Good evening, everyone. On behalf of the American Society of Surgery of the Hand, I'd like to welcome you all to this webinar. The topic today is osteochondral reconstruction of scaphoid non-unions. My name is James Higgins, and I'm the chair of the webinar tonight, and I'm lucky to be joined by our faculty, which includes Jeff Yao and Nina Su. We're gonna go over some topics pertinent to this issue and explore indications and tips and tricks along the way. But before we go any further, you should be aware that this is a CME event and that attendees can claim 1.25 hours of CME. You can't claim them today. They will be available as of Tuesday, May 20th, and you'll all receive, if you've registered for this, an email indicating that it is now available, and you go through these directions in order to claim those credits. So with that being said, I'm going to get started. The topic today, as I said, is osteochondral reconstruction for scaphoid non-unions. And I was really happy to have this because this is a topic that we have all discussed in various fora, but it's great to get some of the experts in the field together to talk about different techniques, to compare notes on indications and difficulties they've had with these procedures and victories that they've had. So I've asked Nina Su from Emory to talk about hamate osteochondral reconstruction using autographs. And Jeff Yao is joining us from Stanford University who's gonna talk about costochondral reconstruction. And I'll talk about medial femoral trochlea flaps for scaphoid non-unions as well. To sort of set the table, this is the origin of this discussion is this very difficult scaphoid non-union. Scaphoid non-unions like this are not a rare thing, and we're all encountering them in our offices. I think it's something that we all groan when we see because it does appear to be a relatively unsolvable problem from conventional teaching. If you were to see this patient in your office, you would say that's a well-placed screw done by a good surgeon that unfortunately resulted in a predictable non-union in this very difficult, very small proximal pole. So if you were to say to yourself, what am I gonna do in this situation? One would wonder whether or not you should just use conventional techniques. In other words, use another bone graft or a vascularized bone graft and attempt to get that small fragment to heal to the distal pole. Well, there'd be a lot of reasons you would be pessimistic about that. And if you looked at the preoperative risk factors that we face in the office for failure of your scaphoid non-union surgery, I like to think of them as these six. The duration of a non-union, meaning a non-union that's greater than a year since onset of fracture. Location of the fracture, meaning a proximal pole being more difficult than a waist. Size and fragmentation of the proximal pole, meaning if it's really small and fragmented, that makes it a high risk for failure. Previous instrumentation, meaning if you're the second surgeon in, it's higher risk. And then displacement. And generally speaking, we speak about whether or not a patient has a humpback deformity, has displacement, although there's many different ways to measure displacement. And lastly, smoking is a risk factor. But if you were to think of those six risk factors, probably the two that are the most concerning or the most intimidating would be if you had a very, very, very small fragment that was particularly if it was fragmented and the patient had previously undergone surgery. This patient that I showed in that first screen has both of those risk factors. Is it really true that previous surgery is a risk factor for failure of your scapulae nonunion surgery? And I put up these various manuscripts that are all proof positive that this is a well-known and established risk factor for failure of scapulae nonunion surgery. You can look in the top left there and see those papers delineated between their primary and their revision scapulae nonunion surgeries and showed a dramatic difference between their success rates. On the top right, four papers that all explored just their revision scapulae nonunion surgeries, all demonstrating poor success rates. While there are three series out there that you can find that would demonstrate that those authors still had success, I would say the overall picture is one of a bleak outlook when facing revision surgery. In fact, the only two prospective randomized trials of vascularized bone grafting versus non-vascularized bone grafting, and yes, there are two randomized prospective trials, they actually exclude revision surgery in their criteria for inclusion in the study. This obviously speaks to the fact that revision surgery in and of itself is a really intimidating risk factor. And the other issue is, of course, the very small nature of this. So if you were to look at a fragment of that size and say it was fractured or extremely small and it had previously been operated upon, you might say to yourself, wouldn't it be great if rather than having to go back in there and throw the same tools that I've used the first time or the same tools that I would use for scaphoid waste, that I could replace that with a similarly shaped piece of bone and cartilage from somewhere else in the patient's body. So that comes to the question of when is the proximal pole non-salvageable? And I was going to outline how I try to sort of quantify this and it doesn't necessarily mean that it's right, but these are my indications for giving up on a proximal pole because of its size. So I would consider a non-salvageable proximal pole being one where you are the primary surgeon and the proximal pole is less than five millimeters on sagittal cuts of a CT. I say that because on the AP radiograph, as we've all experienced, it can sometimes show you a proximal pole that looks larger than it actually appears on the CT scan. I think the CT scan really enables you to see, of course, the fracture on all different planes and really discern how small and how difficult is it going to be for you to get fixation on that piece without fracturing it. So any primary surgery with a proximal pole segment less than five millimeters, any secondary surgery, meaning a patient's been previously instrumented and the proximal fragment has some comminution. And then for me, because of that high risk of failure with repeat surgery, if I'm the third surgeon in, that's going to be eliminated and reconstructed with some form of osteochondral reconstruction. So if you were to look at what does the conventional literature say or how are we all taught long ago as you were going through your fellowships, well, if you had a non-salvageable proximal hole, then you would shift gears and go to conventional salvage operations such as PRC and mid-carpal fusion. In other words, give up on the scaphoid, take it out and salvage the rest. Well, what do we know about this? And this is the article literally that I will refer to when I'm going through this with patients in the office, because this is specifically addressing the outcomes of four-corner fusions and PRCs in young patients, meaning age less than 45. Now, there are a variety of indications here and the duration of outcomes being measured is obviously important. But if you look at these outcomes and you have a patient that's, say, 22, such as that patient's x-ray that I showed you, and you were to look at this flexion-extension arc, these grip strength numbers, GASH and PRWE scores, you'd say to yourself, I'd like to avoid that if I could. These were the only tools that we had. And I'd like to come up with some sort of novel operation where I could avoid what's conventionally a salvage operation for elderly patients with arthritis in this young population. So to answer those questions, I've asked our panelists to talk about different techniques with really a focus on their indications. And their indication may be different than what I outlined. And also their techniques, some of the successes and failures and their thoughts as they have developed these techniques over the course of their careers. So we're going to start with Dr. Su, who's going to talk about Clamate reconstruction for proximal pole non-unions. You're muted, Nina. All right, there we go. Thank you. Thank you to ASSH as well as Dr. Haynes for allowing me to talk about this. Yes, and this is obviously, I think if you're a hand surgeon, you see this, and this is a problem. And most definitely, many of my indications are the same as was mentioned previously. I think the revision surgeries do extremely poorly. And when they've been multiply operated, particularly if it's not been you, it's very hard to just regraph that and do the exact same thing over again. OK, so I have no disclosure. So this is kind of the overview of what we're going to be talking about. I'm going to talk very briefly about the options. Things that I think about for graft considerations for the handmate when I use it. Also my indications and contraindications for using this procedure. And I tried to do step by step. I was going to do a video, but actually, I decided to do pictures so I can talk a little bit more carefully about the small nuances and mistakes I've made along the way. And also some tips and tricks, just so I didn't forget it. I've also included that. And then we're just going to go through the outcomes. Obviously, this procedure is not super commonly performed, so the literature is relatively brief. In essence, the hemihemate is a non-vascularized bone graft options. But obviously, I think we have to be very cognizant that there's a lot of non-vascularized bone graft options. There's a lot of literature on those options. And the dorsal radius is obviously one of the common ones. And that's what I sometimes will use primarily. And