Allograft bone for metacarpal reconstruction

Reconstruction of Type IIIB Thumb Hypoplasia Using a Vascularized Hemi-Metatarsal Composite Tissue Flap

BACKGROUND

The aim of this study was to determine the clinical outcomes of vascularized hemi-metatarsal composite tissue transfer for the reconstruction of type IIIB hypoplastic thumbs.

METHODS

Twenty-eight patients with type IIIB hypoplastic thumbs treated with vascularized hemi-metatarsal composite tissue transfer were included in this retrospective study with a mean follow-up of 2.4 years. Preoperative digital subtraction angiography was performed to examine the vessel variance. Clinical measures included grip and pinch strength, scar status, and Kapandji thumb opposition score. Subjective Pediatric Outcomes Data Collection Instrument scores and parent satisfaction were also evaluated.

RESULTS

Radial arteries were hypoplastic in 82.1% of the cases, and the common palmar digital artery was chosen as the recipient vessel for the tissue transfer. There was no neurovascular complication. The only donor-site complication was a metatarsal fracture that healed with casting. Key pinch and tripod pinch were 29.5% and 45.8% of the normal side, respectively. The mean grip strength was 51.7% of the unaffected side. The mean Kapandji score was 6. The Pediatric Outcomes Data Collection Instrument scores were high for global function; upper extremity function; transfer; and basic mobility, happiness, and comfort. The Vancouver Scar Scale showed an average score of 2.1. All parents were satisfied with the clinical outcomes.

CONCLUSION

Vascularized hemi-metatarsal composite tissue transfer for type IIIB thumb hypoplasia can provide improved subjective outcomes and is a feasible method for the attainment of a five-digit hand.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Surgical Reconstruction of Severe Tophaceous Gout in the Hand: A Customized Approach

Tophaceous gout can represent a major problem for hand surgeons when it turns into aggressive nodules, spreading and destroying soft tissue and bone. The combination of ablative and reconstructive surgery may also be complex when the patient refuses amputations and multiple segments are involved. We present a difficult case, where a customized approach, chosen according to the different features of the osteoarticular and tendon involvement of fingers, adopted different solutions for the four affected rays. A patient suffering from severe gout arthritis with osteoarticular destruction in both hands refused amputations and was treated with several reconstructive procedures. After excision of the tophaceous deposits, a long bone autograft, two segmental cement spacers together with distal arthrodeses, and an osteoarticular allograft were used. Functional pinches were maintained in both hands, even at a 13-year follow up, with the allograft preserved and working. On the other hand, significant osteolysis and bone resorption in all the segments that had undergone stabilization was documented, producing extrusion of both cement and distal interphalangeal joint fusion screws. Pre- and postoperation range of motion, visual analogue scale, disabilities of the arm, shoulder, and hand score, and pinch strength tests showed reduced pain and improved function. A review of literature is presented in particular regarding different reconstructive approaches. Combining different techniques in the same hand can lead to successful osteoarticular reconstruction after tophi resection, above all to avoid amputation. However, long-term follow up shows that functional osteoarticular reconstructions seem to be more stable, whereas osteolysis may damage bone grafts used for arthrodesis and produce screw extrusion.

Metacarpal Aneurysmal Bone Cyst En Bloc Resection Reconstructed With Osteoarticular Allograft

Aneurysmal bone cysts are large lytic lesions that appear most often around metaphyseal bone. The lesions are locally aggressive with high recurrence rates. Therefore, wide resection is commonly necessary, leading to challenging reconstruction of the defect, especially when the articular surface is involved. We present a case of an aneurysmal bone cyst of the fourth metacarpal, treated with an en bloc resection and reconstruction with a metacarpal osteoarticular allograft. At 8 years after surgery, the patient has shown no signs of recurrence, but radiographic articular reabsorption was noted. However, the patient showed an excellent outcome with a satisfactory active range of motion and grip strength. Despite potential complications, osteoarticular allograft is a feasible alternative when autologous osteoarticular reconstruction is not an option.

