Primary vascularized distal radius bone graft for nonunion of the scaphoid

Scaphoid Nonunions Treated with Nonvascularized Bone Grafting and Screw Fixation

Background  Vascularized bone grafting with screw fixation is currently considered the treatment of choice for scaphoid nonunions with avascular necrosis (AVN) of the proximal pole. A viable alternative to using vascularized bone grafts for scaphoid nonunions with AVN is nonvascularized bone grafting with screw fixation. Question  What are the functional outcomes of patients with scaphoid nonunions and associated proximal pole AVN who are treated with nonvascularized distal radius bone grafting and screw fixation? Patients and Methods  Eight scaphoid nonunions with AVN, which received nonvascularized distal radius bone graft and screw fixation, underwent a retrospective review. Range of motion, strength, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores were obtained. Follow-up X-rays were compared with immediate postoperative X-rays. Results  At a mean follow-up of 88.9 months, thumb palmar abduction and radial abduction were significantly higher on the operative side ( p  = 0.28 and 0.49, respectively). Extension/flexion arc was significantly lower in the operative wrist ( p  = 0.148). There was no significant difference between the operative and nonoperative sides with regard to strength. The median postoperative DASH score was 2.9 (interquartile range [IQR]: 8.3). There was no progression of osteoarthritis when immediate postoperative and follow-up X-rays were compared. Radiographic union was observed in six of the seven (85.7%) patients who were able to return to the office for follow-up radiographs. The mean scapholunate and radioscaphoid angles measured on X-rays were within normal anatomic range postoperatively. Conclusions  Using nonvascularized distal radius bone graft and screw fixation in the treatment of scaphoid nonunions with associated AVN has favorable radiologic and functional outcomes and should be considered a viable treatment option for this difficult problem.

The Outcome of Scaphoid Fracture Nonunion Managed by 1,2 Intercompartmental Supraretinacular Artery (1,2 ICSRA) Vascularized Bone Graft

BACKGROUND

Scaphoid fracture is most often missed and mismanaged leading to scaphoid nonunion with or without avascular necrosis. When avascular necrosis of the proximal pole is confirmed with intraoperative evaluation, conventional bone graft is not enough. The treatment modalities are evolving day by day. The current trend is vascular bone grafting, which has shown good outcomes in terms of union and wrist function.

METHODS

Fifty patients with nonunion fracture of the scaphoid were treated with vascularized pedicle bone graft from the dorsum of the distal radius using the 1st and 2nd intercompartmental supraretinacular artery, from 2014 to 2022. Preoperative and postoperative clinical evaluation included pain, range of motion, grip strength, and satisfaction. The average follow-up period was 12 months.

RESULTS

Among 18 patients, 14 were clinically improved after a mean follow-up period of eight weeks. Thirteen patients reported the absence of any discomfort, three patients reported slight discomfort after hard work, and two patients reported pain with light work. The wrist range of motion improved significantly, and the hand grip strength also improved. According to the modified Mayo wrist scoring chart, clinical results were rated as excellent in 24 cases, good in 19 cases, and poor in four cases.

CONCLUSION

1,2 intercompartmental supraretinacular artery (1,2 ICSRA) is superficial to the extensor retinaculum and is a proper pedicle of vascularized bone graft due to the ease of visibility and dissection. The functional results and union rates were satisfactory in our study.

Scaphoid Nonunion Vascularized Bone Grafting in 2021: Is Avascular Necrosis the Sole Determinant?

The decision regarding the use of vascularized bone grafting (VBG) or nonvascularized bone grafting for the treatment of scaphoid nonunion (SNU) needs guidelines based on patient- and fracture-specific risk factors. Historically, the presence of avascular necrosis was viewed as the primary indication for VBG; however, avascular necrosis is not the only indicator to determine whether VBG can improve our treatment of difficult SNU cases. The methods of detecting scaphoid avascular necrosis lack consensus and accuracy, limiting their use as decision-making tools. Additionally, many other preoperative risk factors for SNU surgery failure have been reported and require careful and standardized study, including the location of nonunion in the scaphoid proximal pole, the duration of nonunion, previous failed nonunion surgery, smoking, and fracture nonunion displacement or collapse. An appropriate study size and design are needed to determine the factors that guide the use of VBG or nonvascularized bone grafting to optimize the outcomes of SNU surgery.

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.

How Long Should We Immobilize the Wrist after Vascularized Bone Grafting for the Treatment of Scaphoid Nonunion?