I actually do use a dorsal radius bone graft, actually, in conjunction with my hemihemate, which I'll describe a little bit later as well. Iliocresta, obviously, has a lot of literature written about it. It's very classical. And it gives quite a lot of bone, which sometimes if you have a large defect and you really want to pack, I do think packing a lot of bone really makes a difference. So the iliocresta is also a very good one. The rib autograft, obviously, Dr. Yao is going to talk about. And this is probably the only one I have not had experience using. So I'm very interested in the next talk as well. And then we will be focused on the hemihemate. So really, one of the reasons why I started to try using this is obviously because it's local to the primary operative site. You do everything in one spot. A lot of my background is obviously in biomechanical research. And we're going to talk about it. Like, there are biomechanical studies on it, some of which I have done as well. And there are good biomechanical principles to using that graft. And then, in theory, using the capital hemihemate ligament for scapholunate reconstruction just kind of makes sense to me logically, although we will discuss even if you need to do that. Because obviously, there are many studies that don't say that you actually need that. There's obviously the number one risk that you always have to worry about is like, does this actually affect your carpal kinematics, right? Does taking a big chunk of the bone come out? And we'll see some x-rays of this. The piece is actually fairly large. So the x-rays can be slightly disconcerting, I think, particularly the first couple of times I've done it, and whether you're going to destabilize the intercarpal ligaments because of your graft. So just to start off the shoot, this is obviously not my idea or my technique. This is the article that really got me thinking about it in 2016. And I've spoken to Dr. Ellison as well as Kakar about this procedure. And this is a really short, sweet paper. And then they describe their technique. And much of what I do is actually their technique. And we will talk later on when we look at some of the pictures that we've done. Some of them were from Dr. Ellison, in one of the chapters we had written together. But one of their first, so the first described technique was in this 18-year-old male who had a failed prior ORF, as mentioned previously, revision surgery. You start to lose options as to what you can do. And they had followed the patient out for 3 and 1 half years, and it healed. And importantly, there was no evidence of SL instability. So what is the hamate? So obviously, we always talk about the lunae. We talk about the capite. Sorry, we talk about the lunae. We talk about the scaphoid a lot. We talk about the trapezium. The hamate, yeah, we do the hemihamates for finger reconstructions. But we don't think about, well, at least I didn't in 2016 think about the hamate very much, even though I do a lot of carpal research. But it's obviously a wedge-shaped bone. It's indicated in the brown, of course, on the ulnar side of the carpus. There's really three main ligaments that help keep it in place. So there's the triquetrum hamate, which is important and which you want to preserve during these procedures. The capito hamate, which is very important, has three components to it. It has the dorsal volar as well as the deep. The volar is what is then turned around and becomes your repair for your dorsal SL. And remember, the hook of the hamate also is one of the components that holds onto your transverse carpal ligament volarly to help cover your carpal components. So there's important structures in the way of taking this graph. So this is just something to think about. And one of the other things I also, when I first heard about this graph, was about the vascularity. So how is the hamate actually vascularized? So it does have dorsal volar branches from middle transverse carpal arch. And a lot of the proximal pole of the hamate actually is interosseous from that transverse carpal arch. But it also has terminal branches of the anterior interosseous and ulnar recurrent artery. And the ulnar recurrent artery sends branches to your hook of the hamate. So AVN of the hamate is obviously not as common as, for instance, kymebox and prisors. But it is actually reported in the literature. And most times when you do get AVN, it's typically the hook or the proximal pole. So potentially taking that, when I thought logically, taking that as the graph kind of makes sense when I read that papers, because it kind of goes from like that retrograde supply. So us taking the proximal pole may not cause any problems in terms of the rest of the hamate dying. Next is like, is this a size match, right? So yeah, kind of looks the same, but is it? And there is actually good literature on this in terms of looking at the topographical assessments to see if it's actually a good match, right? One of those studies we did in 2019, I wanted to see if there was a way to figure out like, okay, like if I have a hamate, I have a scaphoid, is that gonna be a good match before I'm like intraoperatively looking at and then realizing it's not a good match. So were there any parameters we can do? So for this study, we use the third of the scaphoid height because these are proximal pole fractures. We delineated it and you resect, we used about 15 each. So then we turned the graft around. So your capital hamate joint surface now becomes your scaphocapitate joint surface. And then we kind of overlaid them. And then we found actually the hamate has a wider radial ulnar width at the osteotomy site and the scaphoid has a wider bolar dorsal width. And then there's three areas where it was a little bit larger, but generally actually the size match was good. We found if we were gonna select patients, and this is kind of what I did prior to actually starting my first case was to how to select my patients. This is the one case where, you know, I think I try not to shave too much. I try to pick so that the patients maybe have a good chance that the graft is actually gonna fit nicely. Is the hamate radial ulnar width is less than 10 millimeters scaphoid radial ulnar width is less than 10 millimeters and the scaphoid bolar dorsal width is 16. These are smaller grafts. The smaller they are, they typically fit a little bit better I have found. And I don't know about the other speakers, but I have always found that when I do this, everything, even though I take the time to measure, everything is 10 by 10 all the time. It's always one centimeter graphs I'm taking for some reason, irrespective of how many times I cut or I like measure. And so the one thing is I think it's absolutely, if you're gonna take this kind of graph you're thinking of today, you must have a CT scan and you have to have sagittal cuts, you have to have 3D reconstructions and you have to turn the bone because remember you have to like cut and you have to turn and flip the bone 180. So it often helps having the 3D reconstructions. And some institutions, obviously that's automatic, but for most institutions it's not. So, and that helps with actual measurements as well. Again, as I mentioned, I have a background in kinematics. We really care about this type of thing. So if you look at the literature on the carpal kinematics of this, so even prior to the description, so there are things called halt lesion, which is essentially proximal arthrosis and previously in 2004, there was studies looking at like how much did you have to have to resect to unload the hamate lunate articulation? So they actually found no effect of like taking out 2.4 millimeter resections, but obviously the graphs we're taking are larger than that. But then subsequently the original descriptor of this technique, Kekker and Alisson actually did hamate osteotomies and they assessed for carpal kinematics and did not notice a much effect on the carpal kinematics. So here's kind of, I guess, the meat of the conversation of like how to do this or how I have found to do it and like how also not to do it is also very important, of course, because I've obviously done it and it hasn't worked out sometimes. So indications and contraindications. So first, obviously you should not be doing this. If there's any way to salvage this proximal pole, I would elect to salvage it. And I will say a large portion of my practice, like in the beginning of my practice, obviously arthroscopic techniques for scaphoid non-union surgery were not as common. So I would say now I've started to shift my practice. So if there's any way I can salvage that proximal pole, I probably would do things arthroscopically and not take it out completely, I would say. So, but if it is truly, particularly if it's a multiply operated, the revision surgeries, those are very hard to do with revision, even arthroscopic techniques. The patient's not a candidate for microsurgical techniques if they've had radial artery harvest or they've had other surgeries in the area or something. So you don't really have microsurgical techniques, for instance, of some of the techniques that are vascular in nature. And of course, if your expected resection is greater than the height of the proximal pole to your hookah hammate, then this is not the graph that you can use, okay? Because it is just not gonna be big enough for you. You should not be breaching into the hammate. And so your resection, I really try to make sure that the resection does not go all the way up to the hook of the hammate. Contraindications, of course, if you have arthritis at the radial scaphoid joint, you need to think of some type of salvage procedure. You need to do something else that, sometimes I have had patients where, even though they're young, the screw has backed out, it's