Capitate Osteochondral Graft for Reconstruction of Unstable Proximal Interphalangeal Joint Injury.

Background: Hemi-hamate osteochondral grafting is a surgical technique that is utilized to reconstruct the proximal interphalangeal (PIP) joint in cases of unstable dorsal fracture-dislocation with >50% articular surface involvement. However, hemi-hamate osteochondral grafting can be technically challenging, has been reported to have various technical modifications, and can lead to complications such as overstuffing of the joint. This surgical technique article describes successful PIP joint reconstruction with use of a hemi-capitate osteochondral graft, which may offer a viable alternative to hemi-hamate osteochondral graft.

Description: A volar approach to the PIP joint is utilized, and a trapezoidal incision is made. The skin, subcutaneous tissue, and neurovascular bundles are carefully retracted. The flexor tendon sheath is opened, and adhesions are released to expose the volar plate. The volar plate and collateral ligaments are reflected. The finger is hyperextended to expose the joint. Damaged cartilage and bone fragments are removed, and healthy cartilage is preserved. The capitate-3rd and -4th metacarpal joints are localized with use of fluoroscopy. A transverse incision is made over the joints, and the extensor retinaculum is incised. The capitate is exposed, and the required graft is marked and predrilled. An osteotomy is performed to harvest the graft. The capitate graft is trimmed and placed into the defect in the middle phalanx base. The graft is temporarily pinned with use of a Kirschner wire and then is secured with 2 bicortical screws. The middle phalanx is reduced, and free movement is confirmed. The volar plate is sutured to the collateral ligament. The flexor tendon sheath is passed beneath the flexor tendons to allow free gliding movements over the newly laid graft. The skin is sutured.

Alternatives: Hemi-hamate osteochondral graft is the most common alternative to hemi-capitate osteochondral graft.

Rationale: The capitate bone may offer several advantages over the hamate bone for PIP joint reconstruction. The capitate has a more uniform articular surface that closely resembles the middle phalanx base, which may reduce the risk of overstuffing1, Additionally, harvesting a graft from the capitate may be less likely to cause donor-site morbidity compared with harvesting from the hamate.

Expected outcomes: Hemi-capitate osteochondral graft is a promising technique for PIP joint reconstruction. In our previous article¹, the patient achieved good PIP joint movement and stability at the time of the latest follow-up. The osteochondral capitate graft united well, and there were no signs of graft collapse or resorption. The patient had good range of motion and minimal pain, and was able to return to his previous work.

Important tips: Careful attention should be paid to graft size and placement to ensure proper joint congruency and stability.Early postoperative mobilization is important to prevent joint stiffness.

Acronyms and abbreviations: K-wire = Kirschner wireFDS = flexor digitorum superficialisDASH = Disabilities of the Arm, Shoulder and HandVAS = visual analogue scale.