Comparative meta-analysis on the various vascularized bone flaps used for the treatment of scaphoid nonunion

Arthroscopic treatment of scaphoid nonunion with distal radius bone graft: A retrospective series of 31 cases

The objective of this study was to evaluate the clinical outcomes of arthroscopic bone grafting for the treatment of scaphoid nonunion. This was a retrospective, multicenter study involving 31 patients with scaphoid nonunion, all treated arthroscopically. The procedure included harvesting of a cancellous bone graft from the distal radius, arthroscopic debridement of the nonunion site, injection of the bone graft under arthroscopic control, and retrograde percutaneous fixation. At an average follow-up of 11.7 months, 90.3% of the fractures had consolidated at a mean time of 12.2 weeks. The Visual Analog Scale for pain decreased from 4.9 to 1.3, and strength increased from 24.2 kg to 32.3 kg. The Mayo Wrist Score improved from 53.9 to 79, and the Quick Disability of Arm Shoulder and Hand score improved from 40.5 to 10.3. This is a minimally invasive technique that preserves scaphoid vascularization, with results comparable to other techniques. LEVEL OF EVIDENCE: III.

Union rate and clinical outcomes of second-try scaphoid reconstructions after failed primary scaphoid osteosynthesis or reconstruction. A retrospective, single-center cohort study of 52 patients

Introduction

Scaphoid non-union after failed primary surgery presents significant therapeutic challenges.

Methods

In this retrospective study, 52 patients (50 males; mean age 29.5 years) underwent secondary reconstructions (2009-2020) for proximal pole (38.5%, n = 20) and waist non-unions (61.5%, n = 32). Treatments included non-vascularized iliac crest grafts (17 patients), vascularized pedicled distal radius grafts (26), and free medial femoral condyle flaps (9). Union and scaphoid alignment were assessed by CT, while carpal alignment and arthrosis were evaluated using radiographs. Statistical analysis employed chi-square, Fisher's exact, Mann-Whitney U, and McNemar tests (R v4.4.2; p ≤ 0.05).

Results

Union rates differed significantly between proximal pole (40%, 8/20) and waist non-unions (68.75%, 22/32; p = 0.04). Graft type (p = 0.616), osteosynthesis method (p = 0.827), age (p = 0.095), smoking (p = 0.582), avascular necrosis (p = 0.42), and prior surgeries (p = 0.974) showed no significant association with union. Proximal pole non-unions with AVN trended toward lower union (22.2% vs. 54.5% without AVN), though this was not statistically significant. In patients achieving union, scaphoid humpback deformity was corrected in 9/15 cases (p = 0.0348), and dorsal intercalated segment instability improved significantly (p = 0.0143). Functionally, the union group had an average extension-flexion of 112° (81% of the healthy wrist) and radial-/ulnar adduction of 40° (72% of the unaffected wrist), with grip strength averaging 42 kg (range 25.2-59.7) and a DASH score of 11 (range 0-67). The non-union group showed 114° extension-flexion (91% of the unaffected wrist) and 38° ulnar/radial abduction (78% of the healthy wrist), with grip strength averaging 46 kg (range 37.6-59.3; 89% of the unaffected wrist) and a DASH score of 10 (range 3-33).

Discussion

Secondary scaphoid reconstruction demonstrates location-dependent success. The decision between secondary reconstruction, which aims to restore anatomical integrity, and salvage procedures, which prioritize predictable outcomes, hinges on balancing union potential, functional results, and patient preferences. A tailored approach remains essential to align treatment goals with individual needs.

Comparing the Palmar Radiocarpal Artery Vascularized Bone Graft with Alternatives for Unstable Scaphoid Nonunions: A Retrospective Analysis

PURPOSE

We compared the radiographic union and magnitude of humpback deformity correction when using different vascularized bone grafts (VBGs) and nonvascularized bone grafts (NVBGs) in the treatment of unstable scaphoid nonunions (USNUs).

METHODS

This was a retrospective radiographic review of 93 patients with an USNU treated between 2013 and 2022 at a single center by a single surgeon. Inclusion criteria included skeletally mature patients with radiographic evidence of an USNU resulting from failure of either nonsurgical or operative treatment. There were three treatment groups. Two groups were treated with either a palmar radiocarpal artery (PRCA) VBG or a 1,2 intercompartmental supraretinacular (1,2 IC-SRA) VBG. The third group comprised patients who were treated with a heterogeneous mix of NVBGs. Patients were followed radiographically at regular intervals until they were deemed healed or underwent a salvage procedure because of treatment failure. Measurements of carpal and scaphoid alignment were then repeated on the final imaging series and compared to preoperative measurements.

