Simultaneous Autologus Mandible and Temporomandibular Joint Reconstruction.

Ablative surgery of mandible often necessitates combined reconstruction of the mandible and the temporomandibular joint. Fibula-free flaps with gap arthroplasty or osseochondral grafts are common procedures in the authors' practice. In search for a better reconstructive option free fibula flap is used together with a metatarsal bone flap for the vascular reconstruction of the mandibular body and the condyle at the same time. The 2 osseous-free flaps have been fused and used as a combined flow through double-free flap. The literature has been reviewed for other reconstructive options, but no alternatives providing autologous reconstruction of both the mandible and the condyle with vascular tissue have been found. This is a preliminary report of this new technique which the authors humbly think is very promising.

En bloc Excision and Matched Metatarsal Transfer for Expansive Benign Osteolytic Lesions of the Metacarpal.

PURPOSE: Benign aggressive expansile osteolytic lesions such as giant cell tumors and aneurysmal bone cysts involving the metacarpal head pose problems in management. Unacceptably high rates of recurrence are reported after curettage and bone grafting. An en bloc excision of such tumors ideally requires osteoarticular replacement of the excised metacarpal heads to retain mobility and function. We used nonvascularized metatarsal head and shaft harvested from the foot to replace the metacarpal defect after en bloc resection to retain movement and function of metacarpophalangeal (MCP) joint. The purpose of this study was to evaluate results of patients who underwent this procedure. METHOD: Nine patients treated with metatarsal transfer for osteoarticular reconstruction after en bloc excision of benign aggressive osteolytic metacarpal head tumors were reviewed retrospectively. The postoperative evaluation included examination of radiographs, joint mobility, and patient rated return of function using the Michigan Hand Questionnaire. RESULTS: Of 9 patients, 4 had aneurysmal bone cyst, 4 had giant cell tumor, and 1 an atypical cartilaginous lesion. Patients were aged between 14 and 45 years at the time of surgery. After an average of 44 months of follow-up (minimum follow-up of 24 months; range, 24-104 months), all patients had good postoperative function, satisfactory results, and no recurrence of tumor. The mean active range of motion at the reconstructed MCP joint was 75° (range, 0° to 90°). The Michigan Hand Questionnaire score averaged 80 (range, 69-92). No patient complained of donor site morbidity. One patient underwent MCP joint fusion after a pin tract infection. CONCLUSIONS: Use of a matched metatarsal graft for osteoarticular reconstruction after en bloc excision of benign aggressive tumors involving the metacarpal head is a potential treatment option. In this limited series, consistent results with respect to functional range of motion at MCP joint, and without recurrence of tumor or notable donor site morbidity were obtained. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Giant cell tumor of the metacarpal bone in children: free osteoarticular metatarsal transfer: case report.

We present a successful total resection of metacarpal bone and nonvascularized joint transfer in a giant cell tumor of the fourth metacarpal bone in a 13-year-old girl. At the 6-year follow-up, a good functional outcome was achieved, with 85° range of motion of the metacarpophalangeal joint and no clinical or radiographic evidence of tumor recurrence and no signs of degeneration of the joint.

Vascularized graft from the metatarsal base for reconstructing major osteochondral distal radius defects.

PURPOSE: To present our experience of reconstructing distal radius articular defects with a vascularized osteochondral graft from the metatarsal base and to present the mid-term outcomes. METHODS: Seven patients (average age, 36 y; range, 26-55 y) who had reconstruction of major defects of the articular surface of the radius are presented. In 5, the lunate facet and sigmoid notch were reconstructed; in 1, an isolated defect on the surface of the lunate facet was reconstructed; and in 1, the scaphoid facet was reconstructed. In 6, the base of the third metatarsal was transferred, and in 1, the base of the second was transferred. RESULTS: All flaps survived without complications. At the latest follow-up (range, 20 mo to 8 y), the flexion-extension arc improved an average of 50°, and the pain on a visual analog scale decreased from 8 to 1 on average. Disabilities of the Arm, Shoulder, and Hand score improved from 54 to 11 on average. One patient did not improve. No major complaints related to the donor site were mentioned (average American Orthopedic Foot and Ankle Society score of 96/100). CONCLUSIONS: Our mid-term results are promising; however, the decision-making process and the operation are complex. The operation is not indicated when the carpals are devoid of cartilage or when the defect involves the whole radius surface.

