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Schäfer RC, Nusche A, Einzmann A, Illg C, Daigeler A, Rachunek K. The corticocancellous press fit iliac crest bone dowel for recalcitrant scaphoid nonunion: analysis of union rate and clinical outcome. Arch Orthop Trauma Surg 2023; 143:6001-6010. [PMID: 37012506 PMCID: PMC10449721 DOI: 10.1007/s00402-023-04846-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/12/2023] [Indexed: 04/05/2023]
Abstract
INTRODUCTION Scaphoid nonunion after failed primary treatment remains challenging particularly when entailed by bone loss, avascular necrosis or deformity. We describe a scaphoid augmentation and fixation technique for cases of recalcitrant nonunion after screw placement by autologous press fit corticocancellous dowel. This study aims to provide reliable data on clinical and radiological outcomes and to contextualize in the face of other treatment options. MATERIAL AND METHODS The study included 16 patients with recalcitrant nonunion of the scaphoid. All patients received screw removal and scaphoid reconstruction by a dowel shaped non-vascularized corticocancellous bone graft from the iliac crest facilitating packing of the screw channel. Bone union, the scapholunate, radiolunate and intrascaphoidal angles were evaluated on X-ray and CT images, range of motion noted. Additionally grip strength, DASH and Green O'Brien scores were obtained from eight patients. RESULTS A union rate of 73% was noted after mean follow-up of 54 months. After revisional reconstruction of the scaphoid an extension-flexion rate of 84% of the healthy side was noted while pronation-supination reached 101%. DASH score averaged at 2.9, rest pain on a numeric rating scale was 0.43 with 99% peak grip force of the healthy side. CONCLUSION In complex cases of revisional scaphoid nonunion after screw placement, the corticocancellous iliac crest pressfit dowel is an option for augmentation and stabilization of the scaphoid by preserving the articular surface. LEVEL OF EVIDENCE IV, retrospective case series.
