TECHNIQUE
Post-traumatic Malunion of the Distal Radial Intra-articular Fractures Treated With Autologous Costal Osteochondral Grafts and Bioabsorbable Plates Kayoko Furukawa, MD, Akinori Sakai, MD, PhD, Kunitaka Menuki, MD, PhD, Toshihisa Oshige, MD, PhD, Yukichi Zenke, MD, PhD, and Toshitaka Nakamura, MD, PhD
Abstract: Intra-articular distal radial fractures with partial bone loss at the wrist were reconstructed using osteochondral grafts in 2 patients who were followed up for at least 18 months. Both patients experienced posttraumatic arthrosis of the wrist joint. The materials of the intra-articular fixation were bioabsorbable plates and screws. Reconstruction of a partially destroyed articular surface using a costal osteochondral graft is reliable and allows filling and resurfacing an articular cartilage void. Key Words: costal cartilage graft, radiocarpal joint arthrosis, bioabsorbable plate, surgical treatment
imaging revealed cartilage and bone defects at the scaphoid fossa and the lunate fossa. The defect size was 11 10 6 mm in the first patient and 10 16 17 mm in the second patient. The articular cartilage defect was assessed using arthroscopy and could be easily visualized, despite the joint space narrowing, owing to partial arthrosis. We confirmed mild fibrillation on the carpal side and partial loss of articular cartilage on the radial side. On the basis of the patient symptoms, the CT images (Fig. 1), and the arthroscopic findings (Fig. 2), we decided to perform autologous costal osteochondral graft.
SURGICAL TECHNIQUES
(Tech Hand Surg 2014;18: 15–19)
First Phase: Costal Osteochondral Graft Harvest
D
isplaced intra-articular distal radial fractures are initially managed with open reduction and internal fixation with volar locking plates. However, residual problems such as pain and stiffness cause loss of mobility in patients who demand a high level of function. Various methods are available for the treatment of radiocarpal arthrosis. They include arthrodesis, vascularized joint transfers,2 joint replacement, and perichondrial graft. However, classical existent techniques have some problems, such as neighboring carpal joint arthrosis, graft size, and donor site complications. We selected out costal osteochondral autografting and bioabsorbable plating for partial destruction of the radiocarpal joints surface that were treated with.
PATIENTS AND METHODS The 2 patients injured their right wrists and experienced destruction of the distal radius of their dominant hands while they were working. The first patient was a transport operator, and the second was a building contractor. They had highenergy joint fractures, which were classified as AO classification C3 (Table 1) and initially reduced in surgeries with volar locking plates. Rapid arthritic progression subsequently followed because of cartilage and bone defects. In both cases, the patients complained of the following symptoms: moderate but continuous pain (Quick DASH score: one was 45.8, the other was 66.0), functional loss in flexion/extension, and loss of wrist strength (less than half that of the dominant side). Pronation/supination was almost preserved in both the cases. Six months after the first surgery, computed tomography (CT) From the Department of Orthopaedic Surgery, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan. Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding. Address correspondence and reprint requests to Kayoko Furukawa, MD, Department of Orthopaedic Surgery, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishiku, Kitakyushu 807-8555, Japan. E-mail: [email protected]. Copyright r 2013 by Lippincott Williams & Wilkins
Techniques in Hand & Upper Extremity Surgery
Surgery was performed under general anesthesia to harvest the grafts. The procedure was performed through a horizontal incision, with the anterior cartilaginous portion between fifth and seventh rib exposed. Osteochondral junction identification was easy because of the color difference between the bone and the cartilage (Fig. 3). We harvested the graft as a block that included the osteochondral junction without breaking costal continuity.
Second Phase: Approach to the Radius The radius was approached dorsally in the third compartment. There was adhesion between the lunate and the radius, and the radiocarpal joint space was narrow. The joint destructive zone of the radial epiphysis was resected through an epiphysealmetaphyseal cut to avoid damaging the distal radioulnar joint.
