union incidence was 89% and 90%. In patients with previous surgery, grip strength was higher but not when expressed in percent of the contralateral hand. There were no differences in pinch strength, active wrist motion, functional scores, carpal height or scapholunate angle. We conclude that repeat surgery to the scaphoid did not seem to be a major risk factor for the overall outcomes, keeping in mind that a vascularized bone graft was more frequently used for secondary reconstructions.Level of evidence: III.

Vascular and Bone Regeneration of the Donor Site After Corticoperiosteal Flap From the Medial Femoral Condyle

Background: The aim of this study was to evaluate the morbidity and regeneration of descending genicular artery and bone on the donor site, the medial condyle of the femur, after harvesting the corticoperiosteal flap and to report the clinical, functional, and radiographic outcomes of the treatment of atrophic nonunions of upper limb with corticoperiosteal vascularized flap at 5-year follow-up. Methods: From January 2011 to January 2018, 36 patients (average age of 45.8 years) were enrolled and evaluated with clinical and radiographic follow-up (average time of 66 months). In 20 patients, magnetic resonance angiography was also performed preoperatively and postoperatively to investigate the fate of the descending genicular artery after harvesting the corticoperiosteal flap. Results: Radiographic evaluation demonstrated a success rate of 94.4% (average time of bone healing of 5.2 months). At the recipient site, clinical evaluation showed excellent results in 75% to 80% of cases, and at the donor site, no statistical differences were found between before and after surgery clinical condition. In all patients who underwent magnetic resonance imaging, images showed a complete recovery of the blood supply of the medial femoral condyle. Conclusions: Medial condyle corticoperiosteal flap represents a valid choice for the treatment of upper limb nonunions. This technique brings a very low morbidity on the donor site, with complete restoration of blood supply and bone tissue. The limit of this flap is its low mechanical support, which suggests performing this technique especially for the treatment of upper limb nonunions.

Metacarpal reconstruction with a medial femoral condyle flap based on a 3D-printed model: a case report

Metacarpal bone reconstruction renders a surgical challenge. We describe a case using 3D printing assisted medial femoral condyle flap for extensive metacarpal reconstruction after wide resection of a large giant cell tumor recurrence. Thus, the length and stability of the entire third ray could be restored without any tumor recurrence. (50 w)

Chronic Recurrent Multifocal Osteomyelitis of the Hand: A Rare Pediatric Condition

Background: Chronic recurrent multifocal osteomyelitis (CRMO) is a rare autoinflammatory condition characterized by bone pain and swelling, secondary to sterile bone osteolytic lesions. Estimated incidence is 1:1 000 000, with ~2% involving the hand. We present a case series of CRMO of the hand and review the available literature, with the aim of educating and raising awareness of this condition. Methods: A retrospective chart review was conducted for all patients presenting to the institution diagnosed with CRMO involving the hands. Subsequently, a literature review was performed. Results/Case Series: Three cases of CRMO of the hand were identified. Age ranged from 20 months to 6 years, with 1 female. Time from presentation to diagnosis ranged from 3 to 15 months. Two had a single lesion, with the remaining patient having a second lesion on full-body magnetic resonance imaging (MRI). Three lesions involved phalanges, and one involved a metacarpal. Two received antibiotics without improvement prior to diagnosis. After diagnosis of CRMO, two received intravenous pamidronate. They both later showed improvement on MRI. Conclusion: CRMO is a rare disease with scarce literature to guide management. We present a series of CRMO specifically of the hand. The cases educate key stakeholders, raise awareness of the diagnosis, and illustrate challenging aspects of managing these patients. This includes the special functional and anatomical consideration essential in managing cases involving the hand.

Vascularized pedicled bone graft from the distal radius supplied by the anterior interosseous artery for treatment of ulnar shaft nonunion: An anatomical study of cadavers and a case report

BACKGROUND

A vascularized distal radius graft can be a reliable solution for the treatment of refractory ulnar nonunion. The aim of this study is to establish the anatomical basis of a vascularized bone graft pedicled by the anterior interosseous artery and report its clinical application, using cadaveric studies and a case report.

