Vascularized Second Metacarpal Bone Graft for the Treatment of Idiopathic Osteonecrosis of the Capitate.

Background: Idiopathic osteonecrosis of the capitate is rare condition with few reports of treatment using vascularized bone graft. Methods: A case of a 45-year-old woman with idiopathic necrosis of the capitate who underwent surgical treatment with a vascularized bone graft from the base of the second metacarpal bone is reported. Results: At 14 months postoperatively, the range of motion of her wrist was maintained, and localized wrist pain was relieved. Conclusions: This bone graft, which has a reliable pedicle with few anomalies, offers sufficient cancellous bone for the capitate, and can be harvested in the same operative field, is desirable for the treatment of osteonecrosis of the capitate.

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.

Growth of the New Thumb Metacarpal After Pollicization for Thumb Hypoplasia.

PURPOSE: To investigate the radiographic length and width of the new thumb metacarpal in relation to the middle finger proximal phalanx; to assess the incidence of premature physeal closure of the new metacarpal; and to consider whether there is a relationship between growth characteristics and the presence of union or nonunion of the new trapezium to the retained index finger metacarpal base. METHODS: Forty pollicizations were assessed with preoperative or immediate postoperative radiographs and follow-up radiographs to establish the growth characteristics of the new thumb metacarpal. Functional outcomes comprising grip strength, pinch strength, and range of motion were correlated with radiological findings of presence or absence of open physes and presence or absence of union of the new trapezium to the metacarpal base. RESULTS: The new thumb metacarpal physis was open in 28 pollicizations and closed in 12. In the latter group, all physes of the hand had closed indicating skeletal maturity. The length and width indices of the new thumb metacarpal in relation to the middle finger proximal phalanx were equivalent to or greater than the perioperative growth indices. There was a reduced postoperative length ratio in those patients with nonunion of the new trapezium to the base of the metacarpal. There was no change in strength and range of motion parameters with growth other than that related to normal improvement with age. CONCLUSIONS: We are unable to demonstrate premature physeal closure following routine pollicization. The growth of the metacarpal continues in a normal manner to skeletal maturity. A failure of union of the new trapezium to the metacarpal base may compromise growth. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Bone-ligament-bone Cuenod grafting technique modified by Saffar-Romano for the treatment of chronic scapho-lunate dissociation.

BACKGROUND AND AIM OF THE WORK: The authors show their experience about six patients suffering of chronic scapho-lunate (S-L) dissociation treated with the Cuenod method modified by Saffar-Romano. METHODS: Clinical assessment was performed in all patients and compared before and after surgery at follow-up measuring pain value through the VAS, ROM of the wrist with a goniometer, grip strength by Jamar test, functional outcome with the Italian version of the Disability of Arm, Shoulder and Hand (DASH) score. Radiological assessment consisted in measuring S-L angle and classifying radio-carpic and inter-carpic osteoarthritis. RESULTS: At radiographic check-up the reduction of the dissociation remained within the normal range of S-L angle (30°-60°) in 5/6 patients (83%). Clinical results were satisfactory for all the patients due to complete absence of pain and a good recovery of wrist function with more than 80% of the force and mobility compared to the contralateral side for three patients, and a recovery of more than 60% of the force and mobility for another patient. Mean DASH score was 8. All the patients returned to their previous job after a mean time of 4 months. CONCLUSIONS: Cuenod modified by Saffar-Romano grafting technique can be considered a brilliant solution for chronic S-L dissociation where S-L ligaments are completely worn included cases of SLAC I wrist.

Reverse second dorsal metacarpal artery vascularized bone flap for index distal bone loss: A case report.

Fingertip trauma with resultant bony loss is optimally reconstructed with an autologous bone substitute, offering a unique opportunity for use of a local vascularized bone graft. The second dorsal metacarpal artery is well-described for use in soft tissue and bony reconstruction, with recent cadaveric studies suggesting a reverse-flow second dorsal metacarpal artery bone flap could reach defects in the distal phalanx. The aim of the current report is to illustrate the use of this technique in reconstructing the distal digit in a traumatized index finger with bony loss of the middle third of the distal phalanx. A 49-year-old man presented with a traumatic circular saw injury to his left index finger, with the unique finding of distal phalanx bony loss to the middle third of this bone, with no associated disruption of palmar or dorsal structures. Reconstructive goals were solely that of bony reconstruction, with no soft tissue coverage required. A reverse SDMA vascularized bone flap was successfully used for reconstruction, with the vascularized bone flap mobilized on its reverse SDMA pedicle and pivoted at the level of the distal anastomoses between the palmar and dorsal metacarpal arteries. There was uncomplicated donor and recipient site closures, and good functional outcomes with the ability to retain full distal interphalangeal joint motion and force on distal pinch grip. This case shows that the reverse second dorsal metacarpal artery vascularized bone flap may be undertaken to reconstruct bony loss in the distal phalanx.