Third Phase: Interposition of the Cartilaginous Autograft The graft was easily remodeled with a scalpel to match the size of the corresponding cavity in the radial epiphyseal zone. We trimmed the cartilage to 2 mm in length in contact with the defect of the lunate scaphoid fossa. We made a space on the dorsal side of the distal radius and implanted the costal osteochondral graft with a temporal fixation using 1.5 mm Kirschner wiring. The dorsal radial cortex was reduced to cover the window. We chose the bioabsorbable mesh sheet for internal fixation because it could be molded into the dorsal aspect and because the implant would not need to be removed. Bioabsorbable mesh sheet is made from u-hydroxyapatite (40% wt/wt) and poly-L-lactide (60% wt/wt) composite (SuperFixsorbMX40 Mesh; Johnson & Johnson Co., Ltd, Tokyo, Japan, and Takiron Co., Ltd, Osaka, Japan). The thickness of the sheets was 0.7 mm. Bioabsorbable screws (SuperFixsorb MX30) were made from u-hydroxyapatite (30% wt/wt) and poly-L-lactide (70% wt/wt) composite. The screws were 2.0 mm in diameter.1 The bioabsorbable plates could be shaped and bent in a 681C water bath to be fitted to the narrow space of the dorsal aspect surrounded by the extensor tendons (Fig. 4). We covered the plates with half-cut extensor retinaculum, to avoid interference with the
Volume 18, Number 1, March 2014
www.techhandsurg.com |
15
Techniques in Hand & Upper Extremity Surgery
Furukawa et al
Volume 18, Number 1, March 2014
TABLE 1. Preoperative Lesions and Function
Patients Occupation Age 28 y, male Age 31 y, male
Transport operator
Initial Treatment
Initial Injury
Substance Loss Complaints
Pain (Quick DASH Score)
Wrist Strength R/L Flexion/ (kg) Extension
Right distal radius fracture AO C3
ORIF with volar locking plate
Scaphoid fossa
Pain, stiffness
45.8
17.6/38.9
20.30
Building Right distal radius contractor fracture AO C3
ORIF with volar locking plate
Lunate fossa
Pain, stiffness
66.0
8.0/47.0
70/20
ORIF indicates open reduction and internal fixation.
FIGURE 1. Posttraumatic defect of the articular surface.
extensor tendons, and the other was returned to the original position.
Fourth Phase: Dressing and Casting Postoperatively, the wrist and the radiocarpal joint were immobilized with a splint until swelling and pain had sufficiently diminished. The period of splinting was about 3 weeks in both cases. Active range-of-motion exercises were then begun to the extent that pain allowed.
EVALUATION Both patients were followed up prospectively at 1, 1.5, 2, 3, 6, 12, 18, and 24 months. Total range of motion and grip strength were evaluated 18 months after surgery. Bone union was assessed by bony bridging callus or connecting trabeculae on radiographs and CT. The articular cartilage was assessed using magnetic resonance imaging. There was no necrotic change during the follow-up period. Persistent swelling or complex regional pain syndrome were also checked.
RESULTS FIGURE 2. Arthroscopic examination showing the osteochondral defect of the lunate fossa.
16 | www.techhandsurg.com
The results for this series are summarized in Table 2. There was no step-off or defect of the articular surface at the followup CT (Fig. 5). Both patients obtained stable radiocarpal joints for their daily activities, except for minor discomfort with r
2013 Lippincott Williams & Wilkins
Techniques in Hand & Upper Extremity Surgery
Volume 18, Number 1, March 2014
bone
The New Technique and Material for Wrist
cartilage
incision
FIGURE 3. Costal cartilage graft and the skin incision of the chest.
FIGURE 4. A, The view showing the articular surface from the dorsal aspect. Neither step-off nor any defect was found after the costal cartilage (*) was implanted. B, Postoperative 3D-CT: bioabsorbable plate was located to fix the costal cartilage graft from the dorsal aspect. 3D-CT indicates 3-dimensional computed tomography.
manual labor at full flexion and extension (Fig. 6). There were no postoperative complications such as hematomata, adherence of the extensor tendon, or infection of either the donor site or the reconstructed wrists treated with bioabsorbable plates.