METHODS

Fourteen fresh frozen cadaveric upper limbs were used. The branches of the anterior interosseous artery (the 2, 3 intercompartmental supraretinacular artery and the fourth extensor compartment artery) were measured at the bifurcation site. The anatomical relationship between the anterior interosseous artery and motor branches of the posterior interosseous nerve was investigated. An anterior interosseous artery pedicled bone flap was used in a 48-year-old woman with refractory ulnar nonunion.

RESULTS

There were two variations depending on whether the 2,3 intercompartmental supraretinacular artery branched off distally or proximally from the terminal motor branch of the posterior interosseous nerve. The proximal border of the graft was located at an average of 10.5 cm (range, 6.5-12.5 cm) from the distal end of the ulnar head in the distal type (57%) and 17.5 cm (range, 9.5-21.5 cm) in the proximal type (43%). In the clinical application, successfully consolidation was achieved 4 months post-surgery. The patient had not developed any postoperative complications until the 2-year postoperative follow-up.

CONCLUSIONS

The anterior interosseous artery-pedicled, vascularized distal radius bone graft would be a reliable alternative solution for the treatment of an ulnar nonunion located within the distal one-third of the ulna.

Repair of Critical-Sized Long Bone Defects Using Dipyridamole-Augmented 3D-Printed Bioactive Ceramic Scaffolds

There are over two million long bone defects treated in the United States annually, of which ~5% will not heal without significant surgical intervention. While autogenous grafting is the standard of care in simple defects, a customized scaffold for large defects in unlimited quantities is not available. Recently, a three-dimensionally (3D)-printed bioactive ceramic (3DPBC) scaffold has been successfully utilized in the of repair critical-sized (CSD) long bone defects in vivo. In this study, 3DPBC scaffolds were augmented with dipyridamole (DIPY), an adenosine A2A receptor (A_2A R) indirect agonist, because of its known effect to enhance bone formation. CSD full thickness segmental defects (~11 mm × full thickness) defects were created in the radial diaphysis in New Zealand white rabbits (n = 24). A customized 3DPBC scaffold composed of β-tricalcium phosphate was placed into the defect site. Groups included scaffolds that were collagen-coated (COLL), or immersed in 10, 100, or 1,000 μM DIPY solution. Animals were euthanized 8 weeks post-operatively and the radii/ulna-scaffold complex retrieved en bloc, for micro-CT, histological, and mechanical analysis. Bone growth was assessed exclusively within scaffold pores and evaluated by microCT and advanced reconstruction software. Biomechanical properties were evaluated utilizing nanoindentation to assess the newly regenerated bone for elastic modulus (E) and hardness (H). MicroCT reconstructions illustrated bone in-growth throughout the scaffold, with an increase in bone volume dependent on the DIPY dosage. The histological evaluation did not indicate any adverse immune response while revealing progressive remodeling of bone. These customized biologic 3DPBC scaffolds have the potential of repairing and regenerating bone. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2499-2507, 2019.

Wrist arthrodesis with the medial femoral condyle flap: Outcomes of vascularized bone grafting for osteomyelitis

BACKGROUND

Osteomyelitis of the wrist is rare but destructive. Subsequent bone defects often require vascularized bone for successful healing. Recent literature has pointed to the successful use of the medial femoral condylar (MFC) flap for difficult non-unions, yet it has not been specifically described for wrist fusion. We present our experience with this technique for limited and complete wrist arthrodesis.

PATIENTS AND METHODS

We reviewed 4 cases of radiocarpal bone loss from osteomyelitis. All cases utilized debridement of nonviable tissues, and at least 6 weeks of intravenous antibiotics, followed by vascularized bone grafting with a MFC flap. The flap was based on the horizontal periosteal branch of the descending geniculate artery, and utilized to directly bridge the bony defects following resection.

RESULTS

Three patients healed primarily, and 1 patient required secondary cancellous bone grafting to reach union. One patient required revision of the donor site closure. None of the patients had a recurrence of infection or other complications. Average follow up was 8.5 months after reconstruction. Average time to union was 11.5 weeks. Three patients demonstrated full composite fist, and 1 patient had incomplete finger range of motion following several flexor and extensor tendon grafts.

CONCLUSIONS

These cases illustrate the use of the MFC in wrist arthrodesis after osteomyelitis defects. In all cases, there was complete union in a short time, no recurrence of infection, and low donor-site morbidity.