Background: Although vascularized bone grafting can effectively treat scaphoid nonunion, the optimal duration of the immobilization period after bone grafting is unclear. Therefore, we aimed to examine the difference in the union rate and range of motion between short and long immobilization periods and infer the optimal post-immobilization period after pedicled vascularized bone grafting for scaphoid nonunion treatment. Methods: A total of 23 wrists (21 men and 1 woman) with scaphoid nonunion treated using an intercompartmental supraretinacular artery pedicled vascularized bone graft were analyzed. We examined the difference in the union rate and range of motion between patients immobilized for less than 49 days (short immobilization group) and those immobilized for more than 49 days (long immobilization group). The range of motion of the wrist joint was measured before and after surgery. Patient outcomes were also assessed. Results: The overall union rate was 95.6%. A significant difference was found in postoperative extension and flexion between the two groups, but not in terms of the functional outcome. If the intraoperative fixation is solid, intraoperative proximal pole bleeding is confirmed, and the follow-up radiograph shows a normal healing process, we propose immobilization of the wrist for ≤ 7 weeks. Conclusions: The immobilization duration should depend on the solidity of intraoperative fixation and a satisfactory appearance on follow-up radiography: absence of a gap at the graft interface, surrounding lucency, or movement of the implant and displacement of the graft. If there are no signs of graft failure and fixation is solid, immobilization of the wrist for 7 weeks or less is recommended.

Bone Grafting for Scaphoid Nonunions: Is Free Vascularized Bone Grafting Superior for Scaphoid Nonunion?

BACKGROUND

Nonvascularized bone grafting (NVBG) and vascularized bone grafts (VBGs) have been used to treat scaphoid nonunions. A comparison of a single institution' s experience using structural iliac crest bone graft (ICBG), 1,2-intercompartmental supraretinacular artery (1,2-ICSRA), and medial femoral condyle (MFC) grafts to treat scaphoid nonunions was undertaken.

METHODS

Thirty-one patients underwent ICBG, 33 patients underwent 1,2-ICSRA, and 45 patients underwent MFC grafting. Mean time to follow-up was 16 months (range, 2-153). Twenty-three percent used tobacco products. Mean age was 24 years (range, 11-66), with 86% male patients. Outcomes included union rate, time to healing, range of motion, complications, and reoperations.

RESULTS

Union rates and mean time to union were 71% and 19 weeks for the ICBG group, 79% and 26 weeks for the 1,2-ICSRA group, and 89% and 16 weeks for the MFC group, respectively. Failure of union was associated with tobacco use but not with age, gender, time from injury to surgery, or type of fixation. There was no significant difference between the groups regarding range of motion or strength.

CONCLUSIONS

These findings demonstrate the need for careful patient selection. In patients with the most complicated scaphoid nonunions (avascular necrosis, carpal collapse, and previous surgeries), the MFC group had the highest union rate and fastest time to union. Patients with risk factors for failure should be counseled on the outcomes and possible need for salvage fusion surgery.

Treatment of Proximal Pole Scaphoid Fracture Nonunions With Intramedullary Cancellous Autograft and Cannulated Headless Compression Screw

Management of proximal pole scaphoid nonunion remains a challenging problem. Multiple surgical techniques have been described, although no treatment has proven superior. Recent studies have questioned the need for vascularized bone grafting, even in in the setting of avascular proximal poles. We present a relatively simple technique of intramedullary autogeneous cancellous bone grafting that does not disturb the intact cortical shell of the nonunion, which has so far provided gratifying clinical results.

Surgical Strategy for Scaphoid Nonunion Treatment

Scaphoid fracture is the most common carpal fracture. Nonunion rate has been reported around 10 to 15% of scaphoid fractures. Risk factors for scaphoid nonunion are known as location, displacement, poor vascularity, time to treatment etc. The goals of surgical treatment for scaphoid nonunion are to achieve bony union, to correct carpal deformities and also to prevent progressive carpal instability and arthritis. Scaphoid nonunion can cause scaphoid nonunion advanced collapse (SNAC) which is a pattern of progressive degenerative radiocarpal and midcarpal arthritis secondary to posttraumatic pathomechanics of the scapholunate joint. Achieving bony union is essential to prevent carpal collapse or arthritis. To improve bony union, many surgical procedures including various forms of bone grafting have been developed and attempted. However, there is a controversy about which procedure is the most effective. In this review, we provide an overview of surgical treatment methods for scaphoid nonunion and discuss proper surgical strategies for scaphoid nonunion which requires surgical management.

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.

Bone graft in the treatment of nonunion of the scaphoid with necrosis of the proximal pole: a literature review

Scaphoid fractures are the most common fractures of the carpal bones, corresponding to 60%. Of these, 10% progress to nonunion; moreover, 3% can present necrosis of the proximal pole. There are various methods of treatment using vascularized and non-vascularized bone grafts.

To evaluate and compare the rate of scaphoid consolidation with necrosis of the proximal pole using different surgical techniques.

The authors conducted a review of the literature using the following databases: PubMed and BIREME/LILACS, where 13 case series were selected (ten with use of vascularized bone grafts and three of non-vascularized bone grafts), according to inclusion and exclusion criteria.

In most cases VBGs were used, especially those based on the 1,2 intercompartmental supraretinacular artery, due to greater reproducibility in performing the surgical technique.

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

We did a meta-analysis of the literature in order to clarify which of the vascularized bone flaps (VBF) used for scaphoid non-union treatment has the best outcome with regard to various parameters. We analyzed 54 articles that present nine different types of VBF. The analysis concerned demographical patient information, radiographic parameters, fracture classification, including the presence or non-presence of avascular necrosis of the scaphoid proximal pole (PP AVN), parameters that have to do with the surgery itself and the postoperative protocol, the healing of the nonunion and functional scores. The meta-analysis showed best healing potential for the femoral graft despite the complexity of the operation. On the other hand, the most commonly used 1,2-ICSRA flap makes the procedure more reproducible but showed worse results. The femoral flap was also among the most successful flaps when used for patients with PP AVN. The consolidation rate, in general, was not affected by the time elapsed between the fracture and the operation but by smoking and the presence of PP AVN. The meta-analysis could not reach many significant statistical conclusions because of either the small number of patients in some flap groups or the heterogeneity and lack of documentation in most of the articles. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1076-1085, 2017.

Vascularized Bone Grafting in Scaphoid Nonunion: A Review of Patient-Centered Outcomes

Background: The radiographic and clinical outcomes following vascularized bone grafting (VBG) for scaphoid nonunion have previously been reported in the literature; however, few studies report on patient-derived outcomes. The purpose of this study was to determine the effect of VBG for scaphoid nonunion on patient-derived outcomes. Methods: The MEDLINE and PubMed databases were queried for the use of VBG in scaphoid nonunion. We included studies that reported on patient-derived outcomes. We excluded studies with less than 10 patients or less than 6 months of follow-up. The primary outcomes assessed included functionality, percent and time to return to preinjury activity, postoperative pain, and patient satisfaction. Results: Twenty-six articles described the outcomes of 520 patients with an average of 19.3 patients per study. Functionality was most commonly assessed by the Mayo Modified Wrist Score and Disabilities of the Arm, Shoulder and Hand scores, which improved by 53.1% and 81.7% postoperatively, respectively. Within 16 weeks, 90.3% of patients returned to their previous occupation or sporting activity. Pain was most commonly reported using a 0 to 10 visual analog scale and improved 4-fold postoperatively. Complete satisfaction was reported by 92% of patients. The most common complications were superficial infections (1.56%), neuropathic pain (1.56%), and complex regional pain syndrome (1.25%). Conclusions: VBG for scaphoid nonunion results in the improvement of patient-derived outcomes, and high rates of return to preinjury activity levels and patient satisfaction. Multiple metrics of patient-derived outcomes were utilized by the studies in our review without a clear consensus as to which metric is most responsive and accurate.

Scaphoid nonunion treated with vascularised bone graft from dorsal radius

INTRODUCTION

The main aim of this retrospective study was to present our experience on scaphoid nonunion treated with vascularised bone graft.

METHODS

Between 2006 and 2012, 58 patients presenting with symptomatic scaphoid nonunion were eligible to participate in this study. Topography of the nonunion included 29 proximal, 25 waist and 4 distal scaphoid nonunions. Vascularised bone graft from distal dorsal radius was used in all cases which were stabilised with the headless cannulated compression screws. Scapholunate angles, Natrass carpal height ratio were evaluated pre and postoperatively. Range of motion of the affected side was compared to that of the contralateral side after the surgery.

RESULTS

Radiographic union was achieved in 50, out of 58 cases with an average time of 9.9 weeks (range, 6-18 weeks). Out of all the non-united cases, four of them were in proximal, three in the waist and one was in distal scaphoid. In nine proximal nonunions treated by 4+5 ECA graft all but one were united. The mean follow up was 21.7 months (12-62 months). The flexion was 91.6%, the extension was 91.5%, the radial deviation was 81.2%, and the ulnar deviation was 89.5% compared to the other side. The grip strength was 93%. Preoperative DASH score was 61.5 diminishing to 28.7 postoperatively. There was no significant change in Natrass carpal height ratio but a slight improvement occurred in scapholunate angles both pre and postoperatively.

CONCLUSION

Vascularised bone graft is a good solution for scaphoid nonunion to enhance the healing rate especially in the presence of avascular necrosis. Proximal pole nonunions, humpback deformity and smoking are important negative factors for scaphoid nonunion despite the use of a vascularised bone graft. A trapezoidal wedge graft is necessary for the volar type nonunions with humpback deformity. 1,2 ICSRA offer an advantage with its proximity to scaphoid in all nonunion locations. Nonetheless, 4+5 ECA graft is also a good solution for proximal nonunions.

An alternative graft fixation technique for scaphoid nonunions treated with vascular bone grafting

PURPOSE

To present our experience with vascularized bone grafting based on the 1,2-intercompartmental supraretinacular artery for the management of established scaphoid nonunion and to investigate the efficacy of graft immobilization with a combination of Kirschner wires and transarticular external fixation.

METHODS

A retrospective chart and radiographic review was conducted for patients with the diagnosis of scaphoid nonunion of the proximal pole or the waist treated with the 1,2-intercompartmental supraretinacular artery-based vascularized graft and fixed with a combination of Kirschner wires and transarticular external fixation between 2007 and 2011.

RESULTS

We observed 23 consecutive patients for a mean of 34 ± 4 months. All patients were males with mean age of 25 ± 5 years. All patients had scaphoid nonunion and associated humpback deformity. The mean duration of nonunion was 7 ± 1 months. All scaphoid nonunions united after the index procedure at a mean of 10 ± 1 weeks. Two patients had avascular necrosis of the proximal pole based on the preoperative magnetic resonance imaging findings. After surgery, deformity correction was achieved in all patients, as recorded by the decrease in the lateral intrascaphoid angle and the increase in the dorsal scaphoid angle. At the last follow-up, no patients reported wrist pain. The mean Disabilities of the Arm, Shoulder, and Hand score improved significantly from 32 ± 12 before the operation to 5 ± 3 at the last postoperative visit. All patients showed statistically significant improvement in the range of motion and the grip strength of the involved wrist.

CONCLUSIONS

The results of this study support the combined use of Kirschner wires and transarticular external fixation for fixation of a 1,2-intercompartmental supraretinacular artery-based vascular bone graft in the treatment of scaphoid nonunions.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The 1,2-intercompartmental supraretinacular artery vascularized bone graft for scaphoid nonunion: management and clinical outcome

PURPOSE

To evaluate the clinical outcome of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft for scaphoid nonunion (SN).

METHODS

A retrospective study was performed to evaluate patients with SN and treated with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft between 1997 and 2010. Functional measures, quality of life by Short Form SF-36 questionnaire, and analysis of risk factors were included.

RESULTS

Out of 39 patients who were eligible for the study, 11 were lost to follow-up. Out of the remaining 28 patients, union was achieved in 21 (75%). The mean length of follow-up was 63 ± 45 months. In hands with scaphoid union, the grip strength and the radioulnar active range of motion were less than the contralateral side but greater compared with patients with nonunion. Active extension-flexion was less compared with the noninjured hand but similar to patients with nonunion. Disabilities of the Arm, Shoulder and Hand (DASH) score decreased from 58 to 23 in dominant hands and from 46 to 13 in nondominant hands. Smoking was found to be a risk factor for nonunion. Patients with scaphoid union tended to higher scores in 8 domains of SF-36-Item Health Survey quality of life without significant difference.

CONCLUSIONS

Surgical treatment of SN with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft provided a union rate comparable with other vascularized bone graft techniques. Previous scaphoid reconstruction with standard iliac crest bone graft was not associated with higher risk for secondary nonunion. There was an upward tendency seen in DASH score and quality of life after scaphoid union.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

[Results of treatment of scaphoid nonunion with microvascularized bone grafts of the 1, 2 intercompartmental supraretinacular artery and osteosynthesis]

OBJECTIVE

To analyze the results of treatment of scaphoid nonunion with questionable viability of the proximal fragment, but without significant deformity or collapse, using a vascularized bone graft of 1,2 intercompartmental supraretinacular artery (1.2 ICSRA) and subsequent osteosynthesis.

MATERIAL AND METHOD

A retrospective study was performed on 10 male patients with a radiographic diagnosis of nonunion. Functionality, pain using Visual Analog Score (VAS), grip strength, patient satisfaction and reintroduction to working life, using QuickDASH and May specific wrist scales were assessed after the treatment. The integration of the graft was checked by radiography.

RESULTS

The mean follow-up was 31.4 months, and 90% of the questionnaires were satisfactory. The VAS decreased by 4.6 points and the flexor-extensor mobility gain was 5°. The total graft consolidation rate reached 40% in 5.5 months on average.

DISCUSSION

Several studies have demonstrated better results using vascularized bone graft versus non-vascularized. From the description by Zaidemberg in 1991, the vascularized graft with 1.2 ICSRA artery, distal radius, has been the most widely used for the treatment of scaphoid nonunion.

CONCLUSIONS

Our results are comparable with the literature reviewed, thus using vascular graft of the 1.2 ICSRA and osteosynthesis with Herbert-type screw, may be an alternative treatment for proximal scaphoid nonunion, without collapse or significant deformity.

2,3 intercompartmental supraretinacular artery pedicled vascularized bone graft for scaphoid nonunions

Scaphoid nonunion is a complex problem that may continue to exist despite conventional methods of bone grafting and internal fixation. Vascularized bone grafting has been proposed as a treatment option for scaphoid nonunions with or without avascular necrosis of the proximal pole. Zaidemberg and colleagues first introduced the dorsal distal radius graft that has gained considerable popularity in the past 2 decades. Less commonly, the 2,3 intercompartmental supraretinacular artery pedicled vascularized bone graft has been used successfully with equally promising results. It has become the graft of our choice for the treatment of scaphoid nonunions as it has a longer pedicle and is able to provide a wider arc of rotation that allows easier reach of the volar carpus. The use of rigid internal fixation with screws also permitted early wrist range of motion and shorter periods of immobilization. In this article, we describe our surgical technique of harvesting the 2,3 intercompartmental supraretinacular artery pedicled vascularized bone graft. The anatomy, indications, contraindications, and complications of treatment are also detailed.

Supplemental graft fixation for distal radius vascularized bone graft

Vascularized bone grafts from the distal radius have been used successfully for the treatment of scaphoid nonunions. Typically, the harvested graft is secured into the scaphoid with a press-fit technique. This type of fixation may lead to graft extrusion in the early postoperative period, and thus to treatment failure. In this technical note, we describe the use of micro bone suture anchors for supplemental fixation of the vascularized bone graft into the scaphoid. It is a simple and quick technique and provides an enhanced fixation of the vascularized bone graft, which is beneficial during the early critical period of bone healing.

Vascularized bone grafts for upper limb reconstruction: defects at the distal radius, wrist, and hand

Vascularized bone grafts have been successfully applied for the reconstruction of bone defects at the forearm, distal radius, carpus, and hand. Vascularized bone grafts are most commonly used in revision cases in which other approaches have failed. Vascularized bone grafts can be obtained from a variety of donor sites, including the fibula, the iliac crest, the distal radius (corticocancellous segments and vascularized periosteum), the metacarpals and metatarsals, and the medial femoral condyle (corticoperiosteal flaps). Their vascularity is preserved as either pedicled autografts or free flaps to carry the optimum biological potential to enhance union. The grafts can also be transferred as composite tissue flaps to reconstruct compound tissue defects. Selection of the most appropriate donor flap site is multifactorial. Considerations include size matching between donor and defect, the structural characteristics of the graft, the mechanical demands of the defect, proximity to the donor area, the need for an anastomosis, the duration of the procedure, and the donor site morbidity. This article focuses on defects of the distal radius, the wrist, and the hand.

Management of scaphoid nonunions

Scaphoid nonunions can exist with or without avascular necrosis of the proximal pole, and waist fractures may have an associated humpback deformity. CT best shows the deformity and bone loss, whereas MRI will show avascular necrosis. Operative treatment should be directed at correcting the deformity with open reduction and internal fixation and bone grafting. Vascularized bone grafts should be used in cases of avascular necrosis.

Pedicled vascularized bone grafts for scaphoid and lunate reconstruction

Conventional bone grafts have some osteogenic potential, whereas vascularized bone grafts retain live, functional osteocytes and osteoblasts. High rates of scaphoid union have been achieved with conventional bone grafting in the absence of osteonecrosis or prior surgery. Vascularized bone grafting is valuable in the management of wrist disorders with compromised bone vascularity (eg, scaphoid nonunion with proximal pole necrosis, Preiser disease, Kienböck disease) or when previous grafting has failed. Improved understanding of the vascular anatomy of the wrist has allowed the use of an array of vascularized bone grafts that do not require microsurgical anastomosis. Successful outcome depends on careful patient selection and appropriate surgical technique.

Outcome after vascularized bone grafting of scaphoid nonunions with avascular necrosis

PURPOSE

Vascularized bone grafting has been proposed as a treatment for scaphoid nonunions with avascular necrosis of the proximal pole. The purpose of this investigation is to report the results of vascularized bone graft and internal fixation for established scaphoid nonunions with proximal pole avascular necrosis as measured by validated outcome instruments.

METHODS

From 1996 to 2004, 30 consecutive patients with established scaphoid nonunion, proximal pole avascular necrosis, and no prior surgery were treated with open reduction and internal fixation in addition to a vascularized bone graft based on 1,2 intercompartmental supraretinacular artery. A total of 19 patients had nonunions of the scaphoid waist and 11 had nonunions of the proximal pole of the scaphoid. Preoperative and postoperative evaluation included measurement of clinical (grip strength and range of motion), radiographic (scapholunate angle, scaphoid height-to-length ratio, and radioscaphoid arthritis), function (Disabilities of the Arm, Shoulder, and Hand questionnaire) and satisfaction parameters. We recorded union and return to activity and analyzed data both in the aggregate and stratified by nonunion location.

RESULTS

Union rate was 28 of 30 (93%) and time to union was 5.1 months (+/-2.4). Significant improvements were found for grip strength, Disabilities of the Arm, Shoulder, and Hand score, satisfaction score, and scaphoid height-to-length ratio (p < .01). No significant difference was found for composite wrist range of motion. Two patients experienced complications and required a second procedure to achieve union. A total of 28 of 30 (93%) of patients returned to work or sports activity at their preinjury level.

CONCLUSIONS

The results of this investigation support the use of a vascularized bone graft for the treatment of scaphoid nonunions with avascular necrosis of the proximal pole.

The use of a vascularised periosteal patch onlay graft in the management of nonunion of the proximal scaphoid

We describe the use of a vascularised periosteal patch onlay graft based on the 1,2 intercompartmental supraretinacular artery in the management of 11 patients (ten men, one woman) with chronic nonunion involving the proximal third of the scaphoid. The mean age of the patients was 31 years (21 to 45) with the dominant hand affected in eight. Six of the patients were smokers and three had undergone previous surgery to the scaphoid. All of the proximal fragments were avascular. The presence of union was assessed using longitudinal axis CT.

Only three patients progressed to union of the scaphoid and four required a salvage operation for a symptomatic nonunion. The remaining four patients with a persistent nonunion are asymptomatic with low pain scores, good grip strength and a functional range of wrist movement.

Although this technique has potential technical advantages over vascularised pedicled bone grafting, the rate of union has been disappointing and we do not recommend it as a method of treatment.

Treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapse. A comparison of two vascularized bone grafts

BACKGROUND

Surgically, it is difficult to achieve union of a scaphoid nonunion that is associated with osteonecrosis of the proximal pole, and those with carpal collapse are especially difficult to treat. A variety of vascularized bone grafts can be used. The purpose of this study was to compare the effectiveness of two types of vascularized bone graft--a distal radial pedicle graft and a free vascularized medial femoral condyle graft--in the treatment of scaphoid waist nonunions associated with proximal pole osteonecrosis and carpal collapse.

METHODS

A retrospective review was conducted at two institutions to identify all patients with a scaphoid waist nonunion associated with an avascular proximal pole and carpal collapse. Between January 1994 and June 2006, twenty-two such nonunions were identified in twenty-two patients. Ten were treated with a distal radial pedicle vascularized graft and twelve, with a free vascularized medial femoral condyle graft. Patient demographics were similar between the groups, and the duration of follow-up averaged twelve months. Union was determined with use of plain radiographs and computed tomography or trispiral tomograms. In addition, carpal angles, time to union, union rates, and complications were recorded.

RESULTS

Four of the ten nonunions treated with the distal radial pedicle graft healed, at a median of nineteen weeks, and all twelve nonunions treated with the free medial femoral condyle graft healed, at a median of thirteen weeks. The rate of union was significantly higher (p = 0.005) and the median time to healing was significantly shorter (p < 0.001) for the nonunions treated with the medial femoral condyle graft.

CONCLUSIONS

A vascularized interposition graft from the medial femoral condyle is the recommended vascularized bone graft for the surgical treatment of scaphoid waist nonunion with avascularity of the proximal pole and carpal collapse.

Vascularised bone grafting in the management of scaphoid non-union - a review of 34 cases

We reviewed the outcomes of 34 patients who had undergone vascularised bone grafting for a chronic scaphoid non-union. Mean age was 27 years (range 16-46 years). The dominant hand was involved in 17 cases. Eleven patients were smokers. In 18 cases the fracture involved the proximal and in 16 cases the middle third of the scaphoid. In 26 patients the proximal scaphoid fragment was deemed avascular. Sixteen patients had previously undergone scaphoid fixation and non-vascularised bone grafting. At a follow-up of 1 to 3 years (mean 1.6 years), 15 of the 34 scaphoid non-unions had united. Injury to the dominant hand and duration of the non-union significantly increased the risk of failure. Persistent non-union was more common in proximal third fractures and in the presence of an avascular proximal pole but these findings did not reach statistical significance.

A comparison of the use of distal radius vascularised bone graft and non-vascularised iliac crest bone graft in the treatment of non-union of scaphoid fractures

We compared two surgical techniques for the treatment of scaphoid non-union, namely, using distal radius vascularised bone graft and iliac crest non-vascularised bone graft. Eighty patients with symptomatic scaphoid non-union underwent surgical treatment, including 35 patients treated with distal radius vascularised bone graft and 45 treated by iliac crest non-vascularised bone graft. Patients were assessed objectively by examination of wrist range of motion, grip strength and radiographic findings in the postoperative period after a mean time of 2.8 (1.4) (range 1-5.2) years. Similar functional results were obtained with the two techniques. All cases of non-union in the non-vascularised group obtained consolidation in a mean time of 8.89 (2.26) months and in the vascularised group in a mean time of 7.97 (3.06) months. Three cases of consolidation failure occurred in the vascularised group and were related to technical difficulties.

Vascularized bone grafts and their applications in the treatment of carpal pathology

Vascularized bone grafts (VBGs) are techniques in the management of certain types of carpal pathology. VBGs have traditionally been advocated for conditions including delayed and nonunion of fractures and avascular necrosis. The most common indications for VBG have been for scaphoid nonunion, lunatomalacia (Kienböck's disease), and osteonecrosis of the scaphoid (Preiser's disease). Advantages over NVBG have been established. VBGs provide improved blood flow, osteocyte preservation, and accelerated healing rates. Local pedicled VBGs are the most commonly used methods. They are technically less demanding than are free VBGs and are associated with less morbidity. Commonly used donor grafts arise from the dorsal vasculature of the wrist and include the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA), the 2,3 ICSRA, the fourth extensor compartment artery (fourth ECA), and the fifth ECA. A 4 + 5 ECA combination graft has been described to provide a longer pedicle. In managing osteonecrosis, most surgeons would agree that VBG should be reserved for carpal bones with an intact cartilaginous shell and no collapse. In treating scaphoid pathology, indications for VBG include fractures/nonunions with proximal pole avascular necrosis and/or small proximal pole fragments.

The detailed anatomy of the 1,2 intercompartmental supraretinacular artery for vascularized bone grafting of scaphoid nonunions

PURPOSE

To describe the configuration of the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA), including the location of the perforators, and to discuss the clinical use of the 1,2 ICSRA for vascularized bone grafting of scaphoid nonunions.

METHODS

Thirteen fresh-frozen cadaveric forearms were used to evaluate the variations in the anatomy of the 1,2 ICSRA. After injection of red latex, the 1,2 ICSRA and its perforators were characterized and measured. Pedicle length and distal reach of the transposed 1,2 ICSRA pedicle was evaluated. We noted the relationship of the 1,2 ICSRA to the dorsal scaphoid branch of the radial artery. Another 10 specimens were injected, frozen, and sectioned to evaluate vascular penetration into the dorsal distal radius.

RESULTS

The 1,2 ICSRA branched from the radial artery 1.9 mm proximal to the tip of the radial styloid (range -6.3-3.2 mm), on average. The average pedicle length was 22.5 mm (range 15-31 mm), which permits its application for both dorsal and volar scaphoid. The relationship between the origin of the 1,2 ICSRA and the dorsal scaphoid branch was categorized into 3 types, including--separate, combined, and shared. The average number of perforating vessels arising from the pedicle was 5.5 (range 3-7), with an average of 2.75 (range 1-7) perforators overlying a 1 by 0.5 cm block of the distal radius bone graft. A graft located between 8-18 mm proximal to the articular surface of distal radius would incorporate the greatest numbers of perforators. The most notable vascular penetration of the distal radius was demonstrated at 10.0 mm proximal to the radial styloid.

CONCLUSIONS

The detailed anatomy of the 1,2 ICSRA presented in this study may guide in planning and dissection to maximize the vascularity of a pedicled bone graft based on this vessel for the management of scaphoid nonunions.

Collapsed scaphoid non-union with dorsal intercalated segment instability and avascular necrosis treated by vascularised wedge-shaped bone graft and fixation

Patients with the specific problem of a collapsed Nakamura volar type, scaphoid synovial pseudarthrosis with avascular necrosis on both magnetic resonance imaging and intraoperative inspection were studied to determine the ability of a trapezoidal wedge-shaped structural bone graft vascularised by the 1,2 intercompartmental supraretinacular artery to simultaneously achieve correction of the scaphoid dimension and a high union rate. Fifteen patients with this specific problem were followed for a mean of 32.1 months and achieved union in all cases at a mean of 11.5 weeks. Improvements were seen postoperatively in wrist flexion and extension, grip strength, degree of dorsal intercalated segment instability and degree of scaphoid collapse. Two complications relating to the fixation technique occurred. Although technically difficult, it is possible to achieve a high rate of union for scaphoid pseudarthrosis while correcting substantial collapse deformity by the use of a structural, wedge-shaped, vascularised bone graft.

Management of scaphoid nonunions

Scaphoid nonunions can exist with or without avascular necrosis of the proximal pole, and waist fractures may have an associated humpback deformity. CT best shows the deformity and bone loss, whereas MRI will show avascular necrosis. Operative treatment should be directed at correcting the deformity with open reduction and internal fixation and bone grafting. Vascularized bone grafts should be used in cases of avascular necrosis.

Scaphoid Nonunions: Management with Vascularized Bone Grafts from the Distal Radius: A Clinical and Functional Outcome Study

BACKGROUND

Scaphoid nonunions remain controversial with regard to optimal management, especially for those located at the proximal third. In this study, the authors aim to assess the union rate, avascular proximal pole revascularization, and functional outcome of scaphoid nonunions managed with distal radius vascularized bone grafts.

METHODS

Thirty patients were treated with vascularized bone grafts between 1999 and 2003 and prospectively followed up. The average nonunion chronicity was 3.3 years. Nine patients (30 percent) had avascular necrosis of the proximal pole, five had unsuccessful previous surgical procedures, and four had radioscaphoid arthritis (Lichtman type III). Twenty proximal third nonunions were managed with dorsal radius bone graft, whereas 10 waist nonunions had palmar grafts. Union was assessed clinically and radiologically and, in 67 percent of the patients, by means of magnetic resonance imaging.

RESULTS

All cases were united by 12 weeks, and magnetic resonance imaging confirmed that all necrotic proximal poles were revascularized. On at least 24 months' follow-up, 90 percent of patients achieved complete pain relief. Wrist flexion-extension and radial-ulnar deviation arcs did not change. The postoperative grip strength was 82 percent of the contralateral side. The Mayo Modified Wrist Score increased significantly from 58 to 85 points and, overall, 77 percent of patients had an excellent or good outcome. No risk factors for compromised wrist function were identified. The scapholunate angle, the scaphoid length, and the Nattrass index improved significantly.

CONCLUSIONS

This series demonstrates the efficacy of distal radius vascularized bone grafts in union enhancement, proximal pole revascularization, pain relief, improved wrist function, and carpal alignment. Vascularized bone grafts are a reliable therapeutic alternative for scaphoid nonunions.

Vascularised bone graft for the treatment of non-union of the scaphoid

A 4/5 compartment pedicled vascularised bone graft from the distal radius combined with internal fixation with a Herbert type cannulated screw was used to treat non-union fractures of the proximal pole of the scaphoid in 13 patients. Non-union was identified on plain radiographs alone. Uneventful clinical and radiological healing was achieved in 11 patients. One patient had progressive signs of failure of the fixation of the screw at the proximal pole; the screw was changed and the fracture was stable at reoperation. One patient had a fall postoperatively, radiographs taken at follow-ups showed only partial healing, and he had a bone graft 12 months later. Twelve patients had clinical and radiological union of the fracture, and one patient fibrous healing alone. The technique may improve healing of non-union of fractures of the proximal pole of the scaphoid, but it is still a technical challenge.

Vascularized bone grafting for the treatment of carpal pathology

Vascularized bone graft procedures have been applied to several maladies of the carpus including proximal pole fractures of the scaphoid, Preiser's disease, and Kienböck's disease. Vascularized bone grafts are capable of primary bony healing without creeping substitution and can thus accelerate fracture healing, replace deficient bone, and revascularize ischemic bone. Long-term data are now available to evaluate the benefits and deficiencies of vascularized grafts in the treatment of many carpal maladies. This article reviews the pertinent literature and provides some treatment algorithms for the use of vascularized bone grafting in cases of carpal pathology.

A capsular-based vascularized distal radius graft for proximal pole scaphoid pseudarthrosis

PURPOSE

To evaluate the clinical results of the application of a capsular-based dorsal distal radius vascularized bone graft in scaphoid proximal pole nonunions.

METHODS

Thirteen patients with symptomatic nonunion at the proximal pole of the scaphoid (10 with avascular necrosis) were treated and reviewed retrospectively. The vascularized bone graft was harvested from the distal aspect of the dorsal radius and was attached to a wide distally based strip of the dorsal wrist capsule. It was inserted press-fit into a dorsal trough across the nonunion site after scaphoid fixation with a Herbert screw.

RESULTS

After a mean follow-up period of 19 months 10 of the 13 nonunions (8 of the 10 with avascular necrosis) achieved solid bone union. No complications other than the 3 persistent nonunions occurred.

CONCLUSIONS

Results of the use of a capsular-based vascularized bone graft from the distal radius for proximal pole scaphoid nonunions compare favorably with the results of pedicled or free vascularized grafts. It is a simple technique that eliminates the need for dissection of small-caliber pedicle or microsurgical anastomoses. No donor site morbidity was observed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level IV.