Osteochondral Graft Syllabus
2013-10-14
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9/26/2013
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Joseph E. Imbriglia, MD
Clinical Professor
University of Pittsburgh Medical Center
Department of Orthopaedic Surgery
Director, Hand Fellowship Program
Osteochondral Grafting in
Proximal Row Carpectomy:
An old idea in a new place
•Peter Tang, MD, MPH
Orthopaedic Surgery Resident
University of Pittsburgh Medical Center
•Kermit S. Muhammad, MD
Hand Fellow
University of Pittsburgh Hand Fellowship
Collaborators
Indications:
•Scapholunate Advanced Collapse
•Scaphoid Nonunion Advanced
Collapse
• Kienbock’s disease with carpal
collapse
•Other arthritides of the wrist
Proximal Row Carpectomy
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Proximal Row Carpectomy
Benefits:
•Pain relief
•Motion preserving
•Grip strength improvement
Contraindication:
•Significant capitate arthritic
degeneration
since the new articulating
surfaces will be the capitate
and lunate fossa of the
radius . . .
Proximal Row Carpectomy
Proximal Row Carpectomy
•With an arthritic
capitate, other
procedures should
be chosen:
scaphoid excision
and midcarpal
fusion or total wrist
fusion
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•When there is minimal involvement (ie. < 3
mm, J Hand Surg 1990), PRC or PRC with
capsular interposition may still benefit the
patient
Proximal Row Carpectomy
CARTILAGE
Hunter stated in 1743 that,
“from Hippocrates down to the
present age, we shall find, that an
ulcerated cartilage is universally allowed to be a very
trouble-some disease; that it admits of a cure with
more difficulty than a carious bone; and that, when
destroyed, it is never recovered.”
What is the limiting problem?
(Philos Trans R Soc London B Biol Sci 1743)
•Is a unique tissue lacking vascular, nerve and lymphatic supply
•Lack of vascular and lymphatic circulation thought to be one
reason for the poor intrinsic capacity to heal
•No inflammatory response elicited unless the subchondral
bone is violated
•Any healing is with fibrocartilage which lacks the
biomechanical properties of hyaline cartilage
CARTILAGE
(Surgery of the Knee 2001)
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In the knee . . .
Symptomatic Treatment
•Lavage
o allows removal of loose articular particles, released enzymes, and
inflammatory mediators
o effect only temporary, underlying pathology not addressed
•Debridement
oRemoves mechanical symptoms
oSymptomatic relief, 80% improvement in first year with
gradual decline
How have other fields dealt with this
problem?
(Surgery of the Knee 2001)
•Multiple Drilling
–Pridie 1959
–Insall showed 40% success at 6 yrs
•Multiple Microfracturing
–Introduced by Steadman and Rodrigo
–75% success at 7 yrs
•Abrasion Arthroplasty
–Introduced by Johnson who showed success
rate of 77% at 2 yrs
Treatments that increase
vascularity
(Surgery of the Knee 2001)
Multiple Microfracturing
(Oper Tech Orthop 1997)
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Abrasion Arthroplasty
(Oper Tech Orthop 1997)
Autologous chondrocyte
transplantation
•chondrocytes harvested from patient and
cultured
•cultured chondrocytes transplanted under
periosteal flap
Autologous chondrocyte
transplantation
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Autologous chondrocyte
transplantation
17 y.o. female 1 year after
pinning of osteochondral
fragment
Autologous chondrocyte
transplantation
Autologous chondrocyte
transplantation
Two years after
autologous
chondrocyte
transplantation
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Osteochondral Autografting
•Matsusue first reported in 1993
•Hangody reported a 2 – 5 yr follow-up with good
or excellent results in 86% to 90% of cases
•Histologic evaluation from animal studies show:
1. Survival of transplanted hyaline cartilage
2. Composite of 80% transplanted hyaline cartilage and
20% fibrocartilage
3. Deep matrix integration at the recipient site
Osteochondral Autografting –
Mosaicplasty (Cobblestoning)
(Oper Tech Orthop 1997)
Osteochondral Autografting –
Mosaicplasty (Cobblestoning)
OPEN ARTHROSCOPIC
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Osteochondral Autografting
5 1/2 years after
mosaicplasty
Osteochondral Autografting
In the wrist . . .