Treatment of posttraumatic bone defects of the forearm with vascularized fibular grafts. Follow up after fourteen years

BACKGROUND

Among several techniques proposed for the reconstruction of posttraumatic bone defects of the forearm, that of free vascularised fibular graft (FVFG) is one of the most widely used.

PATIENTS AND METHOD

We study the long-term outcomes of 14 patients who underwent FVFG between 1994 and 2009, with a minimum follow up of 8 years and a maximum of 23 years (mean: 13.9 years). Demographic, clinical and radiological variables were collected retrospectively. The DASH scale was used for clinical assessment.

RESULTS

Fourteen patients were operated on by the same surgeon, applying FVFG for the reconstruction of posttraumatic bone defects of the forearm (three septic non-union of the ulna or radius, five radius fractures, two ulna fractures and four fractures of both bones). The maximum length of the defect was 11 cm and the minimum length was 6 cm. In four cases, reconstruction of the two bones was achieved using the double barrel technique, and in another four cases, an osteoseptocutaneous flap was used. Fixation was performed with 3.5 mm reconstruction plates in thirteen cases and with 3.5 mm screws in one case. Consolidation was obtained in 12 cases (85.7%) after an average time of 4.2 months (range: 2-6.5 months). In one case, consolidation of the proximal ulnar fracture site was not achieved, and in another, following the failure of reconstruction attempts, an arthrodesis was performed. At the end of the follow-up period, the patients had an average DASH score of 17.1 points (range 1.8-68.1).

CONCLUSIONS

FVFG is a valid option for the reconstruction of posttraumatic bone defects of the forearm. Its use via the double barrel method or as an osteocutaneous composite graft enables the simultaneous reconstruction of both forearm bones and associated soft tissue injuries. Long-term follow-up of patients who have undergone this technique confirms its satisfactory functional and radiological results.

Form and functional repair of long bone using 3D-printed bioactive scaffolds

Injuries to the extremities often require resection of necrotic hard tissue. For large-bone defects, autogenous bone grafting is ideal but, similar to all grafting procedures, is subject to limitations. Synthetic biomaterial-driven engineered healing offers an alternative approach. This work focuses on three-dimensional (3D) printing technology of solid-free form fabrication, more specifically robocasting/direct write. The research hypothesizes that a bioactive calcium-phosphate scaffold may successfully regenerate extensive bony defects in vivo and that newly regenerated bone will demonstrate mechanical properties similar to native bone as healing time elapses. Robocasting technology was used in designing and printing customizable scaffolds, composed of 100% beta tri-calcium phosphate (β-TCP), which were used to repair critical sized long-bone defects. Following full thickness segmental defects (~11 mm × full thickness) in the radial diaphysis in New Zealand white rabbits, a custom 3D-printed, 100% β-TCP, scaffold was implanted or left empty (negative control) and allowed to heal over 8, 12, and 24 weeks. Scaffolds and bone, en bloc, were subjected to micro-CT and histological analysis for quantification of bone, scaffold and soft tissue expressed as a function of volume percentage. Additionally, biomechanical testing at two different regions, (a) bone in the scaffold and (b) in native radial bone (control), was conducted to assess the newly regenerated bone for reduced elastic modulus (E_r ) and hardness (H) using nanoindentation. Histological analysis showed no signs of any adverse immune response while revealing progressive remodelling of bone within the scaffold along with gradual decrease in 3D-scaffold volume over time. Micro-CT images indicated directional bone ingrowth, with an increase in bone formation over time. Reduced elastic modulus (E_r ) data for the newly regenerated bone presented statistically homogenous values analogous to native bone at the three time points, whereas hardness (H) values were equivalent to the native radial bone only at 24 weeks. The negative control samples showed limited healing at 8 weeks. Custom engineered β-TCP scaffolds are biocompatible, resorbable, and can directionally regenerate and remodel bone in a segmental long-bone defect in a rabbit model. Custom designs and fabrication of β-TCP scaffolds for use in other bone defect models warrant further investigation.

MEDIAL FEMORAL CONDYLE CORTICOPERIOSTEAL FLAP: ANATOMIC STUDY

Objective

The medial femoral condyle corticoperiosteal flap is irrigated by the descending genicular artery, and when this is absent, by the superior medial genicular artery. The descending genicular artery divides into the muscular, saphenous, and osteoarticular branches. The objective of this study was to describe the variables involved in the dissection of the medial femoral condyle flap.