RESULTS

Ninety patients were included in the final analysis. PRCA VBG had the highest radiographic union rate, followed by 1,2 IC-SRA VBG and finally NVBGs. PRCA VBG had a significantly higher rate of union than NVBGs. Scapholunate angle change and scaphoid length change were greatest with PRCA VBG. These differences were statistically significant for the former when compared with 1,2 IC-SRA VBG and NVBGs and for the latter when compared with the 1,2 IC-SRA VBG in both univariate and multivariable analyses.

CONCLUSIONS

PRCA VBG had the highest radiographic union rate compared with alternative grafts as well as providing the greatest degree of humpback deformity correction in the treatment of USNUs.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Scaphoid Nonunions: Local Vascularized Bone Flaps

If untreated, scaphoid nonunions may progress to scaphoid nonunion advanced collapse in a substantial portion of cases and may require salvage procedures. Multiple different techniques have been described to address scaphoid nonunion. Vascularized bone flaps (VBFs) are associated with faster time to union compared with nonvascularized grafts. Because these are local pedicled flaps, they do not require microsurgical anastomoses and should be within the armamentarium of all hand surgeons. Appropriately chosen local VBFs, can achieve union rates up to 90% to 100% in appropriately selected patients.

Clinical outcomes in patients with scaphoid non-union treated with the vascularized medial femoral condyle technique a case series

INTRODUCTION

Non-union is a prevalent complication of scaphoid fractures. Late diagnosis is common and has a clinical impact due to functional limitations for the patient. Multiple treatments have been proposed to manage this complication, ranging from conservative (i.e., orthopedic) to surgical treatment. The vascularized medial femoral condyle technique has shown satisfactory clinical and paraclinical results, mainly in presence of avascular necrosis of the proximal pole but data regarding functional outcomes and patient satisfaction is scarce. This case series aims to describe the clinical and patient-reported outcomes in a consecutive series of patients with non-union of the proximal third of the scaphoid treated with vascularized medial femoral condyle technique.

METHODS

Case series reporting results for a consecutive - initial cohort of patients who presented with a non united fracture of the proximal pole of the scaphoid, avascular necrosis of the proximal pole was documented by CT od MRI imaging preoperatively in all patients. Measurement instruments include the q-DASH and PRWE questionnaires, radiographic images, goniometry, and assessment of grip strength.

RESULTS

Twelve consecutive patients are included and they represent the initial cases for all surgeons involved; bone union was obtained in 10 patients (83%) after a mean follow-up time of 31 months (6-72), successful improvement in the range of motion and grip strength was documented. A high rate of satisfaction expressed by the patient was obtained, with an average score in Q-DASH of 17.3 and 20.1 in PRWE.

CONCLUSIONS

The vascularized medial condyle technique in cases of nonunion of scaphoid fracture is a reproducible treatment in clinical terms, both in imaging and functional terms, and in patient satisfaction. The learning curve is flat for a dedicated multi surgeon team.

Anatomic feasibility study of osteocutaneous free flap from the proximal ulna

OBJECTIVE

The present anatomic study aimed to assess the feasibility of an osteocutaneous free flap harvested from the proximal ulna for reconstruction after complex hand trauma.

METHOD

Nineteen upper limb specimens free of scarring in the elbow region were injected in the brachial artery. After S-shaped incision centered on the medial epicondyle, a systematic approach to the epitrochlear-olecranal groove exposed the superior ulnar collateral artery and ulnar nerve. Bone and skin perforators were screened for during dissection and their emergence with respect to the medial epicondyle was assessed. Pedicle length was also assessed. The skin paddle was harvested in the distal part of the S incision and the operative site was closed by local skin plasticity.

RESULTS

Bone and skin perforators from the superior ulnar collateral artery were found in all 19 specimens. Mean pedicle length from the artery was greater than 9cm in all cases. The skin perforator emerged at a mean 19mm distally from the medial epicondyle, and the bone perforator at a mean 40mm.