•Sandow in 1998 reported
using rib bone/cartilage
autografts in 22 pts for
deficiency of the proximal
scaphoid due to fx or
necrosis
•Found good to excellent
results at median 24 mos
follow-up with the use of the
costo-osteochondral
autograft (J Hand Surg Br 1998)
Osteochondral Autografting
•Salon reported in 2003, 2 cases of
Kienbock’s disease in which peri-lunate
chondral lesions contraindicated classical
PRC or 4 corner arthrodesis
•In one case the lunate fossa of the radius
was damaged
•An osteochondral graft was harvested from
the triquetrum and implanted into the fossa
(Chirurgie de la Main 2003)
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Osteochondral Autografting in
Proximal Row Carpectomy
THE PITTSBURGH SERIES
Osteochondral Autografting in PRC
Essentials:
•Identify patients in whom PRC was planned,
but found to have capitate chondrosis
intraoperatively
•Utilize the resected scaphoid, lunate, and
triquetrum as sources of osteochondral grafts
•Osteochondral autograft these arthritic lesions
Osteochondral Autografting in PRC
To date:
•5 patients have undergone grafting to their
capitate
•Chondrosis rated: Grade 3 in three pts, grade
3-4 in two pts
•Size of defects: 5x5 mm (x4) and 10x6 mm
•1 patient underwent grafting from the
triquetrum to the lunate fossa of the radius
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Case 1
Case 1
Case 1
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Case 1
Case 1
Case 1
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Case 1
Case 1
Case 1
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Case 1
Case 1
Case 2
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Case 2
Case 2
Case 2
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Case 3
Case 3
Case 3
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Case 3
Case 3
graft in place
Osteochondral Autografting in PRC
Summary:
•Osteochondral autografting can be successfully
done in the PRC with capitate chondrosis
•The resected carpal bones provide an adequate
source of autograft
•PRC with osteochondral autografting extends the
indications of PRC and
•broadens the treatment options for arthritides of
the wrist
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Sponsors & Acknowledgements
We would like to thank Arthrex for their kind
donation of grafting tools for this research.
Thanks to our Arthrex Representative Carol
Pribela for her support and interest.
Thanks to our Arthrex Engineer Robert Sluss.
9/23/2013
1
Descending Geniculate Artery flaps
for reconstruction of the
recalcitrant scaphoid nonunion
James Higgins, MD
Chief of Hand Surgery
Raymond Curtis National Hand Center
Baltimore, MD
Medial femoral condyle corticoperiosteal flap:
Scaphoid Nonunions
Doi K et al.
JHS 25(3):507-519. 2000.
10 patients with
established nonunions
10 achieved union at avg
12 weeks
Jones DB, Buerger H, Bishop AT,.
PRS 125:1176-84. 2010.
12 patients
All achieved union avg 13
weeks (6-26)
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Suggested approach
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Subfascial dissection protects
skin perforators
Branches
to muscle
Branches
to skin
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Cartilage-bearing
Medial Femoral Trochlea (MFT)
flaps
20y/o male with 3 year hx scaphoid nonunion
Reconstruction 2006
Courtesy of H. Bϋrger, MD
Kalicke T, Burger H, Muller EJ.
Unfallchirurg 2008; 111:201-205.
© Curtis National Hand Center 2012
9/23/2013
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Courtesy of H. Bϋrger, MD
Surg Radiol Anat (2010) 32:817–825
Vascularized osteochondral graft from the medial femoral
trochlea: anatomical study and clinical perspectives
Sébastien Hugon · Alain Koninckx · Olivier Barbier
Hand Surgery Unit, Orthopaedic Surgery Service,
Namur Regional Hospital Center, Avenue Albert 1er, 185,
5000 Namur, Belgium
With permission
39 y/o male surgeon
Injury Sept 2005
January 2006 ORIF
herbert style screw
dorsal approach
June 2006 ORIF
nonunion with accutrak
screw, iliac crest graft,
volar approach
Currently with 5 year
recalcitrant nonunion
Bϋrger & Higgins
9/23/2013
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Bϋrger & Higgins
Bϋrger & Higgins
Bϋrger & Higgins
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Bϋrger & Higgins
One week postop
Bϋrger &
Higgins
1 week postop
Bϋrger & Higgins
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One week postop
Bϋrger & Higgins
One week postop
Bϋrger & Higgins
8 months postop
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One year postop
3 years postop
27 y.o. RHD male
proximal scaphoid fx 2
years ago
Initially treated
conservatively >
non-union.