An arthroscopic-assisted minimal invasive method for the reconstruction of the scapho-lunate ligament using a bone-ligament-bone graft.

UNLABELLED: We report the outcomes of an arthroscopic-assisted minimally invasive technique to reconstruct the scapho-lunate ligament using a bone-ligament-bone graft in 11 patients (11 wrists). The mean follow-up time was 29 months (range 20 to 38). The preoperative mean wrist flexion, extension, grip strength and patient-rated wrist evaluation score values were 61°, 54°, 115 N and 54, respectively. The postoperative mean values were 64°, 58°, 142 N and 15, respectively. There were no statistical differences between the pre- and postoperative wrist flexion and extension, whereas changes in grip strength and patient-rated wrist evaluation score were significant. Scapho-lunate angles decreased significantly from 69° to 60°. Based on our clinical outcomes, this method provides a reliable alterative for the reconstruction of the scapho-lunate ligament in patients with persistent Geissler type 3 and 4 lesions in the short-term. LEVEL OF EVIDENCE: IV.

Occult Compression Fracture of Metacarpal Head without Evidence of Avascular Necrosis.

We report a case of 4th metacarpal head collapse of a 19-year-old healthy man. MRI revealed T1 low and T2 high regions in the collapsed 4th metacarpal head, as well as in the right 3rd and left 4th metacarpal head. Our initial diagnosis was occult compression fracture due to avascular necrosis, known as Dieterich's disease. However, pathological findings of surgically resected right 4th metacarpal head were compatible with transient osteoporosis and metacarpal head fracture followed by active tissue repair. The autologous osteochondral transplants from costchondral junction survived and maintained their size and shape even at 10-year follow-up.

Atypical thumb polydactyly with duplicated metacarpal bone: a report of 2 cases.

We report 2 cases of patients with thumb polydactyly that were difficult to classify into either Wassel type VI with a remarkable hypoplastic metacarpal or Wassel type VII (triphalangeal thumb). The radial digit was functional but hypoplastic, and the ulnar digit presented a dominant appearance but no active motion. The operative findings revealed that the radial and ulnar MP joints were completely independent and the metacarpal bones were separated, simulating Wassel type VI thumb polydactyly. In both cases, the ulnar digit was transported to the top of the radial metacarpal, accompanied by tendon transfer from the radial to the ulnar digit and rotation flap for web plasty. One year after surgery, the postoperative results showed good appearance and function of the preserved ulnar thumb in both cases.

Free vascularized metacarpal bone graft combined with extended dorsal metacarpal artery flap for phalangeal bone and soft tissue loss: case report.

A 45-year-old man suffered from a complex bone and soft tissue defect of the middle phalanx of his left middle finger after an electric saw injury. Here, we present the patient's clinical and radiological outcomes after reconstruction with a free vascularized metacarpal II bone graft and an extended distally based second dorsal metacarpal artery skin flap (DMCA). To our knowledge, this is the first description of a free vascularized metacarpal bone graft combined with DMCA for distal finger reconstruction.

The dorsal metacarpal arteries: anatomical study. Feasibility of pedicled metacarpal bone flaps.

The vascular anatomy of the dorsal aspect of the hand is variable. Nevertheless the presence of the first and the second dorsal metacarpal artery (DMA) is constant. DMA3 and 4 are more variable. The anatomical study presented demonstrates the segmental vascularization of the metacarpal bones and the possibility of harvesting metacarpal bone flaps. The reliability of such a flap decreases from the second to the fifth metacarpal bone regarding the frequency of presence of the DMAs. The authors describe six new vascularized bone flaps from the third and the fourth metacarpal bones pedicled on the second or the third dorsal metacarpal artery in an anterograde or retrograde flow mode. This study suggests that the radial and the ulnar side of the third metacarpal bone could be harvested respectively on the DMA2 and DMA3. The radial side of the fourth metacarpal bone could also be a reliable vascularized bone donor site. Flaps can be used proximally or distally based to repair bone defects either on metacarpal and carpal bones or on proximal phalanges.