Metatarsal transfer for the treatment of post-axial metatarsal-type foot synpolydactyly: a new technique that allows for comfortable shoe wearing.

We analysed the clinical and radiological outcomes of a new surgical technique for the treatment of heterozygote post-axial metatarsal-type foot synpolydactyly with HOX-D13 genetic mutations with a mean follow-up of 30.9 months (24 to 42). A total of 57 feet in 36 patients (mean age 6.8 years (2 to 16)) were treated with this new technique, which transfers the distal part of the duplicated fourth metatarsal to the proximal part of the fifth metatarsal. Clinical and radiological assessments were undertaken pre- and post-operatively and any complications were recorded. Final outcomes were evaluated according to the methods described by Phelps and Grogan. Forefoot width was reduced and the lengths of the all reconstructed toes were maintained after surgery. Union was achieved for all the metatarsal osteotomies without any angular deformities. Outcomes at the final assessment were excellent in 51 feet (89%) and good in six (11%). This newly described surgical technique provides for painless, comfortable shoe-wearing after a single, easy-to-perform operation with good clinical, radiological and functional outcomes.

Vascularized periosteal graft from the first metatarsal bone: a new technique to prevent collapse of osteonecrosis of the talus in children. A case report.

Several microsurgical techniques have been described for the treatment of osteonecrosis of the talus (ONT). Recently reported in children, vascularized periosteal grafts showed promising revascularizing properties. We report a novel technique using a pedicled periosteal graft from the first metatarsal bone to treat steroid-induced early Ficat-Arlet stage III ONT in an 11-year-old boy. The patient presented initial favorable clinical and radiological results which were maintained at 34 months during the last follow-up. Through this original technique, and basing on the powerful osteogenic and vasculogenic propreties of periosteal flaps, we could effectively induce bone revascularization and prevent further collapse of the talar dome.

Case report: a modified 1-stage technique for the treatment of brachymetatarsia.

UNLABELLED: Brachymetatarsia is an abnormal shortening of a metatarsal. It causes disruption of the normal metatarsal parabola, resulting in metatarsalgia, calluses and dislocation of the digits. Patients often express discontent with the appearance of their feet. Lengthening by distraction osteogenesis and 1-stage intercalary bone grafting procedures are the mainstays of operative treatment. We present a modified 1-stage technique, combining the use of a Chevron osteotomy of the fourth metatarsal with shortening osteotomies of the second and third metatarsals. Bone removed from the third metatarsal was used to lengthen the fourth. The Chevron segments provided mediolateral, dorsoplantar, and rotational stability. The technique was used on both feet of 1 patient. The mean increase in AOFAS score was 34.5 (right foot, 46; left foot, 23.) There were no complications. A 1-stage technique does not require an external fixator or postoperative manipulation and has a quicker healing time. Taking the bone graft from neighboring metatarsals decreases the discrepancy between metatarsal lengths. A smaller increase in the length of the fourth ray is then required, and the chance of neurovascular injury as a result of soft-tissue stretching is minimized. This technique allows restoration of the metatarsal parabola and provides good correction, immediate stability, and good integration. LEVELS OF EVIDENCE: Therapeutic Level IV, Case Study.

Reconstruction of the ulnar head with a vascularized second metatarsal head: case report.

A case of a young patient with avascular necrosis of the ulnar head following a severely displaced ulnar head fracture is presented. Treatment included debridement of the entire ulnar head, leaving the ulnar styloid, sigmoid notch, triangular fibrocartilage, and both distal radioulnar ligaments intact. The head of the ulna was reconstructed by transferring a vascularized second metatarsal head. At 4-year follow-up, the patient had a pain-free wrist with 45° active pronation and 65° supination. He resumed working without limitations as a manual laborer. We conclude that ulnar head reconstruction with a vascularized second metatarsal head is worthwhile in the setting of an unreconstructable traumatic defect, particularly when the sigmoid notch and distal radioulnar ligaments are preserved.

