Management of scaphoid nonunions with vascularized bone grafts from the distal radius: mid- to long-term follow-up

Should we always perform scaphoid nonunion surgery in patients with minor preoperative symptoms?

The objective of this study was to assess the downsides of surgical treatment of scaphoid fracture nonunion in patients with minor preoperative symptoms. Patients were classified with minor symptoms based on the Patient-Rated Hand/Wrist Evaluation questionnaire. Of the 35 included patients, most patients encountered problems with patient-specific activities; 9% reported worse postoperative functional outcomes, 34% were not satisfied with the treatment and 9% were reoperated. The risk of a worse functional outcome after surgery with the need for further operations and the chance of developing wrist osteoarthritis, along with the possibility of poor patient satisfaction and ongoing daily functional impairment, should be considered during preoperative counselling.Level of evidence: III.

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.

Predictors of Failure for Vascularized and Nonvascularized Bone Grafting of Scaphoid Nonunions: A Systematic Review

Objective  This article compares predictors of failure for vascularized (VBG) and nonvascularized bone grafting (NVBG) of scaphoid nonunions. Methods  We conducted a systematic literature review of outcomes after VBG and NVBG of scaphoid nonunion. Fifty-one VBG studies ( N  = 1,419 patients) and 81 NVBG studies ( N  = 3,019 patients) met the inclusion criteria. Data were collected on surgical technique, type of fixation, time from injury to surgery, fracture location, abnormal carpal posture (humpback deformity and/or dorsal intercalated segmental instability [DISI]), radiographic parameters of carpal alignment, prior failed surgery, smoking status, and avascular necrosis (AVN) as defined by punctate bleeding, magnetic resonance imaging (MRI) with contrast, MRI without contrast, X-ray, and histology. Meta-analysis of proportions was conducted with Freeman-Tukey double arcsine transformation. Multilevel mixed-effects analyses were performed with univariable and multivariable Poisson regression to identify confounders and evaluate predictors of failure. Results  The pooled failure incidence effect size was comparable between VBG and NVBG (0.09 [95% confidence interval [CI] 0.05-0.13] and 0.08 [95% CI 0.06-0.11], respectively). Humpback deformity and/or DISI (incidence-rate radios [IRRs] 1.57, CI: 1.04-2.36) and lateral intrascaphoid angle (IRR 1.21, CI: 1.08-1.37) were significantly associated with an increased VBG failure incidence. Time from injury to surgery (IRR 1.09, CI: 1.06-1.12) and height-to-length (H/L) ratio (IRR 53.98, CI: 1.16-2,504.24) were significantly associated with an increased NVBG failure incidence, though H/L ratio demonstrated a wide CI. Decreased proximal fragment contrast uptake on MRI was a statistically significant predictor of increased failure incidence for both VBG (IRR 2.03 CI: 1.13-3.66) and NVBG (IRR 1.39, CI: 1.16-1.66). Punctate bleeding or radiographic AVN, scapholunate angle, radiolunate angle, and prior failed surgery were not associated with failure incidence for either bone graft type ( p > 0.05). Conclusion  Humpback deformity and/or DISI and increasing lateral intrascaphoid angle may be predictors of VBG failure. Time from injury to surgery may be a predictor of NVBG failure. AVN as defined by decreased contrast uptake on MRI may be a marker of increased failure risk for both bone graft types.

Bone grafting for scaphoid nonunion surgery : a systematic review and meta-analysis

AIMS

The purpose of this systematic review was to determine the rates of union for vascularized versus non-vascularized grafting techniques in the operative management of scaphoid nonunion. Secondary aims were to determine the effect of the fixation techniques used, the source of grafting, as well as the influence of fracture location (proximal pole) and avascular necrosis (AVN).

METHODS

A search of PubMed, MEDLINE, and Embase was performed in June 2021 using the Preferred Reporting Items for Systematic Review and Meta-Analyses statement and registered using the PROSPERO International prospective register of systematic reviews. The primary outcome was union rate.