DISCUSSION

An osteocutaneous free flap can be harvested from the proximal ulna and medial side of the elbow. As bone and skin perforators were found in all 19 cases, this flap can be used routinely. Harvesting, however, systematically involves ulnar nerve release and anterior transposition. This osteocutaneous free flap harvested from the proximal ulna offers an alternative for osteocutaneous defects in the hand, with harvesting from the same limb.

CONCLUSION

In this anatomic series, an osteocutaneous free flap could in all cases be harvested from the posterior ulnar recurrent artery via a medial elbow approach. Safety and efficacy remain to be demonstrated in in vivo reconstruction.

LEVEL OF EVIDENCE

III.

Arthroscopic treatment of unstable scaphoid fracture and nonunion with two headless compression screws and distal radius bone graft

BACKGROUND

The treatment of unstable scaphoid fracture and nonunion remains a challenging problem for hand surgeons. Minimally invasive treatment has become the preferred method of treatment.

PURPOSE

This study introduces the arthroscopic technique with two headless compression screws (HCS) fixation and distal radius bone grafting for the treatment of unstable scaphoid fracture and nonunion, aiming to evaluate its clinical and radiological outcomes.

METHODS

It was a retrospective study. From January 2019 to February 2021, a total of 23 patients were included in the current study. Among them, 13 patients with unstable scaphoid fracture underwent arthroscopic treatment with two HCS; 10 patients with scaphoid nonunion underwent arthroscopic treatment with two HCS and a distal radius bone graft. The range of motion of the wrist, visual analog scale (VAS), grip strength, the Modified Mayo Wrist Score (MMWS), the Patient-Rated Wrist Evaluation (PRWE) score, and the Disability of the Arm, Shoulder and Hand (DASH) score were collected at preoperatively and the final follow-up. A computed tomography scan of the wrist was performed on each patient to analyze for union and postoperative osteoarthritis during the follow-up period.

RESULTS

Significant improvement was only observed in wrist extension. Clinical outcomes including grip strength, VAS pain score, MMWS, PRWE score, and DASH score were significantly improved at the final follow-up. In the subgroup analysis, both patients stabilized with either two HCS or a distal radius bone graft and two HCS have improved clinical outcomes after surgery, respectively. All patients achieved union. No screw fixation failure occurred, and no other postoperative complication was observed in any of the patients.

CONCLUSIONS

The arthroscopic technique with two-HCS fixation and distal radius bone grafting is a reliable and effective technique for the treatment of unstable scaphoid fracture and nonunion, providing satisfactory union rates and clinical outcomes.

Vascularised versus non-vascularised bone graft for scaphoid nonunion: Meta-analysis of randomised controlled trials and comparative studies

Background

Numerous studies have investigated surgical techniques for vascularised bone graft (VBG) for scaphoid nonunion; however, their efficacies remain unclear. Thus, to estimate the union rate of VBG for scaphoid nonunion, we performed a meta-analysis of randomised controlled trials (RCTs) and comparative studies.

Methods

A systematic search was conducted using PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials. The search formula was as follows: ((scaphoid nonunion) OR (scaphoid pseudarthrosis)) AND (bone graft). Only RCTs were used in the primary analysis, and comparative studies, including RCTs, in the secondary analysis. The primary outcome was nonunion rate. We compared the outcome between VBG and non-vascularised bone graft (NVBG), pedicled VBG and NVBG, and free VBG and NVBG.

Results

This study included a total of 4 RCTs (263 patients) and 12 observational studies (1411 patients). In the meta-analyses of both RCTs only and RCTs and other comparative studies, no significant difference in nonunion rate was found between VBG and NVBG (summary odds ratio [OR], 0.54; 95% confidence interval [CI], 0.19-1.52 and summary OR, 0.71; 95% CI, 0.45-1.12), respectively. The nonunion rates of pedicled VBG, free VBG, and NVBG were 15.0%, 10.2%, and 17.8%, respectively, and no significant difference was found.

Conclusions

Our results indicated that the postoperative union rate in NVBG is similar to that in VBG; thus, NVBG could be the first choice of treatment for scaphoid nonunion.

The Influence of Smoking on Healing of Scaphoid Non-union after a Vascularized Pedicle Bone Flap Operation: A Review and Meta-analysis

BACKGROUND

The purpose of this study is to compare the vascularized bone flaps (VBF) that are used in operations for scaphoid non-union in smokers and non-smokers and to scrutinize if the better biological potential of the VBFs can counteract the negative influence of smoking on healing.

