Reconstruction Of The Proximal Scaphoid With A Pedicled Vascularized Osteo-Chondro-Ligamentous Graft From The Proximal Hamate : Cadaver Anatomic Study And Description Of A Novel Surgical Technique
Marie Witters, MD1; Charlotte Jaloux, MD, PhD2; Regis Legre, MD, PhD1; Anais Delgove, MD, PhD3; Vincent Casoli, MD, PhD3; Dominique Casanova, MD PhD4; Olivier Camuzard, MD PhD5
1Marseille University Hospital, Marseille, France; 2Marseille University Hospital Timone, Marseille, France; 3University Hospital Bordeaux, Bordeaux, France; 4Marseille Université Hospital, Marseille, France; 5Nice University Hospital, Nice, France
INTRODUCTION: Proximal scaphoid fragmentation inevitably leads to debilitating osteoarthritis. Despite dramatic functional consequences and even though a wide range of surgical techniques have been explored, scaphoid proximal pole reconstruction remains challenging. A recently described procedure, the ipsilateral hemi-hamate graft, seems promising. Indeed, it allows the reconstruction of scaphoid articular surfaces, the restauration of carpus biomechanical balance, and does not burn bridges for salvage procedures. However, given that the preservation of biomechanical properties of a composite graft over time are conditioned by its vascularization, the long-term results of this non-vascularized transfer are likely to be disappointing.
Therefore, we described a new surgical technique for the reconstruction of the scaphoid proximal pole using a vascularized osteo-chondro-ligamentous graft from the proximal hamate.
MATERIALS AND METHODS: The hemi-hamatum flap was harvested from 30 fresh anatomical subjects. On 30 subjects reinjected with colored latex the pedicle characteristics were noted and the dimensions of the hamate and scaphoid proximal poles were compared. On 15 of these subjects, we also performed a canulated screw osteosynthesis and assessed the scapholunate stability and donor site morbidity on dynamic radiographs.
RESULTS: The dorsal intercarpal arch allowed a pedicle transfer on the radial artery in 96% of the subjects. The average arterial diameter was 0.9 mm and average pedicle length was 3.1 cm, which allowed tension-free graft placement in all subjects. The morphology of the scaphoid and hamate proximal poles was very similar. The volar capitohamate ligament allowed reconstruction of the scapholunate ligament in all subjects. There was no carpal instability on dynamic radiographs in the 15 subjects with bone fixation.
There are anatomical variations in the vascularity (absence of anastomosis between the dorsal intercarpal arch and radial vessels in 4%) and morphology of the hamatum (less similarities in some subjects). To address these and select the best candidates for this innovative technique, a protocol including a pre-operative ultrasound able to visualize the pedicle pattern and a CT-scan with 3D reconstruction directly comparing the articular surface of the hamatum with the scaphoid fossa of the radius is being developed.
CONCULUSION: The pedicled hamate vascularized osteo-chondro-ligamentous graft can reconstruct the proximal scaphoid. To our knowledge, this is the first description of a pedicled graft able to reconstruct the complex osteo-chondro-ligamentous anatomy of the scaphoid proximal pole.
Back to 2023 Abstracts