Methods

Thirty thighs from 20 cadavers were dissected and the following variables were recorded: age, height, weight, thigh length, presence of the descending genicular artery, whether the saphenous branch originated from the descending genicular artery, the length of the branches originating from the descending genicular artery, and the diameter of the descending genicular artery and the vena comitans.

Results

The descending genicular artery was present in 93.3% of the specimens (28/30). The saphenous branch originated from this artery in 76.7% of the dissections (23/70). The mean distance between the origin of the descending genicular artery and the knee joint was 13.4 cm (±١.4), the mean length of the descending genicular artery was 7.5 cm (±1.5), the mean diameter of the descending genicular artery was 1.9 mm (±٠.3), and the mean diameter of the vena comitans was 1.7 mm (±٠.3).

Conclusion

The vascularized medial femoral condyle is a versatile option for reconstruction of musculoskeletal injuries. It allows transference of bone associated with muscle and skin, which are each nourished by independent branches. Level of Evidence IV; Case series.

Clinical and functional outcomes of vascularized bone graft in the treatment of scaphoid non-union

Introduction

Scaphoid non-union is a challenging and complex problem. Various methods have been proposed for the management of patients with scaphoid non-union and to reduce the risk of complications. In this study, our aim was to evaluate the clinical and functional outcomes of using a vascularized bone graft in the treatment of scaphoid non-union.

Methods

Patients with scaphoid non-union who underwent 1,2 intercompartmental supraretinacular artery pedicled vascularized bone graft between January 2005 and January 2011 were enrolled. The parameters assessed included clinical and functional outcomes, radiological measures, and potential risk factors.

Results

Forty-one patients were finally included. Thirty patients achieved union (73%) and 11 did not. Smoking was a significant risk factor for non-union after the surgery. In patients who achieved union, grip strength and radioulnar abduction were greater in comparison to that in patients who did not achieve union. Functional measures, including the Disabilities of Arm and Shoulder score and the Modified Mayo Wrist Score, improved in patients with scaphoid union. The scaphoid length also improved significantly postoperatively in these patients.

Conclusion

Surgical treatment of scaphoid non-union using vascularized bone graft led to a high union rate with good clinical and functional outcomes. Smoking is a risk factor for non-union, even with the use of a vascularized bone graft. Avascular necrosis was not associated with an increased risk for non-union.

Pedicled iliac crest bone flap transfer for the treatment of upper femoral shaft fracture nonunion: An anatomic study and clinical applications

PURPOSE

We present the results of a study on the anatomy of the ascending branch of the lateral circumflex femoral artery (AB-LCFA) and the use of the pedicled iliac bone flap transfer perfused by AB-LCFA combined with external fixation for the treatment of the nonunion of upper femoral shaft fractures.

METHODS

The orientation, diameter, length, and distribution of the AB-LCFA from 40 lower limbs of adult cadavers were dissected and measured. From 2000 to 2012, 13 patients with nonunion of upper femoral shaft fractures underwent pedicled iliac bone flap transfer perfused by the AB-LCFA combined with external fixation. The time of bone fracture union was recorded based on X-ray examination. The functional results of the femoral shaft were evaluated by the Klemm classification.

RESULTS

The lateral circumflex femoral artery (LCFA) divided into ascending, transverse, and descending branches in 32 specimens (80%). The diameter of the AB-LCFA at the origin was 3.15 ± 0.9 mm and the length of the AB-LCFA was 8.51 ± 3.06 cm. The postoperative course of the procedure was uneventful in all 13 patients. The average follow-up was 15 months. Bone union was achieved in all patients and the average union time was 5.3 months. 12 patients achieved excellent or good functional results based on the Klemm classification.

CONCLUSION

The AB-LCFA has a consistent orientation and abundant blood flow. The transfer of the iliac crest bone flap perfused by the AB-LCFA while combined with external fixation could be an option for treating the nonunion of upper femoral shaft fractures.