MATERIALS AND METHODS

Our study included articles published until 2016, with scaphoid non-union patients who were operated on with a VBF or a VBG.

RESULTS

Eighteen articles met eligibility criteria with 335 non-smokers and 136 smokers totally. Healing of the scaphoid non-union was significantly more probable in the non-smoking group (OR=5.54, p<0.001). Patients with avascular necrosis in the proximal pole of the scaphoid (AVNPP) and non-AVNPP showed that non-smoking favors a better healing rate in both of these subgroups (p<0.001 and p<0.001, respectively). Non-smokers have 11 times and the non-AVNPP patient's 7.7 times greater probability of healing of the non-union. Meta-analysis of the data for time for healing showed a longer time in the smokers' group by 2.46 weeks, though non-statistically significant. The analysis could not prove that smoking is a predisposing factor for the development of AVNPP (spearman=0.094, p<0.05). Despite that, preoperative smoking cessation proved to be an inadequate healing moderator (OR=3.5, p=0.268). Finally, VBFs showed a significantly better healing rate compared with nVBGs in smokers (p=0.001).

CONCLUSIONS

A hand surgeon should always take into consideration that smoking negatively influences the healing potential of a scaphoid non-union despite the theoretically superior biological background that VBFs offer. In patients who refuse to quit smoking, a VBF may be considered a better choice than a conventional graft.

Fracture, nonunion and postoperative infection risk in the smoking orthopaedic patient: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to analyse negative effects of smoking in orthopaedic and trauma patients.

A PubMed search was carried out for studies published until July 2020 regarding effects of smoking on fracture risk, nonunion, infection after orthopaedic surgery, and persisting nonunion after scaphoid nonunion surgery. Random effects models calculated for outcome parameters, and relative risks (RR) with 95% confidence intervals are provided. No adjustments for covariates were made. Heterogeneity was assessed with Higgins’ I2, publication bias with Harbord’s p (Hp), sensitivity analysis performed on funnel plots and quality of studies was analysed using the Newcastle-Ottawa Scale.

Of 3362 retrieved entries, 69 were included in the final analysis. Unadjusted RR for smokers to develop vertebral (six studies, seven entries; RR: 1.61; p = 0.008; I2 = 89.4%), hip (11 studies, 15 entries; RR: 1.28; p = 0.007; I2 = 84.1%), and other fractures (eight studies, 10 entries; RR: 1.75; p = 0.019; I2 = 89.3%) was significantly higher. Postoperative infection risk was generally higher for smokers (21 studies; RR: 2.20; p < 0.001; I2 = 58.9%), and remained upon subgroup analysis for elective spinal (two studies; RR: 4.38; p < 0.001; I2 = 0.0%) and fracture surgery (19 studies; RR: 2.10; p < 0.001; I2 = 58.5%). Nonunion risk after orthopaedic (eight studies; RR: 2.15; p < 0.001; I2 = 35.9%) and fracture surgery (11 studies; RR: 1.85; p < 0.001; I2 = 39.9%) was significantly higher for smokers, as was persisting nonunion risk after surgery for scaphoid nonunion (five studies; RR: 3.52; p < 0.001; I2 = 0.0%). Sensitivity analysis for each model reduced heterogeneity whilst maintaining significance (all I2 < 20.0%).

Smoking has a deleterious impact on fracture incidence, and (subsequent) development of nonunions and postoperative infections.

Cite this article: EFORT Open Rev 2021;6:1006-1019. DOI: 10.1302/2058-5241.6.210058

Comparison of the functional and radiological outcomes of vascularized and non-vascularized bone graft options in the treatment of scaphoid nonunion

OBJECTIVES

This study aims to compare the functional and radiological outcomes of the patients with scaphoid waist nonunion treated with non-vascularized bone graft and vascularized bone graft options.

