Elsevier

The Journal of Hand Surgery

Volume 40, Issue 10, October 2015, Pages 2075-2080
The Journal of Hand Surgery

Surgical technique
Distal Radius Joint Surface Reconstruction Using a Pedicle Pisiform Osteochondral Transfer

https://doi.org/10.1016/j.jhsa.2015.07.019Get rights and content

Treatment of a large articular cartilage defect in the distal radius poses a significant challenge to hand surgeons. To reduce the development of secondary degenerative arthritis, restoration of the articular surface is preferable. Pedicle pisiform transfer has been reported as a useful treatment option for Kienböck’s disease. We describe a surgical technique involving vascularized pisiform transfer for large cartilage defects after intra-articular distal radius fractures and highlight the vascular supply of the pisiform.

Section snippets

Indications and Contraindications

Patients with volar comminution or osteochondral defect of the distal radius who cannot be treated by corrective osteotomies are indicated for pedicle pisiform osteochondral transfers. The mean size of the articular surface of the pisiform is reportedly 14.7 × 9.5 mm (15.7 × 10.0 mm in men, 13.7 × 8.9 mm in women) (Fig. 1).9 For this reason, the largest cartilage defect size that can be reconstructed with the pisiform is approximately 15 × 10 mm, which is as large as 50% of the lunate fossa. In

Surgical Anatomy

The pisiform bone is attached proximally by the flexor carpi ulnaris (FCU) and distally by the abductor digiti minimi muscle. This bone constitutes the ulnar bony limit of the canal of Guyon in which the ulnar artery enters the hand. The ulnar artery is usually the main source for the superficial palmar arch and includes 2 principal branches, the dorsal carpal and deep palmar branches. The arterial vascularization of the pisiform bone comes from 3 pedicles: an upper pedicle arising from the

Surgical Technique

The surgical technique is basically that previously described by Saffar.6 A tourniquet is used, and the surgery is performed under regional or general anesthesia. A longitudinal palmar incision is made along the FCU tendon to the wrist crease and extended distally in a zigzag fashion. After incision of the flexor retinaculum, the tendons are retracted radially, and the carpal tunnel is opened. The anterior capsule and short radiolunate ligament are incised transversely along the end of the

Case Illustration

A 44-year-old woman sustained a volar Barton fracture with comminuted lunate fossa fragment of the right distal radius and was initially treated by open reduction and internal fixation with a volar plate. The fracture united; however, the patient complained of wrist pain and restriction of wrist motion. On physical examination at 6 months postoperatively, wrist extension and flexion were 60° and 25°, respectively, and pronation and supination were 85° and 20°, respectively. Grip strength was 21

Discussion

The treatment of osteochondral defects remains challenging for orthopedic surgeons. Historically, osteochondral grafting in the knee has been acceptable for managing posttraumatic defects.10, 11 This procedure typically involves harvesting an osteoarticular graft or several plugs (mosaicplasty) from the dorsal surface of the distal femur to cover the defect in the weight-bearing portion of the knee. Nonvascularized osteochondral grafts become revascularized, and the transplanted bone

References (24)

Cited by (5)

  • Vascularized pisiform graft for the treatment of scaphoid nonunion: An anatomical study

    2021, Hand Surgery and Rehabilitation
    Citation Excerpt :

    The pisiform consists of cancellous and cortical bone and provides an ample articular surface. The pisiform vascularized flap is an option for treating Kienböck's disease [17] and defects of the radial articular surface [18], but it has never been proposed as a surgical treatment for scaphoid nonunion because the conventional pedicle is too short. Pisiformectomy is a well described surgical technique with acceptable wrist functional results when it is performed methodically.

  • Reconstruction of a metacarpal head defect due to bite injury: two case reports

    2018, Case Reports in Plastic Surgery and Hand Surgery

No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

View full text