Digital Joint Reconstruction with Osteotendinous Joint Allograft: Experimental Study in Rats

Background:

Fresh or frozen nonvascularized osteotendinous joint allografts (OTJA) have not been used previously, clinically or experimentally, for metacarpophalangeal joint reconstruction. Therefore, we evaluated the viability of OTJA for metatarsophalangeal joint (MTJ) reconstruction in rats.

Methods:

In the experimental group of 12 Lewis rats, we reconstructed the MTJ of the third digit of the hindlimb with a fresh, nonvascularized OTJA obtained from the same digit from 12 donor rats. In the control group of 6 Lewis rats, an autologous composite osteotendinous graft of the MTJ of the same digit was obtained and repositioned in situ as an auto-transplant. Weight, pain, edema, dehiscence, and wound infection were evaluated every 24 hours for 30 days postoperatively. At the end of 30 days, we evaluated digit position, flexion and extension, passive mobility, radiological bone healing, and histological grades of rejection.

Results:

We found no statistically different changes in weight, edema, pain, digit position, or radiological bone healing in either group. No wound dehiscence or infection was seen in any of the rats. Ten degrees of flexion and extension mobility were lost in the control group; the experimental group lost up to 30 degrees (P = 0.009). Histologically, 9 of the experimental group rats (9/12, 75%) showed rejection reactions compared with none of the controls (0%) (P = 0.009).

Conclusions:

Fresh nonvascularized OTJA caused an immune reaction without exposure of the graft, but with bone resorption. However, the rats maintained digital form and alignment with decreased passive flexion and extension of 10–30 degrees.

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.

Vascularized versus non-vascularized bone grafts in the treatment of scaphoid non-union

INTRODUCTION

Conventional non-vascularized bone grafts as well as vascularized bone grafts are used to treat scaphoid non-union (SN). Due to limited available studies, the field of application using both grafts for SN still remains controversial. The aim of this study was to evaluate a treatment algorithm for the use of both vascularized versus non-vascularized bone grafts based on clinical outcomes and quality of life (QoL) to improve the level of evidence.

MATERIALS AND METHODS

Based on a retrospective cohort study, including 28 patients with vascularized and 45 patients with conventional bone grafts, functional parameters, radiological outcome, Mayo-wrist-score, and QoL by SF-36 were applied to statistically compare the outcome of these two techniques.

RESULTS

Time between last procedure or trauma and study group scaphoid reconstruction was almost double in the vascularized bone grafting group. Comparable union rates were achieved with vascularized as well as non-vascularized bone grafts. Significant differences were observed between both groups for grip strength and radial-ulnar active range of motion. Further functional outcomes, radiological outcomes as well as QoL were found similar for both techniques in patients with surgical union.

DISCUSSION AND CONCLUSIONS

In order to achieve comparable and appropriate treatment results, vascularized bone grafts are recommended for patients with delayed treatment, impaired scaphoid vascularity, and revision surgery. Even in preselected, complex cases, the results are comparable to conventional grafts, which are the basis for further patient education and approve the powerful role of surgical angiogenesis of vascularized bone grafts.

Scaphoid Fractures: Nonunion and Malunion

The treatment of scaphoid nonunion and malunions has undergone a considerable transition since the 1960 modification of Matti's technique by Russe.¹ We present a review of articles with clear data on union rates and functional status to review the current methods of treatment for scaphoid nonunion and malunion.

Kienböck Disease: Moving Forward

Over the past decade, a plethora of new information has been reported regarding etiology, natural history, classification, and treatment options for lunate osteonecrosis. New disease classifications have been described based on advanced imaging determination of lunate viability as well as a cartilage-based arthroscopic classification. Here we review the newest literature regarding Kienböck disease and present a new treatment algorithm that incorporates the traditional osseous classification system with a perfusion/viability classification and an articular cartilage-based classification.

