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The use of the 4th extensor compartmental vascularized bone graft for treatment of Kienböck's disease and tips for the appropriate capsulotomy. Cadaveric and clinical study
Frantzeska Zampeli, MD, PhD; Panagiotis Karras, MD; O Paliaroutas, MD; Panagiotis Kanellos, MD, PhD; Emmanouil Fandridis, MD, PhD
KAT Attica General Hospital, Athens, Greece
Introduction
An appropriate capsulotomy is required when performing lunate revascularization with vascularized bone graft (VBG) based on 4th extensor compartment artery (4
th ECA). The feasibility and effectiveness of a modification of Mayo capsulotomy that preserves the dorsal intercarpal arch (DICA) and the anastomotic vessel (AV) that provide retrograde blood flow to the 4
th ECA VBG were tested in a combined cadaveric and clinical study.
Material and methods
A radially based capsular flap was tested in eight freshly frozen cadaveric hands for the following characteristics: 1. The dorsal radiocarpal ligament (DRCL) limb of the capsulotomy should aim to preserve the AV and 4th ECA, and 2. the dorsal intercarpal ligament (DICL) limb should preserve the DICA. Five patients (median age 31years, range 27-37) with Kienböck's disease (3 Lichtman stage II, 1 stage IIIA, and 1 stage IIIB) treated with this technique were prospectively evaluated.
Results
For all cadaveric specimens, the 4th ECA ended up at the dorsal capsule just distally to the radiocarpal joint and ulnarly to Lister tubercle. Distally to this point the AV with the DICA and the course of the AV were not visible (intracapsular course). The DRCL limb of the capsulotomy should start ulnarly to both the Lister tubercle and the point that the 4th ECA ends in the dorsal capsule and should extend to the triquetrum. The capsulotomy then continues in parallel to the EDQ sheath. The DICL limb should extend enough distally, parallel to the level of 2nd/3rd carpometacarpal joint to protect the DICA, since the latter was not visible on the capsule in none of the specimens, but has a known intracapsular course. At median follow-up of 45 months (range, 42-47) pain VAS score improved from 7.3 (7-8) to 2 (1-3), ROM improved from 63° (55-70) to 79° (69-84) for flexion-extension, and from 18º (10-27) to 29º (15-35) for radial-ulnar inclination. The average Modified Mayo Wrist Score improved in 75 (65-85) from 55 (50-65). Evidence of lunate revascularization was shown 6 months postoperatively in MRI for all patients. Radiological progression of disease from stage II to IIIB was noted for one patient. No donor side morbidity neither wrist joint instability was noted.
Conclusions
The proposed capsulotomy allows for lunate approach, harvesting and positioning of the VBG and preservation of the retrograde blood flow of the 4th ECA VBG. The technique allowed for lunate revascularization and functional improvement in patients with Kienbock stage II-IIIB
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