PATIENTS AND METHODS

Between January 2016 and February 2020, a total of 24 patients (22 males, 2 females; mean age: 30.6±9.4 years; range, 18 to 66 years) with scaphoid waist nonunion who were treated with vascularized or non-vascularized bone graft were retrospectively analyzed. Of these patients, eight were treated with iliac crest non-vascularized bone graft (IC-NBG), seven with vascularized free medial femoral condyle (MFC) graft, and nine with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft (1,2-ICSRA-VBG). The grip strength, flexion, extension, radial deviation, ulnar deviation angles were measured and compared to the contralateral hand for functional outcomes. Union rates, the scaphoid height-to-length ratio, the lateral intrascaphoid angle (LISA) were evaluated for radiological outcomes. The Mayo Wrist Score, Visual Analog Scale (VAS) score, and Quick Disability of the Arm, Shoulder and Hand (Q-DASH) Questionnaire score were calculated.

RESULTS

Union was observed in seven (87.5%) patients after IC-NBG, in six (85.7%) patients after MFC bone graft and nine (100%) patients in the treatment group with 1,2-ICSRA-VBG. There were no statistically significant differences among the IC-NBG, MFC and 1,2-ICSRA-VBG groups in terms of the union rates, the scaphoid height-to-length ratio, VAS score, Q-DASH score, grip strength and flexion, ulnar deviation, radial deviation angles after surgery (p>0.05). However, extension was statistically lower in the MFC group than IC-NBG and 1,2-ICSRA-VBG groups after surgery. The Mayo score was better in the IC-NBG group than MFC and 1,2-ICSRA-VBG, indicating a statistically significant difference (p<0.05).

CONCLUSION

Based on our study results, we suggest to use IC-NBG for scaphoid waist nonunion as the primary procedure, as the union rates are comparable with the MFC and 1,2-ICSRA-VBG techniques and it has advantages such as shorter operation time, easier technique, no special experience requirement, and better functional outcomes.

Volar rerouting of the 1,2 intercompartmental supraretinacular artery vascularized bone graft for middle and distal scaphoid nonunions

BACKGROUND

The bone graft vascularized by the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) placed on the scaphoid by a dorsal approach is a technique used to treat scaphoid nonunions with avascular necrosis of the proximal pole and without significant bone loss or carpus collapse. We present the results of patients treated with a volar rerouting of the 1,2 ICSRA graft under the tendons of the first extensor compartment to treat more distal scaphoid nonunions than the proximal pole. The aim of this study was to assess the clinical and radiological outcomes of patients operated with this technique with the hypothesis that it would allow to treat more distal nonunions than those of the proximal pole.

PATIENTS AND METHODS

This retrospective study involved patients treated by a volar rerouting of the 1,2 ICSRA graft for nonunions of the middle and distal thirds of the scaphoid. Assessments included clinical outcomes and radiological bone consolidation. QuickDASH and Mayo Wrist scores were computed. Range of motion and grip strength were evaluated for both the operated and the contralateral sides.

RESULTS

Nineteen patients were followed-up for 33 months (range: 6-75). Mean postoperative QuickDASH score was 10 (range: 0-45), and mean Mayo wrist score was 85 (range: 50-100). Flexion and extension, ulnar and radial deviations were statistically different between the affected and healthy sides (p<0,05). Consolidation was achieved in 17 patients (89%).

DISCUSSION

This technical modification allowed good functional outcomes and scaphoid consolidation. It expands the classic indications of the vascularized 1,2 ICSRA bone graft to more distal nonunions than the proximal pole.

LEVEL OF EVIDENCE

IV.

A Morphometric Analysis of Hamate Autograft for Proximal Scaphoid Reconstruction

Objective  Recently, authors have investigated using the proximal hamate as osteochondral autograft for proximal pole scaphoid reconstruction in the case of nonunion with avascular necrosis. The aim of our study was to analyze the morphology and anatomic fit of the proximal hamate compared with the proximal pole of the scaphoid using cadaveric specimens. Materials and Methods  Ten cadaver specimens (five males and five females) were dissected. Scaphoid and proximal hamate bones were measured by two independent investigators using electronic calipers and radius of curvature gauges. After measurements were determined to have good correlation, the average value of the two observers' measurements were used for further analysis. Sagittal radius of curvature (ROC), coronal ROC, depth, width, and maximum graft length were compared. Results  The average depth of the scaphoid proximal pole was 12.3 mm (standard deviation [SD] = 1.12) compared with 11.3 mm (SD = 1.24) for the proximal hamate ( p  = 0.36). The average width was 7.8 mm (SD = 1.00) in the scaphoids compared with 8.6 (SD = 1.05) in the hamates ( p  = 0.09). There was also no significant difference in the sagittal ROC between hamates (9.1 mm, SD = 1.13) and scaphoids (9.5 mm, SD = 0.84; p  = 0.36). All of these average measurements were within 1 mm. There was a significant difference between the coronal ROC of the hamate (23.4 mm) and scaphoid (21.1 mm) bones in our samples ( p  = 0.03). Females were on average smaller than their males, but there was no significant difference in fit based on sex alone. Conclusion  The proximal pole of the hamate has similar morphology and size as the scaphoid, with similar depth, width, and sagittal ROC. It has potential as an osteochondral autograft for proximal pole scaphoid reconstruction.