Non-Vascularized Free Toe Phalanx Transfers in Congenital Hand Deformities – the Great Ormond Street Experience

Many options of varying complexity are available for the management of congenital short digits resulting from aphalangia in symbrachydactyly and constriction ring syndrome. We have used non-vascularized free toe phalanx transfers for these children when a vascularized toe transfer has been contraindicated. We describe our technique and experience with 22 children who underwent a total of 64 transfers of the proximal (35) or middle (29) toe phalanges (average 3 per child). The mean age at initial surgery was 15 months, and the mean follow-up was 5 years. Duration of time until epiphyseal closure could not be determined accurately, but total digital elongation averaged 6 mm. Complications of this technique include joint instability, premature epiphyseal closure and, in one patient, infection and graft loss. Donor site deformity was determined according to measured growth deficit and toe function. This technique is a simple option for digital elongation and, if performed in the appropriate age group in short fingered and monodactylous subtypes of symbrachydactyly, has the potential to allow growth and function with minimal donor site deficit.

Central Column Reconstruction Following Total Resection of a Third Metacarpal Giant Cell Tumour

A wide resection of a giant cell tumour involving the entire middle metacarpal is presented. Reconstruction preserving the central column and metacarpophalangeal joint was achieved using autologous iliac crest bone as a spacer and structural support. The fibro-osseous cartilage portion of the iliac graft was used as a “hemi-joint” replacement. By using a bridging bone graft and screw to fuse the adjacent proximal phalanges of the middle and index fingers, a stable “internal syndactyly” was achieved. Although independent index and middle finger motion was sacrificed, the approach allowed wide resection for local tumour control, re-established structural integrity, preserved metacarpophalangeal joint motion and allowed early motion. The aesthetic result was also good.

Synostosis of proximal phalangeal bases for loss of distal metacarpal

A finger rendered unstable due to loss of metacarpal head can be stabilized by creating a synostosis at the base of the proximal phalanx of the affected finger with the adjacent normal finger. A cortico cancellous graft bridges the two adjacent proximal phalanges at their bases which are temporarily stabilized with an external fixator. The procedure can be done for, recurrence of giant cell tumor of metacarpal and for traumatic metacarpal loss. The procedure and long term follow up of one patient is presented who had giant cell tumor. This option should be considered before offering ray amputation. There is no micro vascular surgery involved, nor is there any donor site morbidity. The graft heals well without any absorption. The affected finger shows excellent function in the long term followup.

Reconstruction of an entire metacarpal and metacarpophalangeal joint using a fibular osteocutaneous free flap and silicone arthroplasty

Radical resection of the entire ring finger metacarpal for a giant cell tumor resulted in a bony defect extending from the distal surface of the hamate to the proximal surface of the proximal phalanx. We reconstructed the metacarpal with a custom-contoured free fibular osteocutaneous flap and maintained motion at the new fibulophalangeal joint using a silicone arthroplasty. At 4.5 years postoperatively, the patient has shown no signs of recurrence of the giant cell tumor. The silicone arthroplasty has maintained 15° to 85° of motion at the new joint. Because of its similar shape to a metacarpal and because it allows faster bony healing compared with a nonvascularized fibular bone graft, a free vascularized fibular bone graft is an ideal candidate for reconstruction of extensive defects of the metacarpals, and placement of a silicone spacer in its distal medullary cavity can preserve motion at the new metacarpophalangeal joint.

Nonvascularized osteoarticular allograft replacement of the proximal interphalangeal joint after extensive loss of bone, joint, and extensor tendon

Nonvascularized small-joint allografts are a potentially attractive alternative to prosthetic implantation in cases of posttraumatic destruction of the proximal interphalangeal joint combined with metaphyseal and diaphyseal metacarpal or phalangeal bone loss, as well as soft tissue tendon defects of the digital extensor mechanism. Benefits include the absence of donor site defect, the ability to simultaneously reconstruct deficiency of the extensor mechanism, restore digital length and phalangeal (and metacarpal) bone stock in the face of bone loss, and the provision of an osteoinductive platform onto which creeping substitution can occur. Difficulties include an increased potential for infection and the potential for narrowing of the joint space because of articular cartilage loss. Early results suggest that the benefit of this technique lies in its ability to restore bone stock and soft tissue integrity that would make later prosthetic joint replacement feasible.