Thumb metacarpophalangeal arthrodesis with local bone grafting.

A restrospective study identified 47 thumb MP joints in 41 patients who underwent arthrodeses using cup and cone osteotomy secured with Kirschner-wire fixation and augmented with local bone graft from the thumb metacarpal. Union rate was 96% averaging 6.8 weeks. Two patients had nonunion; 6.3 year follow-up of 15 thumbs showed improvement of or no pain. MHQ scores were 56.5 in the operative hand and 66.7 in the contralateral hand. Thumb MP arthrodesis augmented with local bone graft negates the morbidity of obtaining distant graft. It is a safe and effective technique that provides excellent pain relief with an acceptable union rate.

Morphometric analysis of potential osteochondral autografts for resurfacing unicondylar defects of the proximal phalanx in PIP joint injuries.

PURPOSE: This study was designed to morphometrically assess the base of the little and ring finger metacarpals as potential osteochondral donors to resurface distal condylar defects of the proximal phalanx. METHODS: The proximal phalanges were dissected from all 4 fingers in 10 cadaveric hands and the following measurements were obtained from the distal condylar surface: anteroposterior height, radial-ulnar width, and radius of curvature. Measurements were obtained from posteroanterior and lateral radiographic views, which were digitized and analyzed using digital imaging software. Comparable measurements were obtained from the base of the small and ring metacarpals. RESULTS: The anteroposterior dimension of both potential donor metacarpals was large enough to resurface the distal condyles of each of the proximal phalanges; however, this was not true for the radial-ulnar dimensions. The distal ulnar condyle of the long finger proximal phalanx was largest, measuring 4.9 (+/- 0.) mm dorsally and 6.2 (+/- 0.5) mm volarly in the radial-ulnar dimension. Only the small metacarpal base had sufficient stock in the radial-ulnar dimension (9.4 [+/- 1.7]) mm dorsally and 10.6 [+/- 2.0] mm volarly) to resurface this condyle. With respect to radius of curvature (ROC), the donor-to-recipient ROC ratio was 1.43 for the small metacarpal base versus 2.12 for the ring metacarpal base. Linear regression analysis revealed a stronger relationship in ROC between donor and recipient condyle when the small metacarpal base served as the donor (R = 0.96 vs R = 0.60). CONCLUSIONS: As determined from morphometric measurements of the 2 potential donor sites tested, the base of the small metacarpal provides the best match for resurfacing distal condylar defects of the proximal phalanges.

Neurocutaneous metacarpal flaps.

The article describes the possibility of covering large skin defects of the fingers by the use of fasciocutaneous flap from the back of the hand. It is pedicled on a sensory nerve branch and its paraneural tissue. The flap relies on blood supply from the constant para- and intraneural vascular network which gives perforator branches towards the overlying skin as well as on the constant anastomoses between the dorsal and volar arterial pool. We present a patient with a skin defect along the whole radial side of the index who underwent such reconstruction.

Treatment of scaphoid non-unions by a palmar approach with vascularised bone graft harvested from the thumb.

Ten patients with scaphoid non-unions which had been present for longer than 2 years were treated using a vascularised bone graft harvested from the thumb and pedicled on the first dorsal metacarpal artery. Bone harvesting and grafting were performed by a single palmar approach. Concomitant cancellous bone graft was not used. Bone healing was confirmed by CT scans in nine of the ten patients. Persistence of the non-union was observed in one patient who was the oldest in this series, had the longest standing non-union and was a heavy smoker. Twelve months after surgery, nine of the ten patients had significant pain relief with an improved range of motion and grip strength.

Osteonecrosis of the metacarpal head in a patient with a prothrombin 20210A gene mutation.

Osteonecrosis of the metacarpal head is rare and of unknown cause. We describe a 17-year-old girl with osteonecrosis of the fourth metacarpal head and a mutated prothrombin 20210A gene, which suggests a possible relation between a hypercoagulable state and osteonecrosis of the metacarpal head.