fragmented, it's non-union, but you go in there and like, the radial scaphoid joint is completely damaged by the screw that's backed out. Like probably this may not be great, right? To put cartilage on no cartilage and e-brenated bone, you're not really setting yourself up for success. And then of course, if there's concern for vascularity of the fracture site, then that's something. And then of course, I do research to kind of help guide me. So if I find like there's a hammate scaphoid mismatch and I have concerns about that, then I actually will defer because there are other good procedures, which will be mentioned later in this conversation that I would use. So I think one of the things is, so this is one where it's like prior to arthroscopic techniques, I actually like, this is a case that was used, but this is a very small one. This is not one currently that I would think is good to do this technique, okay? So I think this probably arthroscopic techniques or going in and doing primary pair of K wires or something might be better, even though it ended up being extremely, extremely small. But usually I would say, if I'm gonna take out that proximal pole, it's usually because there's been a screw in there before. There's been, it's a revision case. So I use this for example, but this was way a little bit earlier. And like my practice has obviously changed, but this is for illustrative purposes, obviously. So positioning is just regular. It's supine radiolucent arm board, a non-sterile tourniquet on the upper arm for 250 millimeters of mercury. And so this is dorsal approach. Essentially, these are the three of the exact same images. And as I said, the pictures are various different pictures, mainly to illustrate points. So this is the dorsal. I do a standard dorsal approach and I use Penrose drains to help my retraction and things like that. I think I use the ligaments bearing approach and I've kind of made it. So you go through your DRC and your DIC and then your triquetrum is your kind of like point. And then you'd make a little back cut along the joint of the radial scaphoid joint. In essence, usually if you can't find, usually if you're able to find those fibers very nicely, it's very nice to just go through the midpoint. For the DRC, if you're really having trouble, it's like another landmark. I tell my fellows is between your DRUJ and your Lister's midpoint. That's kind of where your DRC lies. The one thing that I changed for the ligaments bearing approach from what Berger originally taught me when I was his fellow, was that I actually extend it so it's a little bit more distal than I would normally do for my DR. So my DIC cut would be more towards the distal aspect of the DIC versus usually I would, if it was a regular ligaments bearing, I would go through the mid portion of the DIC. So I make this cut a little bit more distal and a little bit more ulnar and I square it off. I don't use this little point. So this is how I just changed that I modify it to try to help with my approach for doing a hemate reconstruction. Of course, you just want to take some time, look at the joint and inspect the joint when you do your capsulotomy. I like to actually see everything. So before I cut or do anything, I like to inspect the joint. I like to see my proximal hemate. I like to see my scaphoid before I cut and do anything. So this is where you're obviously going to take this hole is obviously where the proximal pole has been resected. The one key of course is remember, I'm trying to repair my SL. So I really take efforts to take the SL off that proximal pole for as long as possible to try to have it flipped up onto the lunate. So that I, and then sometimes I'll tag it because sometimes it's a little bit flimsy. And then I think as basic principle for scaphoid non-union reconstructions, you have to cut back as much as you need to get to bleeding bone. I think that's one of the keys. And sometimes if there's a lot of cavitary lesions in it, I'll take a curette and curette it out. I usually cut, but I also curette. And then if there's like pocket divot holes, I actually do take dorsal because the distal radius is right there. I do take dorsal distal radius and pack it inside the graft to help like fill in those defects. And then of course I measure and it's always one centimeter for some reason. Next is obviously the hemate osteotomy. And you want to make sure you protect that TH ligament. The one thing is I use a very skinny blade here and it's the small one. It's long with the teeths. You want to protect everything. You want to cut again, one centimeter. You measure out from the tip of the hemate or in theory, whatever your length that you cut out was. And the one thing is, is obviously I go through, I tap the back, but I don't crack the back with this. I use actually a freer to release it. I don't use the osteotome because remember on the other side of this is potentially ulnar neurovascular bundles and you don't want to damage that because your hook of the hemate can be quite close. So I use a freer and I do this very carefully. Graft is very nice. You can hold on. Sometimes this is a picture from Dr. Ellis because he had a very nice fuller CH ligament. Sometimes it's not as robust as this, I will say, but usually you're able to get something as long as you kind of free things more volarly when you're getting this graft. So pre inset, this is a picture. So there's just a lot of empty bone in the carpet. So it's a little disconcerting, I will say. So this is where your hemate's gone, your scaphoid's gone. And it's just a lot of empty space, but funny enough, this is fine. Like the ligaments, as long as you've preserved them to the TH ligaments, everything still stays in place. And then the hemate inset is like any other inset. And usually if I preoperatively kind of chosen and selected the patient, you're able to inset that without too much problem. And then like the graft ends up being more like this whole kind of side area. And then that's what you kind of suture together with two non-absorbable sutures. The one thing I will say is that I will do a capital lunate pin to help, like I put the graft in, and then I put the capital lunate pin to help stabilize the joint. So this is where it is intraoperatively. And I actually keep this capital lunate pin in at least for six weeks or so, or more. Initially I did it until they healed. And then I just use a regular standard screw for the scaphoid, because obviously you're at the dorsal approach, you can go antigrade for this. And this is the postoperative. See the hole is a very large, very disconcerting, but the patient has not had problems with this. So this particular patient, the pre-op pain was gone. And then you did lose some range of motion, obviously. They didn't have great preoperatively, but they didn't have great postoperatively either, but the grip strength actually improved quite a bit. So I guess some of my tips and tricks that I wanted to mention just before I forgot, was like, you wanna really pre-op plan the anticipated graft length. And then you also want during the graft harvesting, you want to use the retractor between the hamate and tricretrum to protect the ligaments. And then you can also use the joy sex in the lunate to correct any DZ if you have one, when you're pinning the capital lunate. I use the 2-0 non-absorbable as a suture to repair the capital, sorry, CH ligament to the SL ligament. And you wanna avoid overly dissecting dorsally, that dorsal blood supply is there. And then the one thing is, is like, I used to always do a D rotation pin for my graft. Like I would do it all along the sides. And then I did crack one. I did crack one of my grafts when I did that. So I have actually, because of that, like I don't use that D rotation pin anymore, even though I routinely do that for my acute scaphoids, just because I'm very scared. Although you can drop it down, like use a 3-5 or something smaller, like that's way off the graft. But like one time I did crack the hamate graft, which is an extremely important event because that's the whole point of your surgery. And then, as I said, I use sometimes distal radius bone graft to supplement any gaps that I might have at my osteotomy site. So this is a systematic review that's still in publication. So it looked at 30 patients in the literature, which again, not a lot has been published on this necessarily, but they did have obviously delayed presentation. Follow-up was about a year or so, which is relatively short, like short to midterm. The hammock graft length was about 6.7 millimeters, and then they had very good radiographic union, and then grip strength was approximately 80%, and the complications, of course, is always present, relatively high. This is another one, obviously, from Ellison and the folks at CACAR at Mayo, and they actually looked at the three things we're talking about in terms of the carpal kinematics, and they really found minimal differences, which I do believe. I think at the end of the day, if you can get the scaphoid to heal and you reconstruct that height, I think the kinematics probably do get restored. Thank you very much. Wow, that was fantastic, Nina. These webinars, you know, the lack of audible feedback, you were crushing it. That was a great talk. I don't want you to think dead silence doesn't indicate an awesome talk. Really appreciate it. I wonder if, as we're teeing up here, Jeff, if you could just say, Nina, so for you, as you said, you're really going with scopes, trying not to do it, but when you do it, you get the CT ahead of time, and then you will rule some patients out if you feel like it's just not a good match. Yeah. Yeah, and if those patients get ruled out, do you go to a rib or what's your play there? So funny enough that if they weren't a great match, I'd probably