Reconstruction of hypoplastic thumb using hemi-longitudinal metatarsal transfer.

The treatment of hypoplastic thumb (modified Blauth's type IIIb and IV) by pollicization is culturally unfavourable in the Chinese population and digit preservation is preferred. An innovative reconstruction method using a nonvascularized hemi-longitudinal metatarsal graft was performed in six cases with an average follow-up of 87.7 months. Overall hand function was good, as assessed using the Jebsen hand function test. Grip strength and pinch power were significantly weaker than the normal contralateral hand. There was no neurovascular or wound complication. The only donor site complication was a metatarsal fracture, which healed uneventfully with casting. There had been no permanent morbidity to the donor site, as all donor metatarsals hypertrophied and regained normal growth potentials. Linear growth of the transferred metatarsals was evident radiologically (average 1.5 mm/year). Free hemi-longitudinal metatarsal transfer is a feasible method with good functional outcome in the attainment of a 5-digit hand in patients with type IIIb/IV hypoplastic thumb.

Transfer of the second to the first metatarsal ray in a case of lawn mower injury: a case report.

The medial longitudinal arch of the foot plays a major role for a physiologic transfer of the load from the heel to the forefoot during walking and running. Traumatic amputation that involve either the great toe or the whole first metatarsal bone can lead to collapse of the medial longitudinal arch, overload of the metatarsal heads, and painful callus formation. If replant of the amputated part is not possible or has failed, it is advisable to reconstruct the medial longitudinal arch in order to re-establish a functional transfer of the load in the foot. We present a case of a young lady who suffered from traumatic amputation at the distal third of the first metatarsal. Replantation failed due to the severity of the initial injury. Despite a good coverage of the defect with a lateral arm flap, the patient developed a painful plantar callus underneath the amputated stump. The adjacent second metatarsal ray was then raised as a pedicled flap including bone and soft tissues and transferred to the first ray in order to reconstruct a physiologic medial longitudinal arch. The patient had excellent functional results with no recurrence of the callus.

[Aseptic osteonecrosis of the head of the metacarpal (Mauclaire's disease)--case report and review of the literature]. / Die aseptische Osteonekrose des Metakarpalekopfes (Morbus Mauclaire)--Fallbericht und Literaturübersicht.

Aseptic osteonecrosis of the head of metacarpal is a rare disease with an unknown aetiology. It was first described by Mauclaire 1927. We now report on the treatment of 2 patients with Mauclaire's disease via transplantation of the calotte of the head of the 2nd metatarsal. At 26 and 30 months, respectively, after surgery both patients were free of complaints in activities of daily live and had free function of their fingers. There was no discomfort in the resection area at the 2nd metatarsal. Based on this experience, the method seems to be a recommendable option in young adults. A prerequisite is that the base of the proximal phalanx be intact.

[Structure of the metaepiphyseal growth plate cartilage in conditions of total isolation from cellular and humoral influences after its transplantation into soft tissues (an experimental study)].

The aim of this study was to determine the effect of a skeletal muscle on the cartilage of growth plate of metaepiphyseal explants of tubular bones of growing and mature Chinchilla rabbits (n = 18) under conditions of their isolation from cellular and humoral influences. In experimental animals, metaepiphyseal explants of metatarsal bones, containing growth plate, were sealed in polyethylene film and were placed, under local anesthesia, in the femoral muscles. One week later these grafts were removed and studied histologically. Despite the absence of the effects of biologically active substances and immunocompetent cells of the donor (foreign) organism, the exposure of the cartilage plate to the environment of the muscular tissue lead to some typical changes in its structure. The results obtained may indicate the susceptibility of the cartilage growth plates to the action of some distant factors, probably, of an electromagnetic nature. The detection of these factors is promising for the development of clinical methods of the stimulation of the damaged cartilage growth plates for the correction of bone deformities.

The use of metatarsal bone grafts in the treatment of saddle nose deformities.