RESULTS

There were 78 studies that met the inclusion criteria with a total of 7,671 patients (87.8% male, 12.2% female). The mean age was 27.9 years (SD 3.8) and the mean follow-up was 30.9 months (SD 25.9). The mean union rate was 88.7% (95% confidence interval (CI) 85.0 to 92.5) for non-vascularized grafts versus 87.5% (95% CI 82.8 to 92.2) for vascularized grafts (p = 0.685). Pooled analysis of trial data alone found a mean union rate of 82.4% (95% CI 66.9% to 97.9%) for non-vascularized grafts and 89.4% (95% CI 84.1% to 94.7%) for vascularized grafts (p = 0.780). No significant difference was observed in union rates between any of the fixation techniques used in the studies (p = 0.502). Distal radius and iliac crest graft source had comparable mean union rates (86.9% (95% CI 83.1 to 90.7) vs 87.6% (95% CI 82.2 to 92.9); p = 0.841). Studies that excluded patients with both proximal pole fractures and AVN (n = 14) had a mean union rate of 96.5% (95% CI 94.2 to 98.9) that was significantly greater than the mean union rate of 86.8% (95% CI 83.2 to 90.4) observed in the remaining studies (p < 0.001).

CONCLUSION

Current evidence suggests vascularized bone grafting does not yield significantly superior results to non-vascularized grafting in scaphoid nonunion management. However, potential selection bias lessens the certainty of these findings. The fixation type or source of the graft used was not found to influence union rates either. Sufficiently designed and powered prospective randomized controlled trials in this area are needed. Cite this article: Bone Joint J 2022;104-B(5):549-558.

Patient-reported physical functioning and pain improve after scaphoid nonunion surgery: A Cohort Study

BACKGROUND

Since all patients with a scaphoid nonunion are generally treated surgically to prevent progressive osteoarthritis, it is important to set postoperative expectations regarding physical functioning and pain. Previous study mainly focus on postoperative scaphoid union and physician-based outcomes. Therefore we aim to report the change from preoperative to postoperative patient-reported outcomes to inform patients with a scaphoid nonunion about their postoperative expectations.

MATERIAL AND METHODS

Data were prospectively collected as part of usual care at the Xpert Clinic in the Netherlands. Adult patients who underwent scaphoid nonunion surgery minimally 3 months after a scaphoid fracture, were eligible for inclusion. Only patients with complete preoperative and postoperative questionnaires regarding our primary outcome (Patient Rated Hand/Wrist Evaluation (PRWHE) were included. As secondary outcomes, we assessed the Visual Analog Scale (VAS) pain and hand function, range of motion of the injured wrist measured by a hand therapist, and patient satisfaction with questionnaires.

RESULTS

We included 118 patients with complete preoperative and postoperative (11 - 92 months) PRWHE questionnaires. The median PRWHE score improved significantly from 47 [IQR 27 - 62]) preoperative to 11 [IQR 5 - 23] postoperative (p<0.001). Postoperative improvement in pain and physical functioning was also observed in the PWRHE subdomains pain and disability separately (p<0.001), VAS pain, and VAS function (p<0.001). There was no difference between preoperative and postoperative range of motion of the injured wrist. Satisfaction with the hand improved significantly from preoperative to postoperative (p<0.001). Good or excellent satisfaction with the treatment result was reported by 69% of the patients and 86% would undergo the treatment again.

CONCLUSIONS

Patients can expect an improvement in physical functioning and pain after scaphoid nonunion surgery. Most patients are satisfied with the treatment result.

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.