Are Vascularized Periosteal Flaps Useful for the Treatment of Difficult Scaphoid Nonunion in Adults? A Prospective Cohort Study of 32 Patients

PURPOSE

To evaluate clinical and radiological outcomes after surgical treatment of difficult scaphoid nonunion in adults with a vascularized thumb metacarpal periosteal pedicled flap (VTMPF).

MATERIALS AND METHODS

Thirty-two patients at least 18 years old, with scaphoid nonunion and characteristics associated with a poor prognosis, who underwent a VTMPF procedure, were included in this retrospective cohort study with a mean follow-up of 17 months. Factors associated with a poor prognosis were a delay in presentation of over 5 years, the presence of avascular necrosis, and previous nonunion surgery. All patients had at least 1 poor prognostic factor and 25% had 2 or more.

RESULTS

In 30 men and 2 women, the mean age was 36 years (range, 19-56 years). There were 11 type D3 nonunions (Herbert classification) and 15 type D4. Five patients had delayed presentation of over 5 years. Fourteen patients had previously undergone an unsuccessful surgical attempt to treat their nonunion. The patients experienced no postoperative complications. Overall union rate was 97% (31 of 32 patients), with 72% cross-sectional trabecular percentage bridging at 12 weeks. Pain subsided after surgery and patients experienced improvements in both their Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Modified Mayo Wrist Score (MMWS). Overall 41% and 42% gains in strength and wrist motion, relative to the contralateral normal side, were observed. At final follow-up, there were no differences between the treated and the untreated (healthy) hands, in terms of wrist range of motion, grip, or pinch strength.

CONCLUSIONS

In this study, the use of VTMPF for difficult scaphoid nonunion in adults was associated with good general outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Carpal Collapse After Scaphoid Nonunion: A Novel Combined Approach to the 1,2 Intercompartmental Supraretinacular Artery Radial Flap

Purpose

Scaphoid nonunion remains a major problem in hand surgery. The 1,2 intercompartmental supraretinacular artery flap (1,2 ICSRA), as first described by Zaidemberg et al, is widely used with reported union rates of approximately 80%. However, its use is limited in the case of associated carpal collapse as in dorsal intercalated segmental instability (DISI) and humpback deformity. In this study, we present a novel approach to this flap enabling the correction of associated carpal collapse.

Methods

Between 2006 and 2015, 9 patients with scaphoid nonunion or delayed union with carpal collapse were treated with a vascularized bone flap based on the 1,2 ICSRA using a combined volar and dorsal approach. Immobilization in a short-arm cast was applied for 8 weeks. Union rates, correction of DISI and humpback deformity, as well as clinical end points were noted. In addition, scapholunate (SL) angles were measured using 2 accepted radiological techniques, employing either the scaphoid midline axis or its proximal radiological landmarks as a reference.

Results

All cases united and a median time to bone consolidation of 4 months (range, 2–5 months) was observed. Preoperative DISI deformities (n = 4) were corrected in all patients. Humpback deformities (n = 5) were also corrected. Two patients had repeat surgery: one for K-wire removal after bony consolidation and the other for neuropathic pain.

Conclusions

The 1,2 ICSRA bone flap is a reliable treatment for scaphoid nonunion associated with carpal collapse. This combined volar and dorsal approach permits the correction of DISI and humpback deformity without compromising the scaphoid vascular supply, which eliminates the need to use free bone flaps from other sites. In this series, we observed a 100% union rate. Two patients required reoperation for symptomatic hardware and dorsal wrist pain linked to superficial neuritis.

Type of study/level of evidence

Therapeutic IV.