do an MFT. Because MFT, it's like a lot of bone. It's great. It's bleeding. It's a big incision, but having said that, I have wanted to try a rib because rib conceptually also makes a lot of sense, but at this moment, like today, if this happened, I'd probably do an MFT. Well, you're going to want to try rib very shortly because Jeff is about to take over here. Tell us a little bit about costal condor rib autographs, Jeff. Thanks, Jim. And thanks, Nina. Great talk. Thanks to the SSH for putting this together and thank you everyone for being on tonight. Can you see my slides okay? Good. Okay. All right. Here's my disclosure slide, nothing relevant to this. We all know there are multiple options for treating scaphoid non-unions, but we're really focusing on the unsalvageable proximal pole. This image looks very similar to the image that Jim showed earlier in his introduction. These are the patients where the proximal pole is no longer salvageable. It's either fragmented or a non-contained defect, and potentially in a patient who's young or there's no evidence of DJD where you would consider a salvage like a four-quarter fusion or PRC. So this is a relatively uncommon scenario, but it does happen and you want to be prepared to treat these patients when you see them. So to illustrate this concept, I'll share a case that we did a while ago, a 20-year-old football lineman treated initially with a screw for his proximal pole scaphoid non-union, resumed high-impact sports, but then developed pain with wrist motion. And if you look at the X-ray, sorry, this is the initial post-op X-ray. So it looks pretty good, nothing too concerning, although it is a very proximal pole. But that five months post-op, you can see there's starting to be a problem. There's lucency around the screw and in the proximal pole. And on the CT scan, most glaringly is on this view, you could see the proximal pole is split in two. And so once it's fragmented, in my opinion, I mean, I guess you could try to bone graft it and put some K-wires in each fragment to try to hold everything together. But at this point, the horse has left the barn. You're looking at an unsalvageable problem. So in this situation, what has been described, you can excise the proximal pole if it's small enough. In this case, it's too large. This patient's a 19-year-old, so you don't want to necessarily go straight to a salvage. You can excise and interpose something, whether it be silastic. We know that's failed in the wrist pretty significantly. In Europe, a pyrocarbon implant has been described and actually has some really good data, but in the US, it's not available. You could use tendon graft, but you're concerned about that collapsing over time. Scaphoid allograft may or may not heal. And for the purposes of this discussion, we're going to focus on these three, and we've already talked about the handmade autograft. I'm going to talk about the rib osteochondral autograft, which is not a new concept. Plastic surgeons have used it forever for nasal reconstruction. We also use bone plugs for knee reconstruction. And Michael Sandow from Australia was instrumental in describing this for reconstructing the scaphoid in 1989, so several decades ago. So here's our patient, 19-year-old, excuse me, with that fragmented proximal pole. You can see it's shriveled up. It's not well contained, and there's not a whole lot that you can do with that fragment, in my opinion, other than to take it out and remove it. And you can see the defect that's left behind. But the remaining distal pole is still quite viable and quite healthy, so you want to preserve that. So this is how it's done. And again, I'm an orthopedic surgeon. I'm not very comfortable around the thorax, but this is not a very difficult approach, and I'll hopefully show that to you today. So here's a seventh rib via submembrane incision. You can see it's a very superficial dissection. It's literally millimeters below the skin. You can see there's a junction between the rib and the costochondral cartilage. There's also often a color change, and there's a number of different rib instruments that you can use to elevate the intercostal muscles off of the rib and the cartilage. I cut the cartilage with the scalpel. It's very soft. And then you take a saw and carefully cut the rib, obviously not plunging into the pleura below. And there are a number of retractors that you can use to protect you on the other side. And this is what it looks like once it's harvested. You really only need a couple of millimeters of bone because you just want that osteosynthesis between the graft and the remaining distal pole. And you want to take a healthy wedge of cartilage so that you can shape it to whatever defect you have. This is kind of the most fun part of the case. You take the cartilage. It's like carving soap. I take a little beaver blade here and carve it to the size that you want. As Jim has shown and as we'll learn about later, for these grafts, you want to tend to overstuff the graft if necessary to maintain your carpal kinematics. Here, you can use a screw, although I find that I'm concerned of the amount of damage to the cartilage, so I just pin these with either a 4-5K wire or 6-2K wire times two. This is somewhat controversial. You can use the remaining scapholunate ligament, which is still attached to your lunate here, and sew it down to whatever perichondrium you have. But let's be honest, it's not very vascular, so it's probably not going to heal, but sometimes it makes you feel better. I have another case which shows that it actually looks pretty good once you repair it. Postoperatively, I get a chest x-ray. Because you are working near the pleura, you want to make sure you don't have a pneumothorax. Again, I realize just saying that creates a lot of fear in a lot of people, but I would submit to you that it's actually quite a safe approach. Immobilize our patient for about 7-10 days and put them in a cast. Usually, about 6-8 weeks or up to 12 weeks, I guess, once we have a CT scan that shows the healing of the rib to your remaining distal pole, you can remove the pins and then start rehab. Here is this patient two weeks post-op. You can see the graft is in there. Obviously, cartilage is radiolucent, so you're not going to see anything there. We maintain the radial height and the linear position. This is the patient after the pins have been removed two years post-op. You can see on the x-ray, it's hard to see the junction between the graft and the rib, but on CT scan, you can see the distal pole of the scaphoid is distal, obviously, and there's the rib right there. You can see the healing of the rib to the distal pole of the scaphoid. This is this guy two years after his surgery, doing quite well with excellent grip strength. In fact, his grip strength was higher than the contralateral side. This is another case we just did last week. If you look at this scaphoid, you can see there's a lot of lysis around the proximal pole of the scaphoid. I'll be honest with you, I love the HandMate Autograft. In fact, I do tend to use that just logistically. Sometimes, it's hard to get a lot of time in the main OR to do the rib graft. I have been doing some more HandMates lately. As Nina said, only about 70% of the HandMates actually fit. If you look at this HandMate, I don't know if you can see my pointer, but you can see this HandMate is very pointy, this proximal pole. I didn't think that that was going to be a good match for my proximal pole of the scaphoid. That's why I thought this would be a great indication for using the graft. You can see the CT scan. This proximal pole is shattered. I don't know of any other reconstructive procedure other than the three that we're discussing today that would be able to solve this problem. Here's their approach again, a little bit of a smaller incision. I like to use an 18-gauge needle to just help find the cartilage. Usually, it's visible. Hopefully, it projects well. You can see here's the cartilage, which is white, and here's the rib that's red. I don't know if you can see that well or not, but there's the junction that we look for. If you can't find it or it's discolored, whatever, you can use the needle to feel the soft cartilage and then feel the hard bone next to it. This is called the Doyen rib stripper. You can get on the other side of the rib, and it strips the pleura atrematically off the backside or the posterior aspect of the rib and the cartilage. Then, like I said, I use a scalpel to cut the cartilage, which is quite soft, and then use a sagittal saw to cut the rib, again, with a retractor on the other side to protect you. I try to get at least two millimeters of the rib. You don't really need that much bone, but you want to make sure you have enough cartilage to overstuff your joint and fill your defect. Then, obviously, check the pleura. Again, as an orthopedic surgeon, we're not used to operating near soft structures like the lung and the pleura, but I can assure you that it's actually a very safe procedure. Now, we're going back to the wrist. You can see that proximal pole is tiny, and it's fragmented. Again, nothing that's salvageable. You can see right here, here's the cuff of the scapholunate ligament still remaining on the lunate. Obviously, we maintain that, and we shell out the proximal pole. There's the distal pole at the tip of my freer elevator. We clean out the necrotic tissue on the distal side as well. Often, I'll use a K-wire to fenestrate the distal pole, the scaphoid, to help bring some bleeding bone to the area as well. You can see in the base here some evidence of bleeding here, even under tourniquet. Again, bring out your inner sculptor. You just sculpt out, carve the soap a little bit, and make your graft, your cartilage the size of the proximal pole that was excised. Again, you