Bone Morphogenetic Protein in Scaphoid Nonunion: A Systematic Review

Background  Scaphoid nonunion can lead to carpal collapse and osteoarthritis, a painfully debilitating problem. Bone morphogenetic protein (BMP) has been successfully implemented to augment bone healing in other circumstances, but its use in scaphoid nonunion has yielded conflicting results. Case Description  The purpose of this study is to assess the outcomes and complications of scaphoid nonunion treated surgically with BMP. Literature Review  A literature review of all available journal articles citing the use of BMP in scaphoid nonunion surgery from 2002 to 2019 was conducted. We included studies that used BMP as an adjunct to surgical treatment for scaphoid nonunions in both the primary and revision settings with computed tomography determination of union. Demographic information, dose of BMP, tobacco use, outcomes, and complications were recorded. A total of 21 cases were included from four different studies meeting inclusion criteria. Clinical Relevance  The union rates were 90.5% overall, 100% for primary surgeries, and 77.8% for revision surgeries. Five patients (24%) experienced 11 complications, including four cases (19%) of heterotrophic ossification. Use of BMP in scaphoid nonunion surgery resulted in a 90.5% overall union rate but was also associated with complications such as heterotopic ossification. All included studies used BMP to augment bone graft, screw or wire fixation, or a combination of methods. The efficacy of BMP in scaphoid nonunion is unclear, and a sufficiently powered, randomized controlled trial is needed to determine optimal fixation methods, dosing, and morbidity of the use of BMP. Level of Evidence  This is a Level IC, therapeutic interventional study.

Pedicled vascularized versus non-vascularized bone grafts in the treatment of scaphoid non-union: a meta-analysis of comparative studies

BACKGROUND

Whether pedicled vascularized bone grafts (PVBGs) are beneficial over non-vascularized bone grafts (NVBGs) still remains controversial. The aim of this study was to compare the clinical results of PVBGs and NVBGs for the treatment of scaphoid non-union.

METHODS

We conducted a meta-analysis of the published studies comparing outcomes of these two different surgical techniques for scaphoid non-union. Outcomes of union rate, time to union, functional results and re-operation rate were analysed.

RESULTS

Seven studies including four randomized controlled studies and three retrospective comparative studies with 413 participants were identified fitting inclusion criteria. Meta-analysis showed that (i) union rate in PVBG groups was 1.13 times of NVBG groups (P = 0.002); (ii) the PVBG groups reached bone union significantly earlier by 1.73 weeks (P < 0.01); (iii) there was no significant difference in functional results, including active range of motion, grip strength, Mayo Wrist Score and excellent and good rate (P > 0.05); and (iv) re-operation rate was similar between the two groups (P = 0.65).

CONCLUSIONS

Although the PVBG technique attains higher union rate and earlier union, this radiological advantage does not bring any functional benefits. In addition, PVBGs are of greater technical difficulty and need more operation requirements. Hence, clinicians should be cautious in electing PVBGs for treating scaphoid non-union.

Correction of humpback and DISI deformities by vascularized bone grafting in patients with scaphoid nonunion

Introduction: Although vascularized bone grafting (VBG) using 1, 2 intercompartmental supraretinacular artery (1, 2 ICSRA) is effective for scaphoid nonunion, dorsal intercalated segment instability (DISI) deformity persists even after correction of humpback deformity (HD). The purpose of this retrospective study was to evaluate the correction of HD and DISI deformity after 1, 2 ICSRA VBG for scaphoid nonunion. Methods: We treated 18 patients (mean age: 25.8, 16 males and 2 females) with scaphoid nonunion using a 1, 2-ICSRA VBG between January 2010 and December 2018. The average time from injury to surgery was 20.0 (3–120) months. The nonunions were located at the waist in all patients. The correction of HD and DISI deformity was investigated on the preoperative images and images at the last examination. Results: In all patients, the correction of HD was positively correlated with that of DISI deformity. Moreover, we focused on the time from injury to surgery and evaluated changes in HD and DISI deformity according to the time to surgery. As a result, changes in HD and DISI deformity were positively correlated in patients with a shorter time to surgery but were not correlated when the time to surgery exceeded 5 months. Conclusions: These results suggest that DISI deformity can be corrected by correcting HD when the time from injury to surgery is short, but that correction is difficult if the time to surgery is prolonged.