Functional and radiographic evaluation of the treatment of traumatic bone loss of the hand using the Masquelet technique

This study was a retrospective evaluation of 18 patients with traumatic bone loss affecting the fingers, hand and wrist who were treated using the induced-membrane technique. Sixteen men and two women, mean age 54years (27-74) presented a hand injury including bone loss. Sixteen patients were treated on an emergency basis and two following nonunion of their fractures. There were 13 cases of open fracture of the phalanx and 5 cases of metacarpal fractures. These patients were treated with debridement and the injuries were covered when necessary. To address the bone loss, the first step of the induced-membrane technique involved placing a cement spacer (polymethylmethacrylate [PMMA]) without antibiotics in the defect. During the second step, the cement spacer was removed and replaced by autologous cancellous bone graft. The graft was placed within the biological tube left empty after removal of the cement. For each patient, bone union was assessed with radiographs and/or CT scan. Failure was defined as nonunion at 1year. In 16 patients, the fractures had healed after 4months (1.5-12months) on average. Two failures were noted (one nonunion treated using a PIP prosthesis and one case of delayed union). Mobility of the fingers, evaluated using the Total Active Motion (TAM) was 145° (75°-270°). The Kapandji score reached 8 for the thumb. Grip strength reached 21kg/F and pinch strength was 5kg/F; these values were 50% of those in the healthy hand. The induced-membrane technique is simple and can be used to treat traumatic bone loss in an emergency, thus avoiding amputation and limb shortening, while preserving limb function. It provides immediate stability and allows early mobilization.

Treatment of Nonunion of Forearm Bones Using Radial Forearm Bone Flap

Background:

Treatment of forearm fracture nonunion is challenging. Several surgical techniques for the treatment of forearm nonunion have been reported.

Objectives:

The aim of this prospective study was to evaluate the effects of the radial forearm bone graft technique in cases with forearm nonunion.

Patients and Methods:

We treated 7 patients with forearm nonunions via radial forearm bone flap and internal plate fixation. On the preoperative examination and last follow-up, the quick disabilities of the arm, shoulder, and hand (Q-DASH) score, elbow, forearm and wrist arches of motion and grip force were measured. At the final follow-up, radiographic union and patient satisfaction and return to work were assessed.

Results:

The mean follow-up duration was 34 ± 23 months. The Q-DASH scores improved from 70 ± 6 points preoperatively to 13 ± 15 points at final follow-up (P < 0.01). The preopetative range of motion (ROM) was 101 ± 26 degrees; whereas the final forearm ROM was 140 ± 17 (P = 0.01). All nonunions united uneventfully (range 3-6 months). At the last follow-up, the grip force was 83% of uninjured extremity and all patients were satisfied with the outcome of the operation.

Conclusions:

Radial forearm bone flap is a safe, useful and novel technique in cases with forearm nonunion.

The Vascularized Medial Femoral Corticoperiosteal Flap for Thumb Reconstruction

Supplemental Digital Content is available in the text.

We present an interesting method of shaping a vascularized medial femoral condyle (MFC) flap into a “neophalanx” for phalangeal reconstruction. Our patient presented with limited strength and function secondary to fracture nonunion of the proximal phalanx of the dominant thumb. Following excision of the pseudarthrosis, an MFC corticoperiosteal flap was harvested, sculpted into a prism shape and inset. The superomedial genicular pedicle was anastomosed to the princeps pollicis artery and a cephalic tributary. On follow-up, new bone growth was seen on radiographs and the patient had substantially improved function, with full metacarpophalangeal extension, a Kapandji score of 9, and a markedly reduced Disabilities of the Arm, Shoulder and Hand score of 2.68. The MFC flap is useful for reconstruction of bony defects, with minimal donor morbidity. This versatile vascularized flap can be crafted to requisite shapes and is useful for small defects in the hand, including phalangeal reconstruction.

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.

Lateral Femoral Condyle Flap: An Alternative Source of Vascularized Bone From the Distal Femur

PURPOSE

To elucidate the vascular anatomy of the superolateral geniculate artery (SLGA) and its supply to the periosteum of the lateral femoral condyle (LFC) and to provide guidelines for flap design and describe an illustrative case.

METHODS

Thirty-one fresh cadaveric limbs were dissected. The vascular anatomy of the SLGA and its distal branches to skin, muscle, and periosteum were identified. Fluoroscopic images were taken during continuous perfusion of a radiopaque contrast dye into the SLGA. Intra-arterial injections of latex rubber were performed in 12 cadaver limbs. The vascular territory was traced from the SLGA to its distal branches, and surrounding soft tissues were dissected.

