Advertisement

Lateral Femoral Trochlea Osteochondral Flap Reconstruction of Proximal Pole Scaphoid Nonunions

Published:November 02, 2022DOI:https://doi.org/10.1016/j.jhsa.2022.08.019

      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.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Sandow M.J.
        Proximal scaphoid costo-osteochondral replacement arthroplasty.
        J Hand Surg Br. 1998; 23: 201-208
        • Zechmann-Mueller N.A.
        • Collocott S.
        • Heiss-Dunlop W.
        Costo-osteochondral graft (rib graft) reconstruction of the irreparable proximal scaphoid.
        J Hand Surg Eur Vol. 2020; 45: 693-699
        • Obert L.
        • Lepage D.
        • Ferrier M.
        • Tropet Y.
        Rib cartilage graft for posttraumatic or degenerative arthritis at wrist level: 10-year results.
        J Wrist Surg. 2013; 2: 234-238
        • Veitch S.
        • Blake S.M.
        • David H.
        Proximal scaphoid rib graft arthroplasty.
        J Bone Joint Surg Br. 2007; 89: 196-201
        • Chan A.H.W.
        • Elhassan B.T.
        • Suh N.
        The use of the proximal hamate as an autograft for proximal pole scaphoid fractures: clinical outcomes and biomechanical implications.
        Hand Clin. 2019; 35: 287-294
        • Elhassan B.
        • Noureldin M.
        • Kakar S.
        Proximal scaphoid pole reconstruction utilizing ipsilateral proximal hamate autograft.
        Hand (N Y). 2016; 11: 495-499
        • Wu K.
        • Padmore C.
        • Lalone E.
        • Suh N.
        An anthropometric assessment of the proximal hamate autograft for scaphoid proximal pole reconstruction.
        J Hand Surg Am. 2019; 44: 60.e1-60.e8
        • Bürger H.K.
        • Windhofer C.
        • Gaggl A.J.
        • Higgins J.P.
        Vascularized medial femoral trochlea osteocartilaginous flap reconstruction of proximal pole scaphoid nonunions.
        J Hand Surg Am. 2013; 38: 690-700
        • Higgins J.P.
        • Bürger H.K.
        Osteochondral flaps from the distal femur: expanding applications, harvest sites, and indications.
        J Reconstr Microsurg. 2014; 30: 483-490
        • Higgins J.P.
        • Bürger H.K.
        The use of osteochondral flaps in the treatment of carpal disorders.
        J Hand Surg Eur Vol. 2018; 43: 48-56
        • Pulos N.
        • Kollitz K.M.
        • Bishop A.T.
        • Shin A.Y.
        Free vascularized medial femoral condyle bone graft after failed scaphoid nonunion surgery.
        J Bone Joint Surg Am. 2018; 100: 1379-1386
        • Capito A.E.
        • Higgins J.P.
        Scaphoid overstuffing: the effects of the dimensions of scaphoid reconstruction on scapholunate alignment.
        J Hand Surg Am. 2013; 38: 2419-2425
        • Aribert M.
        • Corcella D.
        • Bouyer M.
        Free composite medial femoral trochlea osteochondral cutaneous flap for wrist scaphoid and lunate cartilage lesions: advantages of a skin paddle.
        Hand Surg Rehabil. 2019; 38: 262-267
        • Pet M.A.
        • Assi P.E.
        • Yousaf I.S.
        • Giladi A.M.
        • Higgins J.P.
        Outcomes of the medial femoral trochlea osteochondral free flap for proximal scaphoid reconstruction.
        J Hand Surg Am. 2020; 45: 317-326
        • Higgins J.P.
        • Bürger H.K.
        Medial femoral trochlea osteochondral flap: applications for scaphoid and lunate reconstruction.
        Clin Plast Surg. 2020; 47: 491-499
        • Wong V.W.
        • Higgins J.P.
        Medial femoral condyle flap.
        Plast Reconstr Surg Glob Open. 2016; 4: e834
        • Higgins J.P.
        • Bürger H.K.
        Medial femoral trochlea osteochondral flap: applications for scaphoid and lunate reconstruction.
        Clin Plast Surg. 2017; 44: 257-265
        • Wong V.W.
        • Bürger H.K.
        • Iorio M.L.
        • Higgins J.P.
        Lateral femoral condyle flap: an alternative source of vascularized bone from the distal femur.
        J Hand Surg Am. 2015; 40: 1972-1980
        • Parvizi D.
        • Vasilyeva A.
        • Wurzer P.
        • et al.
        Anatomy of the vascularized lateral femoral condyle flap.
        Plast Reconstr Surg. 2016; 137: 1024e-1032e
        • Morsy M.
        • Sur Y.J.
        • Akdag O.
        • et al.
        Anatomic and high-resolution computed tomographic angiography study of the lateral femoral condyle flap: implications for surgical dissection.
        J Plast Reconstr Aesthet Surg. 2018; 71: 33-43
        • Schmidle G.
        • Ebner H.L.
        • Klauser A.S.
        • Fritz J.
        • Arora R.
        • Gabl M.
        Correlation of CT imaging and histology to guide bone graft selection in scaphoid non-union surgery.
        Arch Orthop Trauma Surg. 2018; 138: 1395-1405
        • Windhofer C.M.
        • Anoshina M.
        • Ivusits P.
        • Bürger H.P.
        The free vascularized lateral femoral trochlea osteochondral graft: a reliable alternative for Stage III Kienböck's disease.
        J Hand Surg Eur Vol. 2021; 46: 1032-1041
        • Higgins J.P.
        • Borumandi F.
        • Bürger H.K.
        • et al.
        Nonvascularized cartilage grafts versus vascularized cartilage flaps: comparison of cartilage quality 6 months after transfer.
        J Hand Surg Am. 2018; 43: 188.e1-188.e8
        • Hugon S.
        • Koninckx A.
        • Barbier O.
        Vascularized osteochondral graft from the medial femoral trochlea: anatomical study and clinical perspectives.
        Surg Radiol Anat. 2010; 32: 817-825
        • Messina J.C.
        • Van Overstraeten L.
        • Luchetti R.
        • Fairplay T.
        • Mathoulin C.L.
        The EWAS classification of scapholunate tears: an anatomical arthroscopic study.
        J Wrist Surg. 2013; 2: 105-109
        • Windhofer C.
        • Wong V.W.
        • Larcher L.
        • Paryavi E.
        • Bürger H.K.
        • Higgins J.P.
        Knee donor site morbidity following harvest of medial femoral trochlea osteochondral flaps for carpal reconstruction.
        J Hand Surg Am. 2016; 41: 610-614
        • Neuwirth M.
        • Ziegler T.
        • Benedikt S.
        • et al.
        Donor site morbidity after the harvest of microvascular flaps from the medial and lateral femoral condyle region: Objective, radiologic, and patient-reported outcome of a multi-center trial.
        J Plast Reconstr Aesthet Surg. 2022; 75: 160-172