Arthroscopic-assisted reduction, bone grafting and screw fixation across the scapholunate joint for proximal pole scaphoid nonunion

Background

There are some difficulties in treating proximal scaphoid nonunion, mainly including poor vascularity of the proximal scaphoid fragment and limited space for a stable fixation in the proximal scaphoid fragment. This study reports the outcomes of treating proximal scaphoid nonunion with arthroscopic assist for reduction, bone grafting and screw fixation across the scapholunate (SL) joint.

Methods

Between 2008 and 2017, 21 patients were enrolled. Fracture healing and change in the lateral SL angle and SL gap were evaluated. Functional outcomes were evaluated using the Disabilities of the Arm, Shoulder, and Hand (DASH) score, wrist range of motion, grip strength, and the Visual Analog Scale (VAS) for pain.

Results

Nineteen patients achieved fracture healing and their mean follow-up duration was 31.3 months (24–120 months). The average fracture healing time was 16.3 weeks (10 to 28 weeks). From the preoperative to the postoperative final evaluation, there was some significant improvement in wrist function, including wrist flexion from 54.5^o to 67.4^o, wrist extension from 62.3^o to 71.7^o, DASH scores from 52.4 to 21.4, VAS during activity from 4.6 to 2.1, and grip strength from 9.6 kg to 24.7 kg. The lateral SL angle also improved significantly, from 82^o to 66^o. Seventeen patients requested screw removal after fracture healing because of their cultural belief in not leaving hardware in the body. No significant SL gap widening was noted after screw removal in the sequential follow-ups.

Conclusions

Using arthroscopic-assisted reduction, bone grafting and screw fixation across the SL joint in proximal scaphoid nonunion treatment, satisfactory functional and radiographic outcomes can be achieved.

Revision surgery after vascularized or non-vascularized scaphoid nonunion repair: A national population study

HYPOTHESIS

We aimed (1) to discover the prevalence of vascularized bone grafting in the treatment of scaphoid nonunion and (2) to compare healing using vascularized bone grafting versus standard non-vascularized techniques. Secondarily, we sought to compare resource utilization between procedures and identify factors that may be associated with nonunion repair failure. We hypothesized that, despite being less common, vascularized bone grafts have greater success than non-vascularized bone grafting surgeries.

METHODS

We performed a large population analysis using the Truven MarketScan databases to identify patients from 2009 to 2017 with a diagnosis of a scaphoid nonunion undergoing repair surgery with and without the insertion of a pedicled or free vascularized bone graft. We defined any subsequent scaphoid or wrist surgery within 12 months after surgery as surgery failure. We compared success rates and post-operative resource utilization using Chi-squared tests.

RESULTS

Of 4177 eligible patients, 358 underwent nonunion repair with vascularized bone graft and 3819 patients received non-vascularized bone grafting. The failure rate requiring revision surgery was 5.0% in vascularized repair, versus 6.1% for non-vascularized surgery. Age and comorbidities did not affect bone graft type. Areas with higher median household incomes had more vascularized repairs. Vascularized bone graft patients received significantly more therapy and imaging after surgery.

CONCLUSIONS

Most scaphoid nonunion repairs are performed without vascularize bone grafting. Typical nonunions may not justify the increased time and technical demands of vascularized bone grafting, and traditional repair should remain first line treatment for scaphoid nonunions without additional risk factors. Further studies to elucidate which fractures benefit most from vascularized grafting are needed.

The use of pedicled vascularized bone grafts in the treatment of scaphoid nonunion: clinical results, graft options and indications

Scaphoid nonunion is a challenging situation for orthopaedic surgeons. Nonunion rate is especially high in proximal pole fractures of the scaphoid due to tenuous retrograde blood supply.The use of pedicled vascularized bone grafts for the treatment of scaphoid nonunion provides both good clinical and radiological outcomes.The preserved vascularity of the graft leads to better bone remodelling, less osteopenia, faster incorporation and better maintenance of bone mass compared to the conventional non-vascularized grafting.Pedicled vascularized bone grafts also allow the correction of the carpal alignment and humpback deformity of the scaphoid.Clinical and radiological results have been satisfactory and promising, making us anticipate that the role of vascularized bone grafting for the treatment of carpal diseases will increase. Cite this article: EFORT Open Rev 2020;5:1-8. DOI: 10.1302/2058-5241.5.190021.

