Osteochondral Autograft Transplantation to the Metacarpal Head for Avascular Necrosis in a Young Active Patient: Case Report and Technique Overview

Abstract

Background: Aseptic avascular necrosis of the metacarpal head, or Dieterich disease, is a rare and painful condition of unknown etiology. There is no consensus regarding optimal treatment, although multiple surgical options have been described. Many cases are refractory to nonoperative management. Materials and Methods: We present a case of a young, active patient with avascular necrosis of the long finger metacarpal head that was treated surgically with osteochondral autograft transplantation. An osteochondral autograft system was used to remove a 10×13 mm core, which contained the entire osteochondral defect. An incision was made and the superior lateral aspect of the trochlea was exposed through a small fascial incision. A size-matched core was harvested from the lateral aspect of the trochlea proximal to the sulcus terminalis in the non–weight-bearing portion of the lateral condyle. The harvested osteochondral donor fragment was then transplanted into the defect in the metacarpal head and noted to be an excellent size match. Results: At 2 weeks postoperative, the patient had nearly full range of motion of both the affected hand and the donor knee. Radiographs demonstrated a small intra-articular step-off of <1 mm, which was appreciated in the intraoperative fluoroscopic image and is within the acceptable limits for metacarpophalangeal joint step-off. At one year postoperative he was pain-free with a QuickDASH score of 2.3. Conclusions: Avascular necrosis of the metacarpal head in a young patient can be a challenging problem, especially when it is resistant to conservative therapy. Arthroplasty or arthrodesis could be reliable options in older, lower-demand patients, but are not appropriate for a young, high-demand patient.

Conservative management of avascular necrosis of the metacarpal head: Retraction

“…In most cases, the decision to proceed with surgery was made after failure of conservative treatment. Bone curettage and cancellous bone grafting [ 3 , 6 , 13 ] , flexion osteotomy, [ 20 ] metatarsal transplantation, [ 22 ] costal osteochondral autograft, [ 14 , 23 ] osteochondral autograft transplantation surgery, [ 18 , 24 ] arthroplasty, [ 25 , 26 ] and arthrodesis [ 27 ] have been performed in individual cases. The type of surgery depends on the condition of the damaged cartilage layer.…”

“…A special osteochondral harvester is usually required, and thus there may be a risk of damaging the growth plate. [ 18 , 24 ] Arthrodesis or joint replacement should be considered as salvage operations when cartilage erosion is severe or joint surfaces collapse with persistent symptoms. Almost all the operating cases have reported excellent results.…”

Current management of avascular necrosis of the metacarpal head: a comprehensive literature review

“…On the other hand, the radius of curvature of the donor osteochondral plug should match the recipient’s metacarpal head as much as possible 5 , 49 . The void of the femur can be filled with osteochondral allograft 49 , substitutes, just left behind 5 , 50 . Filling the donor site defect can ensure faster healing and lower donor site morbidity 49 .…”