want to tend towards overstuffing. You'd see the graft was not quite ready at this point, but we got it to a size that we thought was quite good. You can see here's where the ligament drapes over the cartilage, and you could potentially throw some sutures in there to sew it to the perichondrium. I stabilized it with a couple four or five-inch K-wires and packed it down into the cartilage surface, and that's what it looks like at our final contract. You can see good carpal height, good position of the lunae. It's not extended. It's in neutral. This literally we did last week, so I don't have any follow-up on this patient, but I just wanted to show those technique slides. What about some outcome studies? Michael Ossanda, like I said, from Australia, was the one who originally described this. He said in his first group of patients, 19 to 22, good to excellent results at median 24-month follow-up, no deterioration of carpal alignment, no nonunions, and one mild hemothorax. He followed this up in 2047 patients, 85 good to excellent results, and again, minimal to no complications. Veitch, I believe, was one of Sandow's fellows who took this to the UK and started doing this as well, also presented in 2007 excellent results with this technique. I had a chance to visit Michael in Adelaide during my Bunnell Fellowship, and he's been able to show, I don't know if this was ever published, but in his 2013 ASSH poster, he had a minimum 10-year follow-up in 40 patients with 92% considering the surgery a success, only 10%, so a 90% survivorship at 10-year, only 10% unwant further surgery, so that's quite good. It's hard to beat those results. We had a much more modest cohort of patients from our center, three patients, and again, very similar outcomes to what was published from Michael and his colleagues. So, common concerns, okay, what do we do with the scapulonid ligament? I alluded to this earlier. So, like I said, you can try to repair the ligament to the perichondrium, but let's be honest, that's not likely to heal. The key is to overstuff the graft. In fact, Jim and colleagues showed this in the lab, that by overstuffing graft in the setting of reconstructing the proximal escapoid in the MFT setting, this stabilized the SL interval in the carpal alignment. Okay, so the big elephant in the room is operating on the thorax. I get it. I was scared the first couple of times I did this, but there's really no need to be scared. There's a long history of use of rib grafts for other things in plastic surgery, such as nasal reconstruction. Also, in cervical fusions, rib grafts are used as well. Based on these studies, you can see the risk of pneumothorax is quite low, and other complications, hematoma, etc., are quite low as well. But let's say you get a pleural tear. Remember, this is the parietal pleura, so it's actually quite safe. So let's say you get a small little hole there. No big deal. You can actually see the lung inflating and deflating beyond it. You just basically put a little red rubber catheter in the hole. You ask your anesthesiologist to fully inflate the lung. You tie a cerclage suture around the red rubber catheter, and as the lung is inflated, you pull the catheter out and cinch down the suture. That's it. It's pretty simple. And then you can obviously get an x-ray to make sure that the pneumothorax is either not there or resolves over time. But again, it's not as scary as you think. I have some more cases. This is another one that we treated. This had an ICSRA in the past, continued to have pain. You can see that the proximal pole is basically shriveled up. I did an osteochondral autograph with pinning, and this was three years afterwards. You can see the carpal height is maintained. The length is in slight extension, but you can see overall the shape is good, and more importantly, the range of motion is good, and the donor site is pretty minimal. His dash PRWE is quite good. Another patient also treated with the 1,2-ICSRA, continued to have painful motion, nonunion, proximal pole is not very healthy appearing. Did the autograph. He returned to work as a heavy laborer, so you can see it kind of fell apart. In fact, he didn't even come back to get his K wires out. Returned to work as a heavy laborer, so it did fall apart. His motion was actually quite good. His donor site was fine, but you can see his dash and PRWE were not great, and this is again nine years afterwards. It lasted him quite a long time, but arguably, he probably went back to work a little bit too early and didn't even have his pins removed. Anyway, to conclude, luckily, this is an uncommon problem, an unsalvageable proximal pole scaphoid defect. I would submit to you the Osteochondral Rib Autograph is a great opportunity where salvage procedures might not be ideal, particularly your younger patients with no arthritis. In my opinion, I think it's less morbid than the knee and hemi. It can be done outpatient. I like to admit my patients for one night just to make sure that their chest issues are completely resolved, if they have any, but this can be done outpatient. Some of my colleagues do this on an outpatient basis. Obviously, there's no need for microsurgery, and no disrespect to Nina and Basim and Sanja. I think their research is outstanding, but I do worry about that huge hole in the proximal pole of the hemi. I know their studies show that there's no concern, at least in the short term, but I wonder, particularly because of the hemi's role and its articulation with the triquetrum, what that ultimately does with carpal connect. So, I do do that procedure, but I don't even have to worry about that if I use a rib, which obviously has little to zero morbidity. Also, the concern for size matching, as Nina presented it, you know, up to 31% are not suitable for scaphoid reconstruction. So you can eliminate that situation as well. And also the proofs in the pudding. If you look at Tanau's work, you know, the studies show great long-term results. So I would say that it's something that, again, can be scary in the beginning, but, you know, if I can do it, any orthopedic surgeon can do it. So with that, I'd like to thank you and I'm happy to take any questions at the Q&A. Thanks. Jeff, totally awesome. And yeah, for the attendees, we were gonna hold questions till the end, and we do have a Q&A session set up for that. I do wanna, I can't resist, Jeff. I saw in your cases, some of those pins, and I love this operation, but some of them were anagrade, some of them were retrograde. Yeah. Some of the retrograde were in the standard trajectory, fuller to dorsal. Some of them were retrograde dorsal to dorsal. Yeah. Which is what I do. And I wonder, it seemed like the case you did maybe just last week, you said, was anagrade pins, right? And you left them in the radiocarpal joint just to sort of hold it in there? Is that- Yeah. Is that your case? Yeah, so a couple of those cases were from my partners, Rod Hentz, who actually showed this technique to me and taught me this technique. So I have to give credit to him. I prefer to do it anagrade because it's right in the field. But, and obviously I don't let them move until there's healing. So then I take out the pins and then start therapy. So I don't mind if they're in charticular, but certainly you can also put the pins in retrograde as well. I like to do it anagrade because basically I put a hook on them and I packed them in so I get a little bit of compression. So I think that's a benefit of that. But I think either way it can work. Yeah. I think it's a tricky procedure. It's definitely worth trying on a cadaver a few times. But I do feel like, I do sometimes feel like that is actually the lowest morbidity operation for this problem. Okay. I'm breaking my own rule. I said we were going to hold all questions to the end. So here we go. So I was going to talk about MFT reconstruction and I have no, nothing to reveal that's relevant. So this proximal piece here, we talked earlier about wouldn't be great if there was something with shape just like it. Now, by the way, you look at Jeff's thing, next thing you know, if you're a good boy scout and you've got a pocket knife, I mean, you can make a rib fit anything. But Nina and I have to worry about it actually being congruent, I think. And I do wonder how congruent does it have to be, but I'm going off on a tangent, but wouldn't it be nice if something was shaped just like the proximal pole? Turns out there is, this incision is huge and it's not the incision we use, but I'm using it for the purposes here just to give you a peek at this sort of filigree of these blood vessels heading around this area and how they course up to this proximal and medial most aspect of trochlea and how this has led us to a ton of research on this topic. And, you know, A, that shape is kind of nice and particularly in the coronal plane is very much like the scaphoid. But of course, there's questions of like, yeah, it's a free flop, but is it really perfused? Is the cartilage perfused? Is the subcontral bone really perfused when you're done? And I'll show you some stuff about that. So one of the parts that I love about this topic, meaning all osteocontral reconstruction is we can take away this really small non-union, which is so difficult and pesky. And, you know, we're forcing ourselves to work in the worst part of the scaphoid. And you can resect up to the waist because no matter what you're doing, Nina's operation or Jeff's operation or this operation that I'm talking about here, this is the last stop on it. If this doesn't work, you're going to salvage. So you don't have to be too shy about carving into the scaphoid. This is the last move and you've got to make it work. So I would say, get up to the waist, increase your chances. And so this is an MFT and this is a wrist, fingers