RESULTS

The SLGA originated from the popliteal artery 4.9 ± 1.2 cm (range, 2.8-7 cm) from the knee joint and its pedicle diameter was 1.8 ± 0.5 mm (range, 1-3 mm). SGLA pedicle-specific fluoroscopic angiography demonstrated a dense filigree of vessels over the lateral distal femur. Arterial latex injections confirmed that the SLGA supplied the periosteum of the LFC and distal femur shaft. The proximal-most extent of periosteal perfusion was 11.7 ± 2.1 cm (range, 9.3-14.1 cm) from the knee joint. The average pedicle length of LFC osteoperiosteal flaps was 4.8 ± 0.9 cm (range, 3.5-6.3 cm).

CONCLUSIONS

The LFC flap consistently demonstrated almost 12 cm of femur length perfusion based on the SLGA pedicle. The anatomy of this flap enables chimeric designs combining soft tissue, bone, and cartilage.

CLINICAL RELEVANCE

The vascularized LFC flap is an option for reconstruction of osseous defects of the upper extremity.

Functional reconstruction of subtotal thumb metacarpal defect with a vascularized medial femoral condyle flap: case report

Devastating hand injuries require customized reconstructive strategies to maximize functional outcomes. We report a case of thumb metacarpal reconstruction using a vascularized medial femoral condyle osteocutaneous flap in the setting of nearly complete metacarpal loss. In addition to achieving the traditional goals of reconstructing thumb length and providing stability, the medial femoral condyle flap allowed motion at the carpometacarpal joint. The patient's hand function was further optimized by a component transfer of a proximally injured but distally preserved index finger to the amputated middle finger position. The patient regained satisfactory grip and thumb function with minimal donor site morbidity. This case highlights the role of both creative and established approaches to reconstruct composite tissues following devastating hand injury.

The 1,2-intercompartmental supraretinacular artery vascularized bone graft for scaphoid nonunion: management and clinical outcome

PURPOSE

To evaluate the clinical outcome of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft for scaphoid nonunion (SN).

METHODS

A retrospective study was performed to evaluate patients with SN and treated with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft between 1997 and 2010. Functional measures, quality of life by Short Form SF-36 questionnaire, and analysis of risk factors were included.

RESULTS

Out of 39 patients who were eligible for the study, 11 were lost to follow-up. Out of the remaining 28 patients, union was achieved in 21 (75%). The mean length of follow-up was 63 ± 45 months. In hands with scaphoid union, the grip strength and the radioulnar active range of motion were less than the contralateral side but greater compared with patients with nonunion. Active extension-flexion was less compared with the noninjured hand but similar to patients with nonunion. Disabilities of the Arm, Shoulder and Hand (DASH) score decreased from 58 to 23 in dominant hands and from 46 to 13 in nondominant hands. Smoking was found to be a risk factor for nonunion. Patients with scaphoid union tended to higher scores in 8 domains of SF-36-Item Health Survey quality of life without significant difference.

CONCLUSIONS

Surgical treatment of SN with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft provided a union rate comparable with other vascularized bone graft techniques. Previous scaphoid reconstruction with standard iliac crest bone graft was not associated with higher risk for secondary nonunion. There was an upward tendency seen in DASH score and quality of life after scaphoid union.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Expanding the utility of modified vascularized femoral periosteal bone-flaps: An analysis of its form and a comparison with a conventional-bone-graft

BACKGROUND

Vascularized medial femoral condyle (MFC) corticoperiosteal bone-flap is a well-accepted technique when dealing with tissue defects or infection. Its role in refractory conditions and in the possible use for options concerning modifications of this bone-flap compared to a conventional iliac bone graft (conventional-graft) are rarely discussed.

METHODS

We reviewed 21 consecutive cases concerning alternatives with some modifications of original MFC bone-flap surgery used to treat refractory conditions with bone defects, necrosis, or infection in the extremities. We present our devised approaches for this boneflap, and especially modifications of the grafted bone (including strut bone, perforator to the vastus medialis muscle, and the use of one vascular pedicle for some bone flaps) as well as the combined use of artificial bone as hybrid bone transplantation. We also compared the clinical results of 21 cases that received a conventional-graft.

