Successful Metacarpal Reconstruction after Gunshot Injury: First Clinical Application of Novel Vascularized Olecranon Bone Graft
Rakel M. Zarb, MD1; Rachel Cohen-Shohet, MD2; Patrick C Hettinger, MD3
1Medical College of Wisconsin, Milwaukee, WI; 2Medical College of Wisconsin, Wauwatosa, WI; 3Department of Plastic Surgery, Medical College of Wisconsin, Wauwatosa, WI
Background: Due to angiogenic potential and earlier achievement of union, vascularized bone grafting (VBG) has been utilized for hand reconstruction in cases of non-union and avascular necrosis. The medial femoral condyle and iliac crest are well-established options for free VBG, although they are harvested from a distant site relative to the recipient upper extremity. The vascularized olecranon bone graft, which was recently described in a cadaveric study, provides a new surgical option. We present the first clinical application of this novel VBG.
Methods: A 28-year-old man sustained an open fourth metacarpal diaphyseal fracture with severe comminution and a 3 cm bone gap from an unintentional self-inflicted gunshot wound (Fig. 1). After initial debridement and percutaneous pinning, the patient had a persistent nonunion with loss of height, segmental bone loss, and poor active range of motion. He had a history of smoking but was otherwise healthy. We proceeded to the operating room for scar release and reconstruction of the osseus defect with a vascularized olecranon bone graft (Fig. 2). A bone graft (3.5 cm by 1.2 cm) with a 3.5 mm long pedicle based on the recurrent ulnar artery was harvested with preservation of the elbow joint. The deep palmar arch served as the end-to-end recipient vessel.
Results: The patient was discharged home without any immediate complications and has been followed closely as an outpatient for one year post-operatively. The final range of motion of the ring finger metacarpophalangeal joint is 0 to 50 degrees. His final DASH (disability of the arm, shoulder, and hand) score was 7 from 59. He has achieved clinical and radiographic union and has returned to full activity without pain or donor site morbidity (Fig. 3, 4, 5).
Conclusions: The vascularized olecranon bone graft is clinically feasible and was successfully used to reconstruct a metacarpal diaphyseal nonunion due to a gunshot wound. This novel donor site may be considered in cases of challenging hand reconstruction.
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