to the right, elbow to the left, inflection, the proximal pole fragment here, fortunately outlined in purple, which is convenient. And that is the MFT overlying it. So you can see the congruity of it. Here's the resection up to waist. Obviously we're providing convex cartilage that faces the radius, but not the concave cartilage that faces the carpal joint. So if you approach from dorsum, like I do, and Heinsberger, who's the originator of this operation, by the way, will often approach this volatilely, but I always approach it dorsally. The incision would look like this, fingers to the left, and you're looking at the volatile radius scaphoid capitate ligaments. And the incision is allowing access to the radio artery and the snuff box for endocyte and estomose. So I try my best actually not to look at the capitate at all. So usually that mid-carpal joint is closed. Intraoperative x-rays, it's an anti-grade screw. Here's four weeks post-op, and there's usually a bit of step off here because like the rib and like the hamate, I'm sure that the amount of cartilage on this bone is not identical to the amount of cartilage on a scaphoid. So it's not radiographically gonna look identical. And sometimes the screw will even look a little bit proud, but it's countersunk inside that thick layer. So anyway, here's our initial two group publication in 2013 from Heinz's group in Austria and our group in Baltimore. And that's a four years follow-up. So this is really interesting, and it looks a lot like a scaphoid. I sometimes wonder how important is it really to look a lot like a scaphoid? Are we just trying to put a bunch of rubber on the tires? Like if we've got a wrist that moves and you're not creating osteoarthritis, maybe that's all we need to do. Here's a scrolling CT of an MFT. And that, you might be able to fool a radiologist. So we published that, and we also published using this, as you guys know, also for lunates, but that's not really the topic at hand today. With this success, after years of doing it, we put out these papers. It was just like, man, we're screaming along here. Maybe we should keep going. It's so much fun. These are my kids when they were a lot smaller. But then we said, wait a minute, we should do a little bit of research and figure out if this is just a flash in the pan or if it's going to actually carry weight into the future. So I thought two questions for the purpose of this webinar. One is, you know, how is this going to do versus conventional operations or should we just stop doing it? Like if it's no better than PRC, maybe we should just stop doing it. And the second thing is, do we really need to do the microsurgical portion? Well, talking about the durability. So we did this subsequent study, 2020. This is a single institution. It's just easier to get the data if it's in your building. And this was with the help of Mitch Pat and Avi and our research team. And this was a series of 41 patients, mostly young guys, and they mostly had previous surgeries. So 35 of the 41 were revisions. Most of them had pedicle vascularized bone graft or some had a pedicle vascularized bone grafting before. And the summary on this was the radiolunate angle did not vary despite us resecting a large portion of the scapholunate ligament. So you don't have to worry about going into DZ. And this is the sort of data that I share with our patients. And this is a long consult in the office, by the way. They said, look, you're not going to have full range of motion. It's about 65% of the contralateral limb, flexion extension arc, pronus supination, of course, irrelevant, meaning it's normal, but flexion extension important. And then grip strength, it's really not a key pinch issue, but generally speaking, your grip strength should be about 85% of the contralateral limb, if you're average. We also, of course, went through a battery of outcomes measures and found that the mean postoperative dash score is 10. And the change was 15, which is higher than the MCID. It's not incredibly higher, but it's higher than the MCID. So maybe this is still worthwhile, but what about, of course, the leg? Just as Jeff said, worried about the lungs, we're worried about the leg, right? Here's kids that are young patients that didn't have a leg surgery before you started. And we looked at all these post-op scores. Now, by the way, all these things, the COOS modules, the WOMAC, all the things I'm going to show, their scores, 100 is normal. So it's unlike the dash, which is in the inverse. You want to get 100. So here are post-ops in these young, healthy patients. We're not in 100s. And I was like, whoa, wait a minute. Pump the brakes here. You know, we can't have anything but 100. And then I was relieved to find out that when we did preoperative scores, they actually weren't scoring 100 either. So it's kind of like the dash. It is pretty hard to get a perfect score. And maybe that says, well, this is not a good way of measuring this operation. We always end our manuscripts like that. But we ultimately look for significant differences. And we found there were a couple of modules where there was a statistically significant difference in the pre and post-operative scores. So we drilled down on that, felt we were being responsible. We looked at the MCIDs of these modules, and we found that in particular, this COOS sports module was 10 point difference and the MCID was 10, and that was statistically and clinically relevant. So we really honed in on this, said we got to figure out, how can we make this a better operation or how can we better define our outcome? So we did univariate analysis and checked BMI, gender, age, dominance, et cetera. And it seemed at first like maybe male sex and higher BMI were predictive of worse outcomes. But then if you submit that to multivariate analysis and remove the chatter of the other factors, it turned out that BMI was a sole predictor of worse outcomes. And then we looked at the spread and found that if we limited it to BMIs less than 34, all that went away, which is a little bit of a statistical fishing trip, but indeed this led us to, and I think it's a responsible way to sort of proceed with something like this is actually create indications and contraindications as you go, learn from what you're finding out. So from this point forward, BMI less than 34 is a requirement for being a candidate for this. So anyway, we're going forward with this huge battery of outcomes, thanks to our research division, and also doing with similar age match cohorts of all these patients that we do salvage operations for, and we're trying to figure out what a clinically relevant follow-up period is. And so if you look at this, here's my daughter when she's a little bit bigger, but we're in Austria, actually, in that picture. So if you look at what we have so far, we've got prospective date on salvages and MFTs, and the MFTs is a pretty good number. We got 110 for scaphoids and 60 for lunates, and that number's growing. So we're gonna, I think, be able to really make a statement about whether or not this is something that we should continue in the future, or whether or not it just doesn't stack up or the difficulty doesn't pan out. By the way, she is gonna be a hand fellow here in 36. So I wanted to show you guys what we're finding now with longer-term outcomes. So these are pre-ops of patients, because now I have the clips 10 years, pre-ops up top. So these are the patients, and say to yourselves, hey, what I have done in MFT on that patient, pre-ops and post-ops. So this is 10 and a half years later. And how do you evaluate this? Well, I think it's important to evaluate it by saying, does this look like slack or snack? Like, is there narrowing of the scapholunate interval? Is there beaking of the styloid? Is the SL widening? Is the lunate going into DZ? And this patient, I would say, at a 10 and a half year, that's pretty durable, and that looks pretty good. So we, you know, is that lucky? Here's another patient 10 years out. Double screw, I think, by the same metrics. Looking pretty good. Here's another one. Pre-op, post-op, 10 years out. Not, you know, not going into DZ, and has good space between the scaphoid and the scaphoid fossa. Here's nine and a half years post-op. This one has a little chatter in this proximal pole. One wonders about whether or not it retained perfusion. It certainly looks a lot like a scaphoid. Here's one at 10 years. That patient, that surgeon was having a hard time with that case, for sure. So here's 10 years after MFT. A lot of space in here. No beaking of the styloid. Lunate looks pretty good on this not-so-good lateral X-ray. Here's a primary, really small primary piece I MFTed. Uh-oh. Yeah, there we go. Looks like we're stalled here. So there it is, 10 years later. So I find the, is this the case I showed in the very beginning is patients well over 10 years follow-up. And good space. So it seems to show us that, at least at this sort of now decade out, that we are doing pretty well. And if you stacked it up versus those PRC and four-corner fusion data, it looks something like this. Flexion extension arcs, 86. You know, grip strength, 83% compared to contralateral. Dash and PRWE upper extremity scores looking pretty good. So is that enough to say that's better enough than salvage? A little unclear. Enough than salvage, a little unclear. And then the microsurgery piece, just wanted to touch on that because you could say, well, this cartilage is perfused by synovial imbibition. So maybe we don't need to even bother doing the micro. So we created this multinational study. We took a team to Turkey to a medium-sized animal lab. And I'll go through this really quickly, just stay on target here. But this is a great lab at Koukourova University where you can use various size animals, but we use the