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Textbook Outcomes in Medial Femoral Condyle/Trochlea Free Flap Reconstruction for Scaphoid Nonunion
John R. Dennen, BS, Robert G. DeVito, MD, Malik Walker, BS, Ava G. Chappel, MD, Aaron M. Freilich, MD; Brent R. DeGeorge, M.D., P.h.D.
University of Virginia Health System, Charlottesville, VA
INTRODUCTION: In surgery, textbook outcomes represent a composite metric of multiple variables that indicate baseline success in a specific procedure. These outcomes can be compared across surgeons and institutions. This study aimed to define a textbook outcome for the operative repair of scaphoid nonunion using medial femoral condyle (MFC) or medial femoral trochlea (MFT) vascularized bone flaps and identify the rate of textbook outcomes at our center.
MATERIALS & METHODS: Three hand surgeons with expertise in scaphoid nonunion reconstruction using MFC/MFT grafts defined the criteria for a textbook outcome. After obtaining IRB approval, a retrospective review of cases from 2017 to 2024 at a single institution was performed. A textbook outcome was defined as meeting the following criteria: no flap loss, no intraoperative complications, a length of stay of less than two nights, radiographic union at three months postoperative on CT scan, return to baseline hand activities and pain-free hand activities at final follow-up, return to baseline and pain-free lower extremity activities by postoperative day 90, no recipient or donor site infections requiring intravenous antibiotics, no systemic complications, no emergency room admissions or hospital readmissions within 90 days, no mortality, and no surgical complications requiring reoperation.
RESULTS: A total of 38 patients met the inclusion criteria, with 27 (71.1%) achieving a textbook outcome. The most common criteria not met were surgical complications requiring reoperation (10.5%), return to baseline hand activities at final follow-up (7.9%), pain-free hand activities at final follow-up (7.9%), and return to baseline lower extremity activities by postoperative day 90 (7.9%). Of the 11 cases that did not achieve a textbook outcome, 5 violated one criterion (45.4%), 3 violated two criteria (27.3%), and 3 violated more than two criteria (27.3%).
CONCLUSIONS: Textbook outcomes are useful quality metrics for evaluating surgical success. By utilizing 13 criteria for scaphoid nonunion reconstruction with vascularized MFC or MFT grafts, cases can be assessed and compared using a single metric. Statistical analysis can help identify predictors of textbook outcomes, offering future opportunities to improve patient outcomes.
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