Silastic replacement of metacarpal after resection of giant cell tumour. A case report

Giant cell tumours are aggressive lesions, albeit benign. Lesions in the hand, especially those arising from metacarpals require resection with adequate margins and definitive structural reconstructions to ensure preservation of hand architecture, function and cosmesis. Almost all the described reconstructive procedures require a stump of tumour free metacarpal base after resection, for reconstruction of the metacarpal. This report describes replacement of the entire metacarpal with a silastic prosthesis, in a case of giant cell tumour involving the entire metacarpal head and shaft to within 7 mm of the base.

Lengthening of the amputation stumps of the distal phalanges using the modified Ilizarov method

PURPOSE

The purpose of this study was to introduce the technique for distraction lengthening of the traumatic amputation stumps of distal phalanges less than 10 mm long by using the Ilizarov minifixator (Ito Medical Instruments, Tokyo, Japan) and to report the treatment results and the problems we encountered.

METHOD

Six patients (3 men and 3 women) underwent lengthening of the traumatic amputation stumps of distal phalanges using the Ilizarov minifixator. The mean pre-operative length of the distal phalanges was 6.0 mm and the mean deficiency in length was 9.5 mm compared with the contralateral finger or thumb.

RESULTS

In 5 of the 6 patients callus lengthening was completed without early consolidation or bone failure related to the traction wires. The mean gain in lengthening of the distal phalanx was 6.8 mm and the mean final length of the distal phalanx was 12.8 mm. After surgery 4 patients had onychoplasty and advancement flap coverage of the distal phalangeal tip because of excessive skin tension and 1 patient had arthrodesis because of flexion contracture of the distal interphalangeal joint. The patients were satisfied with the cosmetic improvement of their fingertips.

CONCLUSIONS

Although this callus distraction method required multiple surgical procedures it is considered worthy of more frequent application especially in young patients.

Silicone block interposition for traumatic bone loss

In situations where bone is lost secondary to trauma, the use of a hand-carved silicone block provides good results. When bone grafting is undertaken, a well-defined membrane will have enveloped the implant. Incising the membrane allows easy block removal, and after freshening the bone ends, a cavity awaits the bone graft. This technique offers simplicity and adequate stability for therapy, and secondary bone grafting is facilitated by the created space.

Autogenous fibular graft and silicone implant arthroplasty following resection of giant cell tumor of the metacarpal: a report of two cases

Two cases of reconstruction after resection of giant cell tumor of the distal metacarpal are reported in which reconstruction was achieved with a nonvascularized fibular autograft and silicone metacarpophalangeal joint arthroplasty. At 2-year and 1-year follow-up evaluation, respectively, the patients were found to be doing well. This method of reconstruction appears reliable and presents the possibility for vascularized reconstruction if that is thought necessary.

Autograft replacement of small joint defects in the hand

Intraarticular injuries to the small joints of the hand with attendant loss of cartilage can result in the development of posttraumatic arthritis with functional disability due to pain and loss of motion. Traditional treatment options often have yielded suboptimal results in terms of functional return, particularly when applied once contracture or arthritic change already has developed. Acute management of cartilage loss by osteochondral reconstruction with restitution of the articular surface may diminish the likelihood or severity of potential post-traumatic degenerative changes.

Reconstruction of a complex defect of the dorsum of the hand

A 37-year-old right-handed male truck driver was admitted with a severe injury of the dorsum of his right hand following a traffic accident. He had a large combined defect involving skin, tendons and bone. A complex reconstruction was performed using a large iliac crest allograft, a tendon graft and a free serratus anterior flap in one stage, 8 hours after the injury. A skin graft was performed later. 2 years later the functional and aesthetic result are good.