DISCUSSION Various methods are available for the treatment of radiocarpal arthrosis. They include arthrodesis, vascularized joint transfers,2 joint replacement, and perichondrial graft. Partial or total arthrodesis is a classical solution, but it is difficult to predict the functional results for the wrist joints. In the long term, arthrodesis presents a risk for arthrosis of neighboring carpal joints.3 In previous studies, allografts or autografts harvested from non–weight-bearing areas of knee joints were used.
Munro et al4 used osteochondral grafts harvested from the costo-osteochondral junction for reconstruction of the temporomandibular joints and reported the viability of osteochondral grafts. Using the same technique, Hasegawa and Yamano5 and Sandow6 and Sato7 treated finger joint injuries and deficiencies of the proximal pole of the scaphoid because of fractures or necrosis, respectively, and observed satisfactory outcomes. Sato et al8 applied this procedure to the treatment of osteochondritis dissecans of the capitulum humeri and obtained satisfactory results. Costal cartilage graft for posttraumatic malunion of the distal radius was first reported by Obert et al9 in 2011. They treated 7 cases of posttraumatic articular defect associated with distal radius fractures and achieved satisfactory improvement for all cases. They also proved the viability of the cartilage
TABLE 2. Postoperative Results
Patients
Surgical Procedure
Follow-up (mo)
Pain (Quick DASH Score)
Wrist Strength R/L (kg)
Flexion/ Extension
Age 28 y, male Age 31 y, male
Costal osteochondral graft with bioabsorbable plate Costal osteochondral graft with bioabsorbable plate
24
13.6
29.8/38.9
40/50
18
39.0
15.8/47.0
80/65
r
2013 Lippincott Williams & Wilkins
www.techhandsurg.com |
17
Furukawa et al
Techniques in Hand & Upper Extremity Surgery
Volume 18, Number 1, March 2014
FIGURE 5. Postoperative CT scans. There is a cleft between wrist articulations. CT indicates computed tomography.
graft based on fine-needle biopsy during pin or plate removal. Two basic studies proved the availability of costal cartilage physiologically and pathologically after costal osteochondral graft. Sato et al10 reported that the histologic findings showed nearly perfect restoration of articular cartilage defect, and the fluorescent in situ double-staining protocol with confocal laser microscopic analysis revealed viability of chondrocytes in the grafted costal cartilage up to 48 weeks. Kitaoka et al11 reported that costal cartilage shows phenotypic similarities to other cartilages, that is, articular cartilage and embryonic limbs, suggesting that costal cartilage may be very useful as the donor transplantation site for the treatment of cartilage disorders. The patients got such a rapid arthritic progression only for 6 months because the patients require high level of physical activities; the large defect of articular surface was located at scaphoid or lunate fossa, which was frequently affected by
mechanical loading. The technique can only be used with incomplete destruction of the joint surface, which is often the case. Recently it was reported that costal cartilage shows phenotypic similarities to articular cartilage.11 Hyaline cartilage, such as ribs, rather than fibrocartilage, should be chosen for the grafts. The illustrated technique of a composite perichondriocostochondral arthroplasty is an alternative that has considerable potential because it may restore stability and motion while reducing pain. Reducing joint impaction is not possible with the technique, and it is difficult to disturb the near soft tissue because bioabsorbable plates are thin and easily crafted to any shape. Bioabsorbable plates are a novel method for reconstructing a variety of arthrotic and articular defects of the distal radius, especially through a dorsal approach. Despite the encouraging findings in this small series, we believe that it is necessary to conduct further studies of this method over a longer period.
FIGURE 6. Recovery of the range of motion.
18 | www.techhandsurg.com
r
2013 Lippincott Williams & Wilkins
Techniques in Hand & Upper Extremity Surgery
Volume 18, Number 1, March 2014
CONCLUSIONS We reported 2 case of osteochondral grafting from the costosteochondral junction that achieved excellent reconstruction of posttraumatic radiocarpal arthrosis without affecting other joints. Bioabsorbable plate was useful for the internal fixation of the grafting for the uneven and narrow dorsal aspect of the distal radius. REFERENCES 1. Sakai A, Oshige T, Zenke Y, et al. Mechanical comparison of novel bioabsorbable plates with titanium plates, and small-series clinical comparisons for metacarpal fractures. J Bone Joint Surg Am. 2012;94:1597–1604. 2. Ellis PR, Tsai TM. Management of the traumatized joint of the finger. Clin Plast Surg. 1989;16:457–473. 3. Katsaros J, Milner R, Marshall NJ. Perichondral arthroplasty incorporating costal cartilage. J Hand Surg Br. 1995;20B:137–142. 4. Munro IR, Phillips JH, Griffin G. Growth after construction of the temporomandibular joint in children with hemifacial microsomia. Cleft Palate J. 1989;26:303–311.