pig. You're coming in in the pre-op holding area. Why? Because they have a descending genital artery in the medial femoral trochlea. And we were able to elevate the vascularized pedicle osteochondral flap and then a non-vascularized graft. And then we put a layer of cement underneath it and between them, cooled it, replaced the graft and flap, screwed it back into place. The animals were then allowed to return to the post-operative area. They wandered around and lived for six months and ate and ambulated and cycled their knee. And then we went back and harvested the segments. And this is the team that's Heinsberg there in the top right. And we had a blinded histopathologist, musculoskeletal histopathologist who uses International Cartilage Repair Society Visual Histologic Assessment Scale and found that on all but one of these subunits, the vascularized cartilage appeared histologically to be superior to non-vascularized cartilage. So that's interesting. And that was a really, I think, an important landmark study, but it just says histologically what is observed. It doesn't mean that that will correlate with any sort of outcomes from a clinical standpoint, but that's an important piece. So we've done a lot to study the vascularity of that. And I think the sort of 4.0 and this is now micro-CT angiography. So you've all used micro-CT scanning, but this can be done on a research basis with angiography. If you use a dye that is low viscosity enough to penetrate these super small vessels, you can now, and this was just published, you can now see the subchondral plate being profused and where the vessels go. And we've been able to actually delineate exactly how to harvest this so that you capture the majority or a large number of these immediately penetrating vessels right below the subchondral plate. Anyway, we've assessed congruity as well. I won't get into that too much. I think the way to do this is not arc of curvature. But this is our sort of 1.0 study. The one thing I did notice when we were looking at, and Nina could certainly speak to this, but if you look at a native scaphoid and scaphoid fossa, both on coronal and sagittal planes, you know, the relationship is actually not perfect. It's about a 0.8 ratio. Whereas when we put in the MFT, I was looking, I'm like, man, we nailed that. And it's because it's about a 1.0 ratio. It's exactly fit in the coronal plane, but that's not the way we're designed. So we should actually be aiming for sloppy. So the question is, how relevant is this? And I think this is the final answer is to use this 3D morphometric analysis. So creating this mesh of multiple points along the surface of this complex structure to try to determine just how congruent or non-congruent it is. So summary, I want to stop there. I just want to say that it seems like the complexity of mark surgery does help, at least from a histologic standpoint. And it does seem like this technique is going to outperform conventional salvage operations, but we're only at 10, 15 years into this now. And I do think the reality, when you're counseling a 20 year old and his parents are sometimes in the room, it's important to know what the 40 year outcomes are. And what is that going to do to the risk of arthritic changes in the knee or the wrist long run? And is it worth that extra effort and complexity in the short run? So I was going to, if you guys are okay with it, I was going to switch gears and go to some cases and go to a Q&A for the sake of this. Maybe we'll just start with a case. And maybe Jeff, you're unmuted. I see you, right? And Nina, I'm not seeing you. Let me see for a second here. Yeah, yeah. So maybe you two guys unmute. You okay with this format, I'm just going to get right into a case and sort of discuss it open. Yes, that's good. So here's a great example of a challenging case. This is a 19 year old, so you know, definitely don't want to, no one's chomping at the bit to do a salvage on this kid. And his proximal pole is by I think anyone's estimation, not salvageable. There's a scrolling sagittal plane CT. I had mentioned my indication earlier, I don't think anyone would argue that needs to be replaced. So approaching this, and recall everyone, there's not a right answer or wrong answer, but approaching this, what are your considerations Nina, what are you going to do with this kid and maybe his parents that are in the room? Yeah. So I think one of the things is like to understand maybe what the initial postoperative course was sort of like, was he compliant with his immobilization? Did he come to the follow-ups? Like does he smoke, vape, zin, or do anything like that? I probably ask those type of histories. And also I think, I hate to say it for a 19 year old patient who has failed a procedure, I think they have to, I do counsel a lot about the fact that this is going to take several months again, if we're going to do another procedure and are they willing to do it? Because if they're not willing to do it at 19, like do the immobilizations, do the CT follow-ups, do all that, then I don't rush to surgery, I will say. So I would say as crazy as it is, some of the psychosocial aspects of the patient like matters when I operate on these patients. And then of course, then it becomes a discussion of like the actual procedure I would offer. And for this one, the radiographs kind of show it's extremely sclerotic, which is a bit different. So, and like, I would agree, this is not salvageable. This one I wonder whether it would benefit from some vascularity and a more robust, like some type of replacement. What do you think about his DZ? Yeah, his DZ is also a huge problem because he's only 19 too. So that obviously you would see about perhaps correcting that. So it's like, this is maybe one where definitely you would want to over stuff, you would have a bigger graft. I don't think this is like a proximal handmaid candidate to me, something larger, more robust. Jeff, what do you think? Lots of great points already brought up, so I won't reiterate those. There is already an osteophyte on the distal radial aspect of the scaphoid, which is pretty common location and some beaking of the radial styloid. So he's already starting to develop a snack wrist. And so, but that being said, the radial scaphoid articulation still looks quite good. So I don't think this disqualifies him from having a reconstruction, but certainly brings into the conversation a salvage, even in a 19 year old, potentially a mid carpal fusion. But that being said, I think it's worth a try to try to salvage this. I agree with Nina. The size of the defect and again, the proximal handmaid looks is kind of the pointy kind where I'm not sure it would be a good fit. So I'm not sure I would recommend that. So I think whatever reconstruction I'm going to do, I'm going to shave down that radial styloid and try to get to those osteophytes on the radial side of the scaphoid as well. But I would think this would be a good candidate for a rib. I think it'd be a good candidate for an MFT as well. And yeah, that's those are my thoughts. Yeah. I mean, I was looking at this x-ray that was sent to me, you know, hey, Jim, I'm going to send you this guy. And I thought, wow, he's MFT. And then he walks in, he's his BMI is 48. That's that's like, that's it's like sumo wrestler style. So that's a big number. And for me, you know, it's well over 34. So there's that. But I also really like what I like about the rib and this is where I'm going with this is that he does have a little bit of arthritis and I sort of sometimes feel like the ribs so cheap for the patient that put it in there and you can get very big pieces. So you know, that huge cystic resorption here in the mid body of the scaphoid, which is shown on the sagittal CT here, you know, you're going to need to cut into this thing pretty significantly. So I do I do like the the rib for that. And you know, if you feel that maybe maybe a mid carpal fusion. What about size? Does that make the rib difficult for you? Like you said, it was a couple millimeters under the skin. Oh, yeah. Oh, yeah. I mean, I'd love to see an extra, I mean, a clinical photo of the guy. But even still, I mean, you know, the ribs are relatively easy to find. I would certainly use a larger incision in that situation just to make sure that you're you're where you want to be. You can localize as well with percutaneous needles and such with an x-ray, for example. But generally, the ribs are easy to find. The sternum rarely has a ton of ton of adipose along the sternum. And so you can just find the sternum and work your way laterally one side or the other. This is the outcome on this kid. I really learned a lot from this case. Here's a scrolling CT. And I would say if you look at that wafer of bone to scapula, that may not be healed. I mean, maybe it's not. He's not complaining to me. And the great news is that if you look at the amount of cartilage you put in there, like, look at that, that looks like maybe that's not healed, but there's a huge wad of cartilage in there. So maybe it's like it's an arthroplasty. It's an oppositional arthroplasty. I don't think it's going to escape or, you know, as we sometimes we use the term fibrous union. I'm not sure what that means. But, you know, it's staying where it ought to stay. But we still see a line when a defect in the radius, did you take some radius autologous graft as well? Oh, no, that was from you had a previous one twice. Yes. Right. Oh, OK. Yeah. Yeah. I think that's a pretty big hole that didn't fill at all. Was it tough getting the rib from from this guy? Yeah, it was. I thought it was tough. I'm not I'm not necessarily great at it, but it was pretty deep hole and had to be longer in order to get in. Yeah. He's really he's really big. I mean, it's definitely he's professional. Great. Big. So the