One year ago treated
with 1,2-ICSRA
vascularized bone-
grafting and screw
fixation. Continued to
have pain and difficulty
with function.
9/23/2013
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© Curtis National Hand Center 2012
9/23/2013
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9/23/2013
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Example of skin paddle used for monitoring MFT flap
for scaphoid nonunion osteocartilagenous arthroplasty
Skin paddle is removed after two months for contour/cosmesis
9/23/2013
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4 weeks postop.
Bürger H, Windhofer C, Gaggl A, Higgins, JP. Jour Hand Surg (A) April 2013
One year postop
9/23/2013
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Alternative volar approach
Courtesy Dr Heinz Bürger
10/14/2013
1
Thumb Carpometacarpal
Arthroplasty with Ligament
Reconstruction and
Interposition Costochondral
Arthroplasty
Thomas Trumble M.D., Gregory
Rafijah M.D., Dennis Heaton
MSPA,PA-C
Overview
•Multiple techniques currently available for
stabilization, and reconstruction of the basal
joint of the thumb.
•Ultimate goal is to provide substantial pain
relief while maintaining TM height, stability,
and overall strength and function.
Demographics
•58 patients; 66 thumbs.
•Eaton Stage III STT
sparing pattern OA.
•Age range 40-88 years
•48 female, 10 male.
•No patients were insulin
dependent diabetics, or
suffered from
inflammatory
arthropathies.
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Technique
•Curvilinear incision is
made along the volar
radial aspect of the
thumb CMC joint. EPB
tendon, DRSN, and deep
branch of the radial
artery are carefully
dissected and retracted
volarly and dorsally of
the incision .
Technique
•The capsule including,
including the APL
insertion, are sharply
dissected off the
metacarpal, and later
reattached with
braided, non-
absorbable, sutures
through drill holes.
Technique
• An arthrotomy is
performed and the STT
joint is inspected to
confirm that it is free of
degeneration.
•The trapezium is then
partially resected using
an oscillating saw.
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Technique
-The FCR tendon is split
longitudinally, and a
length of 12cm is
harvested through a
longitudinal incision at
the junction of the distal
medial thirds of the
forearm.
-Drill holes are placed
from the base of the
metacarpal to the radial
aspect of the thumb
metacarpal, and from
the palmar surface of
the trapezium to the
distal articular surface.
Technique
-The FCR tendon is split
longitudinally, and a
length of 12cm is
harvested through a
longitudinal incision at
the junction of the distal
medial thirds of the
forearm.
-Drill holes are placed
from the base of the
metacarpal to the radial
aspect of the thumb
metacarpal, and from
the palmar surface of
the trapezium to the
distal articular surface.
Littler ref
-The FCR tendon is split
longitudinally, and a
length of 12cm is
harvested through a
longitudinal incision at
the junction of the distal
medial thirds of the
forearm.
-Drill holes are placed
from the base of the
metacarpal to the radial
aspect of the thumb
metacarpal, and from
the palmar surface of
the trapezium to the
distal articular surface.
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Technique
•A costochondral
allograft is shaped into
a disc to fit the
dimensions of the
resected portion of the
trapezium.
Technique
•22 gauge cerclage wire
is used to weave the
FCR tendon through
the trapezium, the
allograft cartilage, and
the metacarpal. The
tendon is then sutured
back on itself with a
non-absorbable
braided suture.
Post-operative
•0-6 weeks:The patient is placed in a forearm
based thumb spica cast
•6-12 weeks: A removable splint is then fitted,
and the patient begins AROM of the MCP,
and abduction and rotation of the CMC.