RESULTS AND CONCLUSIONS

Following flap placement, 100% of the nonunion sites healed in an average of 2 months, which was significantly shorter than 5.5 months for the conventional-graft. The results showed the expanding possibility for options with regard to the form and options of this bone-flap as well as the shortening the duration of treatment, especially at the site of an infected distal tibia, insertion of the Achilles tendon on the posterior aspect of calcaneal osteomyelitis, distal end of the clavicle, clavicle or forearm with a bone defect, small bones with refractory conditions, and a femur without implant failure. However, it was not efficient for treating a forearm without bone defect.

Use of the vascularized iliac-crest flap in musculoskeletal lesions

Bone loss was in the past treated by several methods, such as bone distraction and the use of nonvascularized or tissue-bank bone grafts. With the advent of modern microsurgical techniques, the vascularized bone flap has been used with good results; it resolves local nutritional problems, repairs soft tissue that is often damaged by severe trauma, and treats bone loss due to tumors, pseudarthroses, and osteomyelitis. This paper reports the authors' experience with the use of vascularized iliac-crest flaps to treat orthopedic pathologies in five patients with traumatic bone loss (<10 cm), three with osteomyelitis, and three with atrophic nonunion. In all cases, the same surgeon obtained a vascularized iliac-crest flap with a pedicle based on the deep iliac circumflex artery. All flaps consolidated within a mean period of 3 months. These findings demonstrate that the use of an iliac-crest flap is a treatment option in cases of bone loss and that it is associated with good functional results and minimal donor-site morbidity.

The use of non-vascularised osteochondral autograft for reconstruction of articular surfaces in the hand and wrist

Bone loss involving articular surface is a challenging problem faced by the orthopaedic surgeon. In the hand and wrist, there are articular defects that are amenable to autograft reconstruction when primary fixation is not possible. In this article, the surgical techniques and clinical outcomes of articular reconstructions in the hand and wrist using non-vascularised osteochondral autografts are reviewed.

The reconstruction of large bone defects in the upper limb

Large bone defects in the upper limb pose many challenges in reconstructive surgery. Conventional and innovative methods have been described, employing the use of microsurgical and non-microsurgical techniques to overcome both bony and soft tissue defects. This article reviews the success and pitfalls of different techniques of reconstruction of large bone defects in the upper limb, including microsurgical transfer of the free vascularised fibula graft as a diaphyseal bone replacement and as a hemivascularised joint transplant, and non-microsurgical options using conventional bone grafting, the induced membrane technique and the role of callotatic distraction-lengthening procedures.

Supplemental graft fixation for distal radius vascularized bone graft

Vascularized bone grafts from the distal radius have been used successfully for the treatment of scaphoid nonunions. Typically, the harvested graft is secured into the scaphoid with a press-fit technique. This type of fixation may lead to graft extrusion in the early postoperative period, and thus to treatment failure. In this technical note, we describe the use of micro bone suture anchors for supplemental fixation of the vascularized bone graft into the scaphoid. It is a simple and quick technique and provides an enhanced fixation of the vascularized bone graft, which is beneficial during the early critical period of bone healing.

Use of the medial femoral condyle vascularized bone flap in traumatic avascular necrosis of the navicular: a case report

The medial femoral condyle vascularized bone flap has a high success rate in published literature regarding its use in nonunions and avascular necrosis of the upper and lower extremities. It is reported to have minimal donor site morbidity and the ability to provide structural support and torsional strength to load-bearing areas. The flap has found particular success in the treatment of scaphoid nonunions. The tarsal navicular, similar to the scaphoid, is largely articular cancellous bone with little surface area for vascular inflow. These anatomic features make the navicular prone to nonunion and avascular necrosis in traumatic scenarios. We describe a case of nonunion and avascular necrosis of the tarsal navicular occurring as sequelae of a high-impact midfoot injury sustained in an automobile accident. After an initial attempt at open reduction and internal fixation with midfoot bridge plating, subsidence and nonunion resulted. An attempt at arthrodesis of the talonavicular and naviculocuneiform joints was then undertaken. This too failed, leading to the development of additional collapse and avascular necrosis. The site was treated with a medial femoral condyle vascularized bone flap. In this single case, the patient returned to pain-free ambulation and reported excellent outcomes and functional capacity. Although we present a successful case, a larger case series is necessary to establish the use of this flap as a reliable option for the treatment of nonunion and avascular necrosis of the tarsal navicular.