first times you took the rib, do you do you do it with thoracic surgeon or something like that when you first tried? I'm actually a stealth plastic surgeon. Oh, no, I know. For me, it definitely was nerve wracking. So that's why I was in the main hospital with thoracic on call in case I got into trouble. Again, it's such a knock on wood, safe approach that I haven't I haven't even called a vascular surgeon to be on call lately. I still do it in the main hospital just because so I can admit them. But like I said, some of my colleagues do it as an outpatient. Interesting, because it's like because I like I like conceptually the rib autograph makes a lot of sense. Like the next one, like I was going to ask a thoracic surgeon to like because obviously they're there all the time. But I was like, so the first time you just kind of did it yourself. Yeah. You're brave. And I might have them actually be on call and available. Yeah. This guy failed. I crashed. Screw is a little proud in the STD. And he's a big guy. Football player for what that's worth. Little bit of DZ, a little bit of some chatter on the dorsal rim of the radius, some chatter in the volar rim of the radius. That sagittal image is pretty intimidating. I think. What do you think, Nina? The sagittal, unfortunately, because I will say on the coronal, I thought maybe if you took this out, you may be arthroscopically grafted and things like that. The sagittal looks not as promising, unfortunately. Yeah. And I find that's that's the thing is like the sagittal is always the most intimidating, particularly also because if there's going to be any sort of hoop stress fractures from the screw, it's going to show up on this sagittal. Yeah. And it seems like it's kind of because it's been he has a bit of a yeah, this one's a this one's a tough one. It looks kind of nice there, but it's not as pointy, I will say. Yeah. So maybe a handmade for that, maybe, but then given his sport, obviously, I would worry a little bit about that, but then I wouldn't want to take it from the knee for that guy. So, you know, the handmaid actually I would I would actually take measurements and stuff, but the handmaid actually doesn't look as pointy, looks a little bit rounder. This was this would be a conversation given his occupation. I don't know necessarily if they would want to take some something from the knee, I would say. So maybe like either a handmaid or or a rib like. What do you think, Jeff? I'm a little bit more optimistic about that proximal pole. I think this might be one where, unfortunately, you have a big channel from that monster screw in there. So I might try to, again, get union with just your standard bone grafting techniques. And again, it's not the not the point of this discussion of vascularized versus non-vascularized bone grafting. I think if you can get that screw out, bone graft it whatever way you like, and then you'd either use a larger screw, possibly integrate, or I have no financial relationship with these companies, but there are nice pre-contoured scaphoid plates that I've been using for this type of nonunion where you can remove the screw and and you don't have to worry about not gaining purchase with another screw because you'll have a volar plate stabilizing the proximal distal poles together. Obviously, I mean, I think that'd be an option, and I think I would probably go to that first before either the rib or the MFT. I agree. I think it's or the handmaid might be an option, too, but it is a little bit of a bigger defect. So, I would do a rib or MFT, but I would say that there's maybe an option to fix that. Mm-hmm. Yeah, that's why I was wondering sometimes, you know, if you start getting reps and reps and reps, you start, you know, as they say, every, when you get the hammer, every nail, what is that expression? Everything looks like a nail. When you're a hammer, everything looks like a nail. So, here's the post-op from a rib, which isn't to say the right answer, but this was, again, a patient, as you guys said, I do get nervous with his size, and it's true, the amount of stress he's going to be putting on his knees. And for me, those CTs were a resection in some sort of osteocon reconstruction, but I did feel a little bit like the rib, again, is a little bit of a freebie. This may have a very favorable handmaid on that view. It's a little bit wider. I feel like I'll be going to be running into things, so I would worry about the stressors on the hand. Like, this is a bad, this is a bad, like, occupation that this patient has. Yeah. This is a tough one. This is a conversation for sure. So, did you let him continue to play, Jim? I actually, I retired that lineman that I presented. I told him, listen, this is going to, this needs to last you the rest of your 80 years of life. He wasn't a high-end player to begin with, but, so I retired him. Yeah. I don't know if that was even an option that was provided to me, so this guy was going to play no matter what. And maybe it's foolish, you know? Maybe it's interesting, and see that cartilage there on the CT. It's a lot of cartilage from that rib. And maybe it's overly optimistic to let him play, but I did. Guys, it's now 20 minutes after, and we were due to finish. I was just looking for, any other questions you guys have or discussion points? I'm going to check the chat room. Yeah. Any questions from our participants? Those are always interesting. This is your chance. Jeff, how many rib autographs did you take before you felt comfortable taking it? The first one I did with Rod, Rod Hentz. He showed me how to do it, and then it's been off to the races. We actually had a pleural injury, and so while I was freaking out, he carefully got the red rubber catheter and just plopped it in there, had the anesthesiologist fill the lung. We tied a circlage wire around the catheter, and then just cinched it up when we pulled the catheter out. I had a tiny little pneumo post-op, but did fine. I haven't knocked wood. I've done, I don't know, maybe 10 to 15 of these now, and I haven't had any, not going to word, any catastrophic pleural issues. I do think all three of them. It's an interesting topic of when do you feel comfortable? Can you watch a video and do the operation, or can you see one and do the operation, or you have to scrub in and do one? What's your threshold for feeling comfortable with the risks associated with it? Something I often wonder about, what is the necessary degree of comfort you need? I think it varies person to person, but sometimes I'll see people that stop and visit our center and say, I'd love to see one. I wonder, is that enough? Yeah, that's a great point. As you stated from the very beginning, these are very high, very technically challenging procedures, all three. How do you gain that experience? Most people won't see these over the course of their fellowship because they're so few and far between, so how do you learn? I'll be honest with you, in terms of my experience with the MFT, which is quite honestly, listening to you talk, Jim, and I got to spend some time, not in the OR, but spend some time with Heinz just talking to him, and he would share some tips and tricks. Luckily, we have a great group of plastic surgeons here, plastic hand surgeons that I work with that we double team it when we do an MFT or an MFC. I'm working on the wrist while they're harvesting the grafts, so that helps out tremendously as well. It also makes it logistically a little bit more difficult because it's hard to get both of us to have OR time at the same time, or to be free at the same time to do the cases. That's why I think it's a great procedure. It's just logistically, it's the hardest of the three for me to do. Yeah. Well, I think these are the types of things, and there's a lot of other sort of subcategories of hand surgery where it's definitely worth ... We've all seen the benefits of work travel, meaning visiting colleagues, making friends, becoming familiar with how other centers operate. I've really enjoyed that over the years, and it's been such a benefit for my career and you guys too, I'm sure. Maybe that's a little shout out for whether it's the homemade or the formal traveling fellowship, it's always beneficial. Yeah. I think we may have to ... I don't hate to keep everyone ... Oh, we have one question. Oh, wait. Oh, here we go. Yes. Would any of you be willing to review x-rays for a patient with a waist fracture that failed for a primary repair? The second operation, the patient was told he would have vascularized bone graft and had a large incision, but hardware removal only for some reason. The surgeon told him he had arthritis from the screw. I can't share x-ray on Zoom for some reason. Yes. I think that the ability to share by the people that are registered, you can only share as a faculty member, but I'd be certainly happy to view that x-ray via email, as I'm sure Nina and Jeff would as well. Yeah. Yeah. Sure. Well, guys, thank you so much. I think in an effort to stay on time, we're going to call it. We're seven minutes over now. It was a great discussion. I learned a lot and please, anyone that has signed on to this, you will have our emails available and you can send us questions in a delayed fashion and also keep in mind that this CME is going to be achievable on or after May 20th, and you'll all get an email in that regard. All right. So signing off. Thank you very much, Nina. Thank you. Thank you, Jeff. Thanks, Jim. Thanks for organizing. This was great. And I look forward to more in the future.

osteochondral reconstruction

scaphoid non-unions

hemi-hamate autograft

osteochondral rib autograft

medial femoral trochlea flap

surgical techniques

revision surgeries

biomechanical suitability

personalized treatment

multidisciplinary approach

surgery outcomes

functional restoration