PROM is not started to avoid stress to the
ligament reconstruction.
•At 8- 10 weeks unrestricted thumb motion is
started.
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Results
•DASH questionnaires were completed by each
patient.
•Grip strength and lateral pinch.
•TM height.
•TM subluxation.
•Radial abduction
•Palmar abduction.
•MCP ROM
•IP ROM
Results- Radiographic
•TM Height is measured by
taking the distance from
PA radiographs.
•Measurments are taken
from the proximal edge of
the trapezium to the
distal end of the
subchondral bone of the
metacarpal.
•The proximal phalanx of
the thumb was used as a
comparative standard.
Outcomes
•Avg. DASH postop was 11
•Grip increased by 32%
•Pinch increased by 38%
•TM height well maintained (53.1mm pre; 52.9mm
post.)
•TM alignment maintained, minimal
subluxation.(0.21mm pre; 0.22mm post.)
•Radial abduction increased by 3˚ (± 6°)
•Palmar abduction increased by 1˚ (± 8°)
•MCP and IP ROM did not significantly increase or
decrease
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Outcomes
0
10
20
30
40
50
60
1 2 3 4
TM Height Before
TM Height After
Grip Before
Grip After
Pinch Before
Pinch After
Outcomes
•Postoperative pain relief and pinch/grip
strength had a direct correlation with patient
satisfaction.
•Grip and pinch improved with maintenance of
TM height and decreased TM subluxation.
•DASH score decreased as function and
stability were maintained, as evident in the
maintenance of pinch, grip, and overall TM
stability.
Complications
•1 patient in the series progressed to develop
stage IV OA ofthe STT joint.
•A complete trapeziectomy was performed. A
silastic tie-in prosthesis was used to maintain
TM height. At one year follow up, the patient
had excellent pain relief, and was able to
return to all pre-operative activity.
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Discussion
•Research published by Luria et al, entitled,
“Biomechanic Analysis of Trapeziectomy,
Ligament Reconstruction, and Tie-In
Trapezium Implant Arthroplasty for Thumb
Carpometacarpal Arthritis: A Cadaver
Study.”(J. Hand Surg. 2007;32A 697-706)
Thumb Stability and Function
•Conclusions: Interposition arthroplasty to
maintain height and ligament reconstruction
for stability provided the most stable
construct.
Luria Et al, J. Hand Surg 32A 697-706
Figure 5. The average axial displacement (proximal metacarpal migration)
ratio with loading of the tendons (n 12). Implant,
silicone trapezial implant; Trap, trapeziectomy
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Luria Et al, J. Hand Surg 32A 697-706
Tension Applied to Tendons Simulates Pinch
Luria Et al, J. Hand Surg 32A 697-706
Figure 5. The average axial displacement (proximal metacarpal migration)
ratio with loading of the tendons (n 12). Implant,
silicone trapezial implant; Trap, trapeziectomy
Discussion
•This technique of interposition arthroplasty
and ligament reconstruction showed
improved patient outcomes, based on clinical
measurments obtained postoperatively,
including DASH, TM height, TM subluxation,
grip, pinch
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Thank You
9/10/2013
1
Scaphoid Nonunion
Jeffrey Yao, MD
Associate Professor of Orthopaedic Surgery
Stanford University Medical Center
II Curso Internacional de Post Grado
Actualización en Cirugía de
la Mano, Muñeca y Codo
August 8, 2013
Disclosures
•The following relationships exist:
1. Grants
American Foundation for Surgery of the Hand
2. Royalties and stock options
Arthrex
3. Consulting income
Smith and Nephew Endoscopy, Arthrex, Axogen
4. Research and educational support
Arthrex
5. Editorial Honoraria
Elsevier, Lippincott
6. Speakers Bureaus
Arthrex, Trimed
Treatment Options for Scaphoid
Nonunions
–Bone Graft
•Iliac Crest, Russe Method, Volar Wedge Graft
(Humpback)
–Vascularized Bone Grafts
•1,2 ICSRA
•Vascular Bundle Implantation (Hori)
•Pronator Pedicle Graft
•Volar carpal artery pedicled graft
•Free medial femoral condyle graft
9/10/2013
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Treatment Options for Scaphoid
Nonunions, Cont.