r
2013 Lippincott Williams & Wilkins
The New Technique and Material for Wrist
5. Hasegawa T, Yamano Y. Arthroplasty of the proximal interphalangeal joint using costal cartilage grafts. J Hand Surg Br. 1992;17B: 583–585. 6. Sandow MJ. Proximal scaphoid costo-osteochondral replacement arthroplasty. J Hand Surg Br. 1998;23B:201–208. 7. Sato K, Sasaki T, Nakamura T, et al. Clinical outcome and histologic findings of costal osteochondral grafts for cartilage defects in finger joints. J Hand Surg Am. 2008;33A:511–515. 8. Sato K, Mio F, Hosoya T, et al. Two cases with osteochondritis dissecans of the capitulum humeri, treated with costal osteochondral graft transplantation. J Shoulder Elbow Surg. 2003;12:403–407. 9. Obert L, Lepage D, Sergent P, et al. Post-traumatic malunion of the distal radius treated with autologous costal cartilage graft. Orthopaed Traumatol Surg Res. 2011;97:430–437. 10. Sato K, Moy OJ, Peimer CA, et al. An experimental study on costal osteochondral graft. Osteoarthritis Cartilage. 2012;20:172–183. 11. Kitaoka E, Satomura K, Hayashi E, et al. Establishment and characterization of chondrocyte cell lines from the costal cartilage of SV40 large T antigen transgenic mice. J Cell Biochem. 2001;81:571–582.
www.techhandsurg.com |
19
Post-traumatic Malunion of the Distal Radial Intra-articular Fractures Treated With Autologous Costal Osteochondral Grafts and Bioabsorbable Plates Kayoko Furukawa, MD, Akinori Sakai, MD, PhD, Kunitaka Menuki, MD, PhD, Toshihisa Oshige, MD, PhD, Yukichi Zenke, MD, PhD, and Toshitaka Nakamura, MD, PhD
Abstract: Intra-articular distal radial fractures with partial bone loss at the wrist were reconstructed using osteochondral grafts in 2 patients who were followed up for at least 18 months. Both patients experienced posttraumatic arthrosis of the wrist joint. The materials of the intra-articular fixation were bioabsorbable plates and screws. Reconstruction of a partially destroyed articular surface using a costal osteochondral graft is reliable and allows filling and resurfacing an articular cartilage void. Key Words: costal cartilage graft, radiocarpal joint arthrosis, bioabsorbable plate, surgical treatment
imaging revealed cartilage and bone defects at the scaphoid fossa and the lunate fossa. The defect size was 11 10 6 mm in the first patient and 10 16 17 mm in the second patient. The articular cartilage defect was assessed using arthroscopy and could be easily visualized, despite the joint space narrowing, owing to partial arthrosis. We confirmed mild fibrillation on the carpal side and partial loss of articular cartilage on the radial side. On the basis of the patient symptoms, the CT images (Fig. 1), and the arthroscopic findings (Fig. 2), we decided to perform autologous costal osteochondral graft.
SURGICAL TECHNIQUES
(Tech Hand Surg 2014;18: 15–19)
First Phase: Costal Osteochondral Graft Harvest
D
isplaced intra-articular distal radial fractures are initially managed with open reduction and internal fixation with volar locking plates. However, residual problems such as pain and stiffness cause loss of mobility in patients who demand a high level of function. Various methods are available for the treatment of radiocarpal arthrosis. They include arthrodesis, vascularized joint transfers,2 joint replacement, and perichondrial graft. However, classical existent techniques have some problems, such as neighboring carpal joint arthrosis, graft size, and donor site complications. We selected out costal osteochondral autografting and bioabsorbable plating for partial destruction of the radiocarpal joints surface that were treated with.