Scaphoid nonunions in adolescents: Treatment with vascularized bone grafts

INTRODUCTION

Scaphoid nonunions (SN) are rare in adolescents. The use of vascularized bone grafts (VBG) from the distal radius as an alternative to conventional grafting for the treatment of established SN in adolescents is described.

PATIENTS AND METHODS

The technique was applied in 13 patients with symptomatic SN resulting from fractures. All patients were male with average age of 16.5 years (15-17.5). The average period from injury to surgery was 8.3 months (4-13). Patients underwent vascularized bone grafting and internal fixation with K-wires. In 6 patients with proximal pole nonunion a VBG from the dorsal distal radius was used, and in 7 with a waist nonunion a VBG from the palmar distal radius was used. The valuation was clinical (grip strength, range of motion, VAS pain score, DASH) and radiographic. The time to return to activity was also recorded.

RESULTS

The mean follow-up was 9.8 years (range, 4-16). The union rate was 100% (11/11 cases). Union was achieved in a mean period of 7.2 weeks (range, 6-10), without growth disturbance or other complications from the epiphyseal plate of the distal radius. The range of motion and grip strength was 89% and 92% of the contralateral respectively. The mean postoperative DASH score was 8 and the VAS score was 1. All patients returned to daily activities and sports in a mean period of 4.5 months.

CONCLUSIONS

The use of VBG from the distal radius provided a permanent solution in the rare case of SN in adolescents, without donor site morbidity or epiphyseal plate disturbance. The deformity and carpal height were corrected resulting in painless motion and grip strength.

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.

The Efficacy of Vascularized Bone Grafts in the Treatment of Scaphoid Nonunions and Kienbock Disease: A Systematic Review in 917 Patients

Background Vascularized bone grafts have become one of the first treatment options for scaphoid nonunions and Kienböck's disease. The aim of this study is to review the current body of the literature regarding the use of four vascularized bone grafts (1,2 ICSRA [1,2 intercompartmental supraretinacular artery] graft, 4+5 ECA [4+5 extracompartmental artery] graft, volar radial graft, and free medial femoral condyle graft) in these pathologies. Patients and Methods A search on MEDLINE and Google Scholar was performed. Exclusion criteria included language other than English, studies with no full text available, case reports, letters, editorials, and review articles. The primary outcomes included consolidation rate of the grafts and time to union regarding scaphoid nonunion, as well as the clinical outcomes (pain, grip strength, range of motion), revascularization of the lunate, and progression of the disease regarding Kienböck's disease. Results A total of 37 articles were included in the study enrolling 917 patients. Regarding scaphoid nonunion, the consolidation rate was 86.3% for the 1,2 ICSRA graft, 93.9% for the volar radial bone graft, and 88.8% for the free medial femoral condyle graft. In patients with Kienböck's disease, progression of the disease was observed in 13% of patients, and grip strength and pain were substantially improved whereas range of motion did not demonstrate statistically significant improvement ( p < 0.05). Conclusion Vascularized bone grafts yield successful outcomes in patients with scaphoid nonunions demonstrating a high union rate. In patients with Kienböck's disease, vascularized grafts lead to revascularization of the lunate in most of the cases with concomitant improvement of the clinical parameters.

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.

Treatment for proximal pole scaphoid nonunion with capsular-based vascularized distal radius graft

PURPOSE

We retrospectively reviewed the results of 89 patients with proximal pole scaphoid nonunion, 58 with avascular necrosis, treated with a capsular-based vascularized distal radius graft.