–Salvage Procedures
•In the case of DJD
•Denervation
–PIN, AIN
•Radial Styloidectomy
•Proximal Row Carpectomy
•Partial or Total Wrist Arthrodesis
•Scaphoid Arthroplasty
What About a Unsalvagable
Proximal Pole Scaphoid Nonunion
with no DJD?
History
•20 y/o football lineman sustained a L
scaphoid fracture during a game
•Treated with CRPF
•5 months later, resumed high impact
activity, developed pain with wrist motion
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Initial Post-Op Xrays
5 Months Post-Op
5 Mos Post-Op CT
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CT Reconstructions
Options?
•Proximal pole excision
–Too large
•Salvage Procedures
–Too young
–No DJD
•Excision and Interposition
–Silastic- synovitis
–Pyrocarbon – more data
–Tendon – carpal height
–Scaphoid allograft – ? healing potential
–Rib osteochondral autograft?
Rib Osteochondral Autograft
•Used for mandibular
reconstruction
–Stone, Arch Otolaryngol.
1965
•Also described for:
–Plastic surgery
•Nasal reconstruction
–Treatment of osteochondral
articular defects
•Scaphoid Reconstruction
–Sandow (1989)
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Fragmented Proximal Pole
Void Following Excision
Bleeding at the Remaining Waist
9/10/2013
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Rib Osteochondral Autograft from
7th Rib via Submammary Incision
Rib Osteochondral Autograft from
7th Rib via Submammary Incision
Cartilage / Bone
Autograft Implanted
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Autograft Pinned
Post-Operative Regimen
•Chest radiograph in PACU
•7-10 days: Splint immobilization
•2-6 weeks: Cast immobilization
•After healing is confirmed (6-12 weeks):
Pins are removed and onset of ROM
exercises, advance to strengthening
exercises as tolerated
•12 weeks: Weight-lifting, pushups
•4-5 mos: Contact sports
2 Weeks Post-Op
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24 Months Post-Op
24 Months Post-Op
24 Months Post-Op
9/10/2013
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24 Months Post-Op
•DASH: 9.1
•PRWE: 18
•ROM:
–Flexion: 80/70
–Extension: 60/65
–RD: 20/15
–UD: 40/40
•JAMAR: 100/110
Scaphoid Nonunion Failed VBG
Exposure to the 7th Rib
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Harvest Rib Graft
Harvested Graft
Harvest Rib with Saw
9/10/2013
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Elevate the Rib from the Pleura
Scaphoid Defect
Shape the Graft
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Inset the Graft
Graft Implanted
Repair SLIL
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Final Fixation
2 Months Postop (pins
removed)
Case #2
•24 y/o with L proximal pole scaphoid
nonunion treated with 1,2 ICSRA VBG 8
months ago
•Continued to have painful ROM
9/10/2013
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8 months Post VBG
Post-Op Rib Osteochondral
Autograft
3 Years Post-Op Rib
Osteochondral Autograft
9/10/2013
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3 Years Post-Op Rib
Osteochondral Autograft
3 Years Post-Op Rib
Osteochondral Autograft
•DASH: 4.5
•PRWE: 11
•ROM:
–Flexion: 85/60
–Extension: 80/70
–RD: 30/10
–UD: 40/38
•JAMAR: 95/75
Case # 3
•18 y/o with L scaphoid nonunion treated
with 1,2 ICSRA VBG 12 months prior
•Continued to have painful ROM
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2 months Post VBG
12 months Post VBG
Post-Op Rib Osteochondral
Autograft
Returned to work as a
heavy laborer
9/10/2013
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9 Years Post-Op Rib
Osteochondral Autograft
9 Years Post-Op Rib
Osteochondral Autograft
9 Years Post-Op Rib
Osteochondral Autograft
•DASH: 36
•PRWE: 56
•ROM:
–Flexion: 80/50
–Extension: 66/40
–RD: 25/12
–UD: 45/35
•JAMAR: 100/62
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Outcome Studies
•Sandow (JHS Br, 1998)
–19/22 G/E results at median 24 month f/u
•Improved grip (59-80%), ROM, less pain
•No deterioration of carpal alignment
•No non-unions, no major complications (1 mild
hemothorax)
Outcome Studies
•Sandow (Techniques H&UE, 2001)
–47 patients
–85% G/E results at median 15 month f/u
•No apparent non-unions, no major
complications (1 mild hemothorax, 1 pleural
effusion)
Outcome Studies
•Veitch (JBJS Br, 2007)
–13/14 G/E results at mean 64 month f/u
–Improved grip, ROM, less pain
–No non-unions, no complications
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Unsalvageable Proximal Pole
Scaphoid Defects
•Uncommon
•Osteochondral autografts
–Viable alternative
•Chronic scaphoid nonunions
•No evidence of arthritis
–where salvage procedures may not be ideal
•Younger patients
•No DJD
–Outcomes studies remain promising
Thank You!