[Scaphoid pseudarthrosis : Complex reconstruction using vascularized bone grafts]

The most important goals of scaphoid reconstruction in pseudarthrosis are correction of the humpback deformity, the realignment of the proximal carpal row and the bony union of the scaphoid. Therefore, in most cases bone grafting is required. To increase the healing rate and to improve vascularization, several kinds of vascularized bone grafts have been developed. Pedicled grafts are preferably harvested from the dorsal or palmar side of the distal radius with fusion rates between 27% and 100%. Free microvascular grafts can be obtained from the iliac crest and the medial or lateral femoral condyle with fusion rates between 60% and 100%. For their application microsurgical equipment and skills are required. Up to now osteochondral grafts from the femoral condyle offer the only chance for joint surface replacement by transferring part of the surface of the femoropatellar joint. The use of vascularized grafts is still a matter of controversy, since their superiority is still unproven compared to nonvascularized grafts, which also achieved 100% fusion rates in several series. They are indicated in secondary procedures after failed reconstruction and nonunion with small avascular proximal pole fragments. Since no evidence-based guidelines exist, this article provides an experience-based treatment algorithm for scaphoid nonunion with special consideration to vascularized bone grafts.

Arthroscopic Management of Scaphoid Nonunion

Arthroscopic bone grafting (ABG) in difficult scaphoid delayed union and nonunion allows thorough assessment and comprehensive management for scaphoid fracture and its sequelae. It provides a favorable biological environment for bony healing and produces minimal trauma to the soft tissues, aiding in rehabilitation. With adequate training and experience, high union rates and satisfactory clinical outcomes can be achieved. Poor blood supply of the scaphoid is not a contraindication to bone grafting; union rates over 80% have been reported, comparable to other existing surgical methods. This article discusses the rationale, surgical techniques, and results of ABG.

The Use of the Proximal Hamate as an Autograft for Proximal Pole Scaphoid Fractures: Clinical Outcomes and Biomechanical Implications

Scaphoid proximal pole fractures remain a surgical challenge because of high propensity for nonunion, osteonecrosis, and ultimately carpal collapse. Options for management of nonsalvageable proximal pole fractures include non-vascularized bone grafts, vascularized pedicled bone grafts, free vascularized bone flaps, and rib cartilage grafts. The proximal pole of the hamate can also serve as a replacement arthroplasty in the setting of proximal pole scaphoid nonunions with collapse, bone loss, and/or osteonecrosis. This novel graft addresses shortcomings of other graft choices by providing a local structural autograft solution with minimal donor site morbidity, correcting carpal collapse, reconstructing the scapholunate ligament, and mitigating the need for microvascular anastomosis.

Plate Fixation With Cancellous Graft for Scaphoid Nonunion With Avascular Necrosis

PURPOSE

Currently, there is no consensus on the optimal treatment for scaphoid nonunion with avascular necrosis (AVN). Various techniques, often involving vascularized corticocancellous bone grafting, have been proposed. The authors hypothesized that similar outcomes might be possible with volar plate fixation augmented with autogenous pure cancellous graft.

METHODS

The authors performed a retrospective chart review of 13 cases of scaphoid nonunions with AVN in 12 patients treated with plate fixation and pure cancellous bone grafting. Surgical management included a volar incision, reduction, impaction of cancellous bone graft from the ipsilateral olecranon and/or distal radius, and application of a volar locking plate. Postoperative outcome measures included time to union based on computed tomography, patient-reported pain and disability scores, grip strength, range of motion, and return to work and sports.

RESULTS

The average patient was 32 years old (range, 17-50 years) and treated an average of 18 months after initial injury (range, 6-49 months). Two of 12 patients (15.7%) were female, 3 of 12 patients (25%) were smokers, and 5 of 12 patients (41.7%) had failed union with previous screw fixation. Twelve scaphoids (92.3%) were treated for AVN associated with a proximal pole fracture, and 1 (7.7%) for AVN proximal to a scaphoid waist fracture. Mean follow-up was 19.5 months (range, 12-29 months). Union was achieved in all patients. Two scaphoids (15%) achieved union by 12 weeks, 7 scaphoids (54%) by 18 weeks, 2 scaphoids (15%) by 24 weeks, and 2 scaphoids (15%) by 30 weeks (range, 8.9-28 weeks). Mean Disabilities of the Arm, Shoulder, and Hand score improved from 30.6 ± 6.2 before surgery to 17.2 ± 6.5 after surgery. All 11 employed patients returned to work, although 3 (27.2%) did not return to full capacity.