METHODS

Seventy-one male and eighteen female patients with symptomatic nonunion at the proximal pole of the scaphoid were included in this study. No patient had a humpback deformity. In all patients, the vascularized bone graft was harvested from the dorsum of the distal radius and was attached to a capsular flap of the dorsal wrist capsule. After fixation of the scaphoid with a small cannulated screw, the graft was inserted press-fit into the scaphoid trough in the nonunion site. Supplementary fixation of the graft with a microsuture anchor into the scaphoid was used in 66 patients.

RESULTS

At a mean time of 12.3 weeks (range 6-24) after surgery, solid union was achieved in 76 of 89 patients (49 of 58 with avascular necrosis). Eleven patients had persistent nonunion and two fibrous union as determined by CT scan. Sixty-six of the patients with solid bone union were completely pain free, and ten complained of slight pain with strenuous activities. No donor site morbidity was observed.

CONCLUSIONS

The capsular-based vascularized bone graft from the distal radius is a reliable alternative technique for scaphoid nonunions. It is a simple and expedient harvesting technique without the need for a microsurgical anastomoses. The supplemental fixation with a microsuture anchor eliminates the risk of graft displacement.

Clinical and functional outcomes of vascularized bone graft in the treatment of scaphoid non-union

Introduction

Scaphoid non-union is a challenging and complex problem. Various methods have been proposed for the management of patients with scaphoid non-union and to reduce the risk of complications. In this study, our aim was to evaluate the clinical and functional outcomes of using a vascularized bone graft in the treatment of scaphoid non-union.

Methods

Patients with scaphoid non-union who underwent 1,2 intercompartmental supraretinacular artery pedicled vascularized bone graft between January 2005 and January 2011 were enrolled. The parameters assessed included clinical and functional outcomes, radiological measures, and potential risk factors.

Results

Forty-one patients were finally included. Thirty patients achieved union (73%) and 11 did not. Smoking was a significant risk factor for non-union after the surgery. In patients who achieved union, grip strength and radioulnar abduction were greater in comparison to that in patients who did not achieve union. Functional measures, including the Disabilities of Arm and Shoulder score and the Modified Mayo Wrist Score, improved in patients with scaphoid union. The scaphoid length also improved significantly postoperatively in these patients.

Conclusion

Surgical treatment of scaphoid non-union using vascularized bone graft led to a high union rate with good clinical and functional outcomes. Smoking is a risk factor for non-union, even with the use of a vascularized bone graft. Avascular necrosis was not associated with an increased risk for non-union.

Scaphoid nonunion: what is the role of the Zaidemberg 1,2 intercompartmental supraretinacular arterial flap?

The reported results for the treatment of scaphoid nonunions with non-vascularized grafts are based on observational studies with a high variability in union rates from 38%-100% and time to union from 6-18 weeks, and there is also a lack of a standard classification. Meta-analyses and systematic reviews have been presented to better support conclusions from large pools of data (604 to 5246 cases), but their interpretation remains limited because of lack of uniformity in the studies analysed. Several authors have presented results from the Zaidemburg flap, with highly variable outcomes despite using the same technique; union rates have ranged from 27%-100% achieved between 6.5-19 weeks. Technical details that may be responsible for the discrepancies are discussed. There is a need for a validated prognostic classification system for scaphoid nonunions that can allow comparisons between outcome studies.

Treatment of the scaphoid humpback deformity - is correction of the dorsal intercalated segment instability deformity critical?

Treatment of scaphoid fractures has been focused mainly on achieving union, with less attention to restoring normal scaphoid shape and orientation. Malalignment of one carpal bone will disrupt the kinetics of the entire wrist. The dorsal intercalated segment instability deformity associated with scaphoid waist nonunion is a nondissociative form of carpal instability. It has to be reduced in the treatment of scaphoid waist nonunions to avoid kinetic problems that will lead to arthritic changes. Computerized tomography scanning has become indispensable to visualize the humpback deformity clearly. Different techniques may be used to restore the normal anatomy of scaphoid, from non-vascularized graft to arthroscopic bone grafting, and also the option of vascularized bone grafting.