The results from segmental fourth metatarsal bone reconstruction of significant nasal dorsal defects are described. Solid bone graft reconstructions frequently lead to an unnatural hardness of the nasal tip. Rib cartilage reconstructions are pliable and soft, but pose a problem because they easily undergo warpage. The operation is performed using the open approach. An outer fourth metatarsal bone graft used for the bone component extends at least two-thirds of the dorsum length. It is secured in place with a compression screw and a Kirschner wire. The cartilage component comprises an abbreviated L-strut constructed of septal cartilage. It is slotted into the metatarsal bone in a tongue-in-groove manner and sutured to it through a drill hole in the bone. The dorsal profile is completed in this manner.

Reconstruction of the distal radius facet by a free vascularized osteochondral autograft: anatomic study and report of a patient.

PURPOSE: Large chondral defects of the distal radius after fractures present a reconstructive challenge. The purpose of this study was to present the anatomic findings from a cadaver of a vascularized osteochondral autograft taken from the third metatarsal appropriate for reconstructing the distal radius articular facet. A patient is presented in whom 70% of the scaphoid fossa was reconstructed with this technique. METHODS: The base of the third metatarsal was studied in the feet of 20 cadavers. The size and shape of the cartilage were measured. Additionally vessel distribution was recorded and the diameters of vascular foramina were measured with Juch's method. RESULTS: The base of the third metatarsal is pear shaped and is wider dorsally than plantarly. It averages 19.2 mm long on its main axis. Its cartilaginous surface is minimally concave or flat and it is slanted slightly proximal-dorsal to distal-plantar and proximal-peroneal to distal-tibial. Nutrient foramina were found in every case in the dorsum and on both sides of the proximal shaft. At least 1 nutrient vessel could be tracked back to the dorsalis pedis in every dissected specimen. CONCLUSIONS: The anatomic features of the base of the third metatarsal make it a potential vascularized autograft to consider for osteochondral defects of the distal radius.

Reconstruction of the temporomandibular joint by the transfer of the free vascularised second metatarsal.

We present our experience of a series of patients who presented for salvage reconstruction of the temporomandibular joint (TMJ) for relief of pain. Reconstruction was achieved by transfer of the free vascularised second metatarsal. This technique has been used for a total of seven TMJ reconstructions in five patients. We describe the surgical anatomy, technique and results during the last 18 years. One joint failed but the other six surviving joints continue to provide adequate pain-free function. We advocate this technique for autogenous salvage reconstruction in joints that have been previously operated on unsuccessfully.

[Reconstruction of the index metacarpophalangeal joint with an osteochondral metatarsal head graft]. / Rekonstruktion des Zeigefingergrundgelenks durch Transplantation des II. Mittelfusskopfes.

We report on a 19-year-old male patient with partial destruction of the index metacarpophalangeal joint due to traumatic middle hand amputation. Six months after replantation the metacarpophalangeal joint defect was reconstructed with an osteochondral metatarsal head graft from the second metatarsophalangeal joint. At a follow-up period of four years the patient achieved full metacarpophalangeal extension, with 40 degrees of flexion and grip strength equal to 90 % of the contralateral index finger. Magnetic resonance imaging showed enhancement of contrast medium as a sign for vitality of the transplant.

Reperfusion injury in free bone grafts after tourniquet-induced ischemia.

For successful revascularization, incorporation, and survival of fracture fragments or free nonpedicled bone grafts, the first days after surgery seem to be most critical. Using intravital fluorescence microscopy, the effects of 3 hours of tourniquet-induced ischemia were assessed on newly formed angiogenic microvessels 4, 8, and 12 days after isogeneic transplantation of metatarsal bones into dorsal skin fold chambers of adult inbred C57BL/6 mice. The microvascular perfusion index of newly formed microvessels was quantified 30 and 120 minutes after initiation of reperfusion. Four days after transplantation, a complete breakdown of the perfusion of all grafts was found accompanied by hemorrhage as a sign of microvascular damage. In contrast, at 8 and 12 days after transplantation a complete breakdown of graft perfusion rarely occurred. Therefore, the tourniquet-induced ischemia was most pronounced in early stages of development of angiogenic microvessels. These experimental data provide rationale for critical application of tourniquets in revision surgery shortly after initiation of fracture treatment or transplantation of free nonpedicled grafts so as not to compromise angiogenesis-induced tissue revascularization.