PATIENTS AND METHODS The 2 patients injured their right wrists and experienced destruction of the distal radius of their dominant hands while they were working. The first patient was a transport operator, and the second was a building contractor. They had highenergy joint fractures, which were classified as AO classification C3 (Table 1) and initially reduced in surgeries with volar locking plates. Rapid arthritic progression subsequently followed because of cartilage and bone defects. In both cases, the patients complained of the following symptoms: moderate but continuous pain (Quick DASH score: one was 45.8, the other was 66.0), functional loss in flexion/extension, and loss of wrist strength (less than half that of the dominant side). Pronation/supination was almost preserved in both the cases. Six months after the first surgery, computed tomography (CT) From the Department of Orthopaedic Surgery, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan. Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding. Address correspondence and reprint requests to Kayoko Furukawa, MD, Department of Orthopaedic Surgery, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishiku, Kitakyushu 807-8555, Japan. E-mail: [email protected]. Copyright r 2013 by Lippincott Williams & Wilkins
Techniques in Hand & Upper Extremity Surgery
Surgery was performed under general anesthesia to harvest the grafts. The procedure was performed through a horizontal incision, with the anterior cartilaginous portion between fifth and seventh rib exposed. Osteochondral junction identification was easy because of the color difference between the bone and the cartilage (Fig. 3). We harvested the graft as a block that included the osteochondral junction without breaking costal continuity.
Second Phase: Approach to the Radius The radius was approached dorsally in the third compartment. There was adhesion between the lunate and the radius, and the radiocarpal joint space was narrow. The joint destructive zone of the radial epiphysis was resected through an epiphysealmetaphyseal cut to avoid damaging the distal radioulnar joint.
Third Phase: Interposition of the Cartilaginous Autograft The graft was easily remodeled with a scalpel to match the size of the corresponding cavity in the radial epiphyseal zone. We trimmed the cartilage to 2 mm in length in contact with the defect of the lunate scaphoid fossa. We made a space on the dorsal side of the distal radius and implanted the costal osteochondral graft with a temporal fixation using 1.5 mm Kirschner wiring. The dorsal radial cortex was reduced to cover the window. We chose the bioabsorbable mesh sheet for internal fixation because it could be molded into the dorsal aspect and because the implant would not need to be removed. Bioabsorbable mesh sheet is made from u-hydroxyapatite (40% wt/wt) and poly-L-lactide (60% wt/wt) composite (SuperFixsorbMX40 Mesh; Johnson & Johnson Co., Ltd, Tokyo, Japan, and Takiron Co., Ltd, Osaka, Japan). The thickness of the sheets was 0.7 mm. Bioabsorbable screws (SuperFixsorb MX30) were made from u-hydroxyapatite (30% wt/wt) and poly-L-lactide (70% wt/wt) composite. The screws were 2.0 mm in diameter.1 The bioabsorbable plates could be shaped and bent in a 681C water bath to be fitted to the narrow space of the dorsal aspect surrounded by the extensor tendons (Fig. 4). We covered the plates with half-cut extensor retinaculum, to avoid interference with the
Volume 18, Number 1, March 2014
www.techhandsurg.com |
15
Techniques in Hand & Upper Extremity Surgery
Furukawa et al
Volume 18, Number 1, March 2014
TABLE 1. Preoperative Lesions and Function
Patients Occupation Age 28 y, male Age 31 y, male
Transport operator
Initial Treatment
Initial Injury
Substance Loss Complaints
Pain (Quick DASH Score)
Wrist Strength R/L Flexion/ (kg) Extension
Right distal radius fracture AO C3
ORIF with volar locking plate
Scaphoid fossa
Pain, stiffness
45.8
17.6/38.9
20.30
Building Right distal radius contractor fracture AO C3
ORIF with volar locking plate
Lunate fossa
Pain, stiffness
66.0
8.0/47.0
70/20
ORIF indicates open reduction and internal fixation.