Digital lengthening in congenital hand deformities

12 hands with congenital short finger in 11 patients were treated with various types of metacarpal bone lengthening. These included three patients with brachydactyly, seven with transverse deficiency, and one with constriction ring syndrome. All cases involved metacarpal lengthening and surgery was performed 16 times in 15 digits. Single-stage lengthening was performed in seven cases, on-top plasty in three cases, and distraction lengthening in six cases. The length gained ranged from 2 to 10 mm in single-stage lengthening, 3 to 17 mm in on-top plasty, and 12 to 30 mm in distraction lengthening. Delayed union and malunion occurred in single-stage lengthening or on-top plasty. After metacarpal lengthening, pinch function was improved in seven out of eight patients with either transverse deficiency or constriction band syndrome, and aesthetic improvement was achieved in three patients with brachydactyly.

Hand reconstruction with allograft demineralized bone: twenty-six implants in twelve patients

A long-term study of 26 phalangeal or metacarpal defects that were reconstructed with allogeneic demineralized bone implants demonstrates healing comparable to that which follows autogenous bone grafting. Average follow-up was 54 months. Five patients had multiple enchondromas (Ollier's syndrome), five children had congenital hand deformities, and all of these had previously had bone grafts harvested for associated craniofacial reconstructions. With the use of demineralized bone implants, tourniquet and operative times were significantly reduced and potential donor site morbidity was eliminated. Further, regional anesthesia was used more frequently and hospitalization time was reduced. There were no postoperative complications. Demineralized bone implants have been particularly useful in patients who previously had refused bone grafting.

Allograft Bone for Arthrodesis and Repair of Skeletal Hand Problems

Banked freeze-dried allograft bone was used in 16 patients who underwent three types of wrist operation. Subjective, objective, roentgenographic and economic end-result evaluations were satisfactory. The mean time to union was 12.4 weeks, and the complication rate was low. Allograft bone compares favourably with autografts and avoids donor site morbidity, as well as the need for general anaesthesia.

The scaphoid allograft: a new operation for treatment of the very proximal scaphoid nonunion or for the necrotic, fragmented scaphoid proximal pole

This is a preliminary report of eight cases in which an allograft was used to replace half of the scaphoid. The indications for the procedure include the following: (1) Severe necrosis with fragmentation of the proximal pole, (2) Very proximal pole nonunion with small (less than 20% of the bone), unreconstructable proximal fragments, and (3) One case of severely comminuted intra-articular fracture of the scaphotrapezial joint and basal joint of the thumb caused by a gunshot wound. The Herbert scaphoid screw was used to provide rigid fixation. Follow-up ranged from 8 to 30 months. The result was good in six of eight patients. It should be emphasized that this is a preliminary report of the early experience with a new operation for salvage of difficult scaphoid fracture problems.

Treatment of enchondromas of the hand with allograft bone

We investigated whether cortico-cancellous allograft obtained from cadaveric banked bone is effective in the treatment of enchondroma of the hand. Twelve patients had 15 operations on 19 enchondromas using allograft bone. These patients were compared with 16 patients with enchondroma treated with autogenous iliac cancellous bone. The distribution of tumors was similar in both groups. There was no significant difference in the patient's age, their occupations, or whether the operation involved the dominant hand. In both groups, immobilization was maintained until clinical union was obtained. The duration of immobilization for both groups was identical. There were no recurrences, refractures, or complications in patients treated with allograft bone. The grafts incorporated and remodeled in all patients. We concluded that a allograft cortico-cancellous bone can be used effectively in the treatment of enchondromas of the hand. It is especially useful in the treatment of patients with multiple tumors.

Autografts in the treatment of osseous defects in the forearm and hand

Twenty-one patients were treated for large defects of the forearm or hand with autografts. Seventeen of the grafts were cortico-cancellous, three were hemiarticular, and one was a hemi joint replacement at each end of the graft. None of these cases involved the whole joint or the growth plate. Cancellous grafts used to fill bone cavities or repair pseudarthroses were excluded from the survey. Patients were followed from 3 to 10 years. In all cases the graft became incorporated and function was maintained. In two cases a second operation was necessary to apply further cancellous graft because of delayed union.