CONCLUSIONS

Scaphoid plate fixation and pure nonvascularized cancellous bone grafting for scaphoid nonunion with AVN yields excellent union rates and good patient-reported and functional outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

MR angiogram confirms sustained blood flow in 1,2 ICSR artery of vascularized bone grafting in scaphoid nonunion treatment

PURPOSE

To evaluate the functioning of 1,2 intercompartmental supraretinacular artery (ICSRA) in vascularized bone grafting (VBG) of scaphoid nonunions with avascular necrosis of proximal pole.

MATERIALS AND METHODS

Fourteen patients with scaphoid nonunion were treated operatively with 1,2 ICSRA VBG. Viability of the pedicle artery was evaluated by MR angiography with intravenous contrast agent.

RESULTS

In 13 out of 14 patients, the 1,2 ICSR artery was found to be patent and functional. Revascularization of scaphoid proximal pole was revealed in all cases, and nonunion healing was confirmed as well.

CONCLUSION

1,2 ICSRA VBG in scaphoid nonunion is an effective surgical technique. It combines the advantages of bone grafting and vascular supply via the transferred pedicle artery which seems to be functional postoperatively if a meticulous operative technique is used.

Clinical outcome after alternative treatment of scaphoid fractures and nonunions

PURPOSE

Achieving stable fixation of scaphoid fractures and nonunions continues to be a challenge. Compression screw fixation has been the current standard surgical procedure. However, in some cases, bone healing cannot be achieved and requires further revision. Recent series reintroduced volar plating as valid option for stable fixation. The aim of the study was to review clinical outcome of alternative scaphoid treatment.

METHODS

From 2011 to 2014, nine patients with scaphoid fracture were treated by Headless Compression Screw (HCS) and seven patients with scaphoid nonunion by HCS or volar mini condylar plate with bone graft. The average age was 34.4 years and the average time to follow-up was 19.3 months. From 1996 to 1998, 38 patients with scaphoid nonunion were treated using compression screw (S-group) or volar mini condylar plate (P-group) with bone graft. The average age was 39.6 years and the average time to follow-up was 26.2 months.

RESULTS

The union rate was 100%. For scaphoid fractures, the mean Modified Mayo Wrist Score (MMWS) was 94.1 and the DASH score 7.4. From 2011 to 2014, the MMWS was 87.9 and the DASH score 7 in scaphoid nonunions. In the period between 1996 and 1998, the MMWS was 67.2 in the P-group and 58.6 in the S-group, and the DASH score 16.8 and 28.2.

CONCLUSIONS

Our study demonstrated that appropriate application of the HCS was able to produce very satisfactory results in scaphoid fractures and nonunions. In our opinion, however, the method of scaphoid plate osteosynthesis can achieve a higher degree of stability, particularly rotational stability, in case of multifragmentary avascular scaphoid nonunions.

Ilizarov fixation for the treatment of scaphoid nonunion: a novel approach

OBJECTIVES

To evaluate the safety and efficacy of the Ilizarov fine-wire compression/distraction technique in the treatment of scaphoid nonunion (SNU), without the use of bone graft.

DESIGN

This is a prospective study of 20 consecutive patients in one center.

PATIENTS AND METHODS

This study included 20 patients (19 males) with a mean SNU duration of 14.5 months. Four patients had proximal pole, 15 had waist, and 1 had a distal SNU. Patients with carpal instability, humpback deformities, carpal collapse, avascular necrosis, and marked degenerative change were excluded. Following frame application, the treatment comprises three stages: The frame is distracted by 1 mm per day until the radiographs show a 2-3 mm opening at the SNU site (mean 10 days); the SNU site is compressed for 5 days, at a rate of 1 mm per day, with the wrist in 15 degrees of flexion and 15 degrees of radial deviation; the wrist is then immobilized in the Ilizarov fixator for 8 weeks.

RESULTS

Radiographic (radiography and CT scan) and clinical bony union was achieved in all 20 patients after a mean of 90.3 days (70-130 days). All patients returned to their pre-injury occupations. Thirteen patients had excellent results, four good, and three fair, according to the Mayo wrist score.

CONCLUSIONS

In these selected patients, this technique safely achieved bony union without the need to open the SNU site and without the requirement of bone graft.