Abstract
In 1910, Kienböck described the idiopathic progressive avascular osteonecrosis of the lunate (Kienböck, Fortschr Geb Rontgenstr XVI(2):77–103, 1910). A multitude of treatment options have been described, as well as clinical, radiographical, and arthroscopic staging classifications. One of the most novel recent reconstructive options is the use of free osteochondral flaps from distal femur in cases of advanced lunate fragmentation and collapse (Lichtman stage IIIa-IIIb Kienböck’s disease).
Two harvest sites have been employed for these osteochondral reconstructive procedures: the medial femoral trochlea (MFT) based on the descending geniculate artery (DGA), and the lateral femoral trochlea (LFT) based on the superolateral geniculate artery (SLGA). This installment will describe the senior author’s preferred treatment using the lateral femoral trochlea for lunate reconstruction.
The SLGA demonstrates constant anatomy. The pedicle is a convenient length for wrist reconstruction, and provides good caliber for ease of microsurgery. The morphology of the LFT is favorable morphology for lunate reconstruction. When examined on the axial plane, the angle created between the lateral cortical surface and the anterior cartilage surface closely approximates 90° (rather than the more sloping angle encountered on the MFT flap). After the fragmented and necrotic proximal lunate is excised, the LFT’s convex cartilage surface is used to reconstruct the proximal articular surface that articulates with the radius. The viable distal lunate is preserved along with the scapholunate and lunotriquetral ligaments. The vascularized LFT flap heals to the preserved distal lunate segment and restoring carpal height, stability, and congruity. The LFT flap provides a joint preserving alternative in cases of advanced Kienböck’s disease. It has shown good clinical outcomes of pain reduction and range of motion. Radiographic follow up has demonstrated healing of the reconstructed lunate without further osteonecrosis, restoration of carpal height, and stability and congruity of radiocarpal and midcarpal joints. An exemplary case is used below to illustrate the surgical technique.
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Anoshina, M., Higgins, J.P., Jiga, L.P., Bürger, H. (2022). Treatment of Kienböck’s Disease Using Free Vascularized Cartilage Bone Flaps from the Lateral Femoral Condyle. In: Gravvanis, A., Kakagia, D.D., Ramakrishnan, V. (eds) Clinical Scenarios in Reconstructive Microsurgery. Springer, Cham. https://doi.org/10.1007/978-3-030-23706-6_45
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