FIGURE 1. Posttraumatic defect of the articular surface.
extensor tendons, and the other was returned to the original position.
Fourth Phase: Dressing and Casting Postoperatively, the wrist and the radiocarpal joint were immobilized with a splint until swelling and pain had sufficiently diminished. The period of splinting was about 3 weeks in both cases. Active range-of-motion exercises were then begun to the extent that pain allowed.
EVALUATION Both patients were followed up prospectively at 1, 1.5, 2, 3, 6, 12, 18, and 24 months. Total range of motion and grip strength were evaluated 18 months after surgery. Bone union was assessed by bony bridging callus or connecting trabeculae on radiographs and CT. The articular cartilage was assessed using magnetic resonance imaging. There was no necrotic change during the follow-up period. Persistent swelling or complex regional pain syndrome were also checked.
RESULTS FIGURE 2. Arthroscopic examination showing the osteochondral defect of the lunate fossa.
16 | www.techhandsurg.com
The results for this series are summarized in Table 2. There was no step-off or defect of the articular surface at the followup CT (Fig. 5). Both patients obtained stable radiocarpal joints for their daily activities, except for minor discomfort with r
2013 Lippincott Williams & Wilkins
Techniques in Hand & Upper Extremity Surgery
Volume 18, Number 1, March 2014
bone
The New Technique and Material for Wrist
cartilage
incision
FIGURE 3. Costal cartilage graft and the skin incision of the chest.
FIGURE 4. A, The view showing the articular surface from the dorsal aspect. Neither step-off nor any defect was found after the costal cartilage (*) was implanted. B, Postoperative 3D-CT: bioabsorbable plate was located to fix the costal cartilage graft from the dorsal aspect. 3D-CT indicates 3-dimensional computed tomography.
manual labor at full flexion and extension (Fig. 6). There were no postoperative complications such as hematomata, adherence of the extensor tendon, or infection of either the donor site or the reconstructed wrists treated with bioabsorbable plates.
DISCUSSION Various methods are available for the treatment of radiocarpal arthrosis. They include arthrodesis, vascularized joint transfers,2 joint replacement, and perichondrial graft. Partial or total arthrodesis is a classical solution, but it is difficult to predict the functional results for the wrist joints. In the long term, arthrodesis presents a risk for arthrosis of neighboring carpal joints.3 In previous studies, allografts or autografts harvested from non–weight-bearing areas of knee joints were used.
Munro et al4 used osteochondral grafts harvested from the costo-osteochondral junction for reconstruction of the temporomandibular joints and reported the viability of osteochondral grafts. Using the same technique, Hasegawa and Yamano5 and Sandow6 and Sato7 treated finger joint injuries and deficiencies of the proximal pole of the scaphoid because of fractures or necrosis, respectively, and observed satisfactory outcomes. Sato et al8 applied this procedure to the treatment of osteochondritis dissecans of the capitulum humeri and obtained satisfactory results. Costal cartilage graft for posttraumatic malunion of the distal radius was first reported by Obert et al9 in 2011. They treated 7 cases of posttraumatic articular defect associated with distal radius fractures and achieved satisfactory improvement for all cases. They also proved the viability of the cartilage
TABLE 2. Postoperative Results
Patients
Surgical Procedure
Follow-up (mo)
Pain (Quick DASH Score)
Wrist Strength R/L (kg)
Flexion/ Extension
Age 28 y, male Age 31 y, male
Costal osteochondral graft with bioabsorbable plate Costal osteochondral graft with bioabsorbable plate
24
13.6
29.8/38.9
40/50
18
39.0
15.8/47.0
80/65
r
2013 Lippincott Williams & Wilkins
www.techhandsurg.com |
17
Furukawa et al
Techniques in Hand & Upper Extremity Surgery
Volume 18, Number 1, March 2014
FIGURE 5. Postoperative CT scans. There is a cleft between wrist articulations. CT indicates computed tomography.
graft based on fine-needle biopsy during pin or plate removal. Two basic studies proved the availability of costal cartilage physiologically and pathologically after costal osteochondral graft. Sato et al10 reported that the histologic findings showed nearly perfect restoration of articular cartilage defect, and the fluorescent in situ double-staining protocol with confocal laser microscopic analysis revealed viability of chondrocytes in the grafted costal cartilage up to 48 weeks. Kitaoka et al11 reported that costal cartilage shows phenotypic similarities to other cartilages, that is, articular cartilage and embryonic limbs, suggesting that costal cartilage may be very useful as the donor transplantation site for the treatment of cartilage disorders. The patients got such a rapid arthritic progression only for 6 months because the patients require high level of physical activities; the large defect of articular surface was located at scaphoid or lunate fossa, which was frequently affected by
mechanical loading. The technique can only be used with incomplete destruction of the joint surface, which is often the case. Recently it was reported that costal cartilage shows phenotypic similarities to articular cartilage.11 Hyaline cartilage, such as ribs, rather than fibrocartilage, should be chosen for the grafts. The illustrated technique of a composite perichondriocostochondral arthroplasty is an alternative that has considerable potential because it may restore stability and motion while reducing pain. Reducing joint impaction is not possible with the technique, and it is difficult to disturb the near soft tissue because bioabsorbable plates are thin and easily crafted to any shape. Bioabsorbable plates are a novel method for reconstructing a variety of arthrotic and articular defects of the distal radius, especially through a dorsal approach. Despite the encouraging findings in this small series, we believe that it is necessary to conduct further studies of this method over a longer period.
FIGURE 6. Recovery of the range of motion.
18 | www.techhandsurg.com
r
2013 Lippincott Williams & Wilkins
Techniques in Hand & Upper Extremity Surgery
Volume 18, Number 1, March 2014
CONCLUSIONS We reported 2 case of osteochondral grafting from the costosteochondral junction that achieved excellent reconstruction of posttraumatic radiocarpal arthrosis without affecting other joints. Bioabsorbable plate was useful for the internal fixation of the grafting for the uneven and narrow dorsal aspect of the distal radius. REFERENCES 1. Sakai A, Oshige T, Zenke Y, et al. Mechanical comparison of novel bioabsorbable plates with titanium plates, and small-series clinical comparisons for metacarpal fractures. J Bone Joint Surg Am. 2012;94:1597–1604. 2. Ellis PR, Tsai TM. Management of the traumatized joint of the finger. Clin Plast Surg. 1989;16:457–473. 3. Katsaros J, Milner R, Marshall NJ. Perichondral arthroplasty incorporating costal cartilage. J Hand Surg Br. 1995;20B:137–142. 4. Munro IR, Phillips JH, Griffin G. Growth after construction of the temporomandibular joint in children with hemifacial microsomia. Cleft Palate J. 1989;26:303–311.
r
2013 Lippincott Williams & Wilkins
The New Technique and Material for Wrist
5. Hasegawa T, Yamano Y. Arthroplasty of the proximal interphalangeal joint using costal cartilage grafts. J Hand Surg Br. 1992;17B: 583–585. 6. Sandow MJ. Proximal scaphoid costo-osteochondral replacement arthroplasty. J Hand Surg Br. 1998;23B:201–208. 7. Sato K, Sasaki T, Nakamura T, et al. Clinical outcome and histologic findings of costal osteochondral grafts for cartilage defects in finger joints. J Hand Surg Am. 2008;33A:511–515. 8. Sato K, Mio F, Hosoya T, et al. Two cases with osteochondritis dissecans of the capitulum humeri, treated with costal osteochondral graft transplantation. J Shoulder Elbow Surg. 2003;12:403–407. 9. Obert L, Lepage D, Sergent P, et al. Post-traumatic malunion of the distal radius treated with autologous costal cartilage graft. Orthopaed Traumatol Surg Res. 2011;97:430–437. 10. Sato K, Moy OJ, Peimer CA, et al. An experimental study on costal osteochondral graft. Osteoarthritis Cartilage. 2012;20:172–183. 11. Kitaoka E, Satomura K, Hayashi E, et al. Establishment and characterization of chondrocyte cell lines from the costal cartilage of SV40 large T antigen transgenic mice. J Cell Biochem. 2001;81:571–582.
www.techhandsurg.com |
19