10/11/2013
1
RANDA L L W . C U LP, M D
SI D N E Y M . JA C OB Y , M . D .
PET E R F. D E LUC A , M . D.
Osteochondral Autograft
Transplantation for Articular
Defects in the Hand and Wrist
Disclosures
I have no conflicts of interest.
Purpose
•The osteochondral autograft transfer system
(OATS) procedure has been described for
osteochondral defects
•i.e., knee/talus
•Hypothesize that this procedure can be used for
articular defects in the hand and wrist, with good
functional results
10/11/2013
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Background
Hyaline cartilage has a poor intrinsic healing capacity
treatment of focal osteochondral defects remains a challenging
problem
Osteochondral defects in the hand and wrist are
relatively infrequent injuries and often present in young
patients with high levels of activity or trauma
No gold standard of treatment
Joint preserving techniques
Debridement, microfracture, ACI, OATS
Salvage techniques predictable for pain relief
Expense of strength/motion
OATS advantages
Hyaline cartilage transplantation
Low morbidity
Methods
Retrospective chart review of four male patients
Treated with an OATS procedure for an articular
defect of their hand or wrist
May 2010 and February 2011.
Avg age: 30 y/o
All pts had failed months to years of conservative
management
Methods
Injuries consisted of osteochondral defects in:
proximal lunate (2)
proximal scaphoid
index metacarpal head
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Outcome variables
four month postoperative grip strength
Jamar III position
range of motion (wrist/MCP)
time to return to normal activity
radiographic evidence of osteochondral plug in-
growth
Patient #1
20 y/o M student
Recreational hockey
LHD
17 mths prior – fall off roof
R distal radius fx and L both bone fx – ORIF
Persistent R wrist pain despite PT
ROM
F/E: 60°/55°
R/U: 20°/45°
Jamar III grip (R/L): 52/65 PSI
Patient #1 (pre-op)
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Patient #2
36 y/o M financial advisor
Avid golfer
RHD
Fall off ladder 1 ½ yrs earlier
R min displaced radial/ulnar styloid fx – non-op tx
Failed 5 mths of PT
ROM
F/E: 25°/40°
R/U: 20°/45°
Jamar III grip (R/L): 100/110 PSI
Patient #2 (pre-op)
Patient #3
40 y/o M CFO
Recreational golf/hockey
RHD
2 yrs s/p R wrist arthroscopy and TFCC repair
Persistent R wrist pain, crepitus radio-lunate joint
ROM
F/E: 40°/40°
Jamar III grip (R/L): 55/80 PSI
10/11/2013
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Patient #3 (pre-op)
Patient #3 (pre-op)
Patient #4
23 y/o M minor league baseball player
RHD
Hit by pitch 16 mths prior
Pain at index MCP
Steroid injection – minimal relief
ROM (MCP) w/ crepitus
F/E: 60°/0°
Jamar III grip (R/L): 75/140 PSI
10/11/2013
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Patient #4 (pre-op) – 5 mths after injury
Patient #4
Surgery
All cases were performed by me
Appropriate-sized graft from pt’s contralateral
lateral femoral condyle was performed by our
sports medicine colleagues
10/11/2013
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Technique for lunate/scaphoid injuries
Diagnostic wrist arthroscopy initially used to
assess the articular surface for carpal injuries
(patients #1-3)
No distal radius lesions noted
Adhesions debrided
3rd/4th compartment extensor interval
approach used and graft tapped into position
using press-fit technique into recipient site
Articular congruity confirmed via direct
visualization and fluoroscopy
Full ROM achieved with no crepitus
Technique for MC head injury
EDC/EIP interval and dorsal capsulotomy utilized
Osteophyte removed
Base of proximal phalanx uninjured
Donor/graft site technique same as for carpal
injuries
Direct/fluoroscopic visualization again confirmed
articular congruity
10/11/2013
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Post-op Protocol
Active range of motion was initiated following the
first post-operative visit
Removable splint for comfort
WBAT to lower extremity
Strengthening w/ formal OT/PT began at 4 weeks
post-operatively
Post-operative radiographs were obtained at 6
weeks
Post op Results
Patient #1 (lunate)
ROM (F/E): 55°/50°
Grip (R/L): 80/80
Patient #2 (scaphoid)
ROM (F/E): 30°/55°
Grip (R/L): 60/95
Patient #3 (lunate)
ROM (F/E): 50°/40°
Grip (R/L): 70/88
Patient #4 (MC head)
ROM (F/E): 0°/80°
Grip (R/L): 90/100
Patient #1 (pre-op)
10/11/2013
9
Patient #1 (post-op) (12 mths)
Patient #2 (pre-op)
Patient #2 (post-op) (4 mths)
10/11/2013
10
Patient #3
No digital post-op films available – outside films
showed graft in-growth
Patient #4 (pre-op) (17 mths after injury)
Patient #4
10/11/2013
11
Patient #4 (post-op (4 mths)
Results
Avg time from injury to surgery: 29 mths
Minimum follow up: 6 mths
Avg gain of motion: 6° (range: -5-20°)
Avg gain of grip strength: 18 PSI (range: -40-28°)
XR evidence of graft position and in-growth seen in
all cases
1 pt w/ knee stiffness that resolved
All patients satisfied with outcome and resumed
their prior levels of activity
Golf/hockey/baseball
Results
Patient S
e
x Injury Age Occupation Wrist F/E MCP F/E Jamar III R/L Subjective
Time to
full
activity
(mths)
Pre Post Pre Post Pre Post
1 M
Osteochondral
defect proximal
lunate, prior
ORIF distal
radius fracture
20 College
student 60/
55 55/
50 - 52/
65 80/
80
No crepitus or pain. No
knee symptoms
Returned to hockey 1
2 M
Osteochondral
defect proximal
scaphoid, prior
radial styloid
fracture treated
non-operatively
36 Financial
advisor 25/
40 30/
55 - 100/
110 60/
95 No crepitus or pain
Mild knee stiffness 4
3 M
Osteochondral
defect proximal
lunate, prior
arthroscopic
TFCC repair, no
history of trauma
40 Chief
financial
officer
40/
40 50/
40 - 55/
80 70/
88
No crepitus or pain
No knee symptoms
Returned to golf and
hockey
3
4 M
Osteochondral
defect index
metacarpal head
and AVN
23 Minor
league 3rd
baseman
- 60/
0 80
/0 75/
140 90/
100
No crepitus or pain
No knee symptoms
Returned to prior level
of play
5.5
10/11/2013
12
Case Reports
JHS Feb 2011
JHS Nov 2007
OATS Procedure Conclusions
•Viable treatment option for the treatment of hand and
wrist osteochondral defects in young, active patients
who have failed conservative management
•Technically demanding
•Incorporates hyaline cartilage plug into the defect site
•Capabilities of regrowth/regeneration7
•Biomechanically superior to fibrocartilage9
•Successful outcomes:
•congruent articular surface is achieved
•motivated patient is able to complete an appropriate course of
occupational hand therapy
Thank you!
Questions?
