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Vascularized Olecranon Free Flap for the Treatment of Kienböck’s Disease
Arthur S Lanoux-Nguyen, MD, Hugo Palacios, MD and Kai Yang, MD, University of Nebraska Medical Center, Omaha, NE

Kienböck’s disease is a progressive avascular necrosis of the lunate. The Lichtman classification stages progression based on radiographic findings and is commonly used to guide treatment. Options range from non-operative immobilization to revascularization and wrist salvage procedures. The use of vascularized bone grafts (VBGs) in hand surgery for non-union, avascular necrosis, and bony reconstruction is favored due to accelerated healing, improved perfusion, and osteocyte preservation. Options for VBGs include pedicled extensor compartmental artery flaps from the distal radius and free medial femoral condyle or iliac crest grafts. These are all practical, however, they are limited by their pedicle or require creation of additional surgical sites beyond the operative limb. The olecranon free flap based on the posterior ulnar recurrent artery can be consistently harvested and relies on a single extremity as both the donor and recipient site. We present the novel use of a vascularized olecranon free flap in the treatment of Kienböck’s disease.

A 5x6x12mm vascularized olecranon free flap was harvested based on the posterior ulnar recurrent artery away from the olecranon tip (5cm pedicle). Microvascular anastomosis was performed to the deep branch of the radial artery and one vena comitans in the anatomical snuffbox. Intraoperative Doppler verified flow of the anastomosis. Post-operatively, the patient underwent scheduled imaging and occupational therapy. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was used to compare pre/post-operative outcomes.

Our patient had Stage 2 disease with sclerosis of the lunate on radiographs and low-intensity T1 signal on magnetic resonance imaging. Follow-up radiographs showed appropriate donor site healing without iatrogenic fractures. Pre-operative DASH score was 84.2, indicative of severe disability. Post-operative DASH score was 10.8, representing an 87.2% reduction in disability score at 5-month follow-up. Ongoing follow-up demonstrates cessation of chronic analgesic use and significantly improved range of motion and function.

The use of a vascularized olecranon free flap in the treatment of early-stage Kienböck’s disease is promising with significant improvement in disability and function. As described in anatomic studies, the flap can be reliably harvested from the proximal ulna based on the posterior ulnar recurrent artery. The consolidation of donor and recipient sites to a single extremity reduces donor site morbidity at multiple regions, decreases recovery time, and promotes earlier rehabilitation. Our experience using the olecranon free flap shows that this new free VBG as a viable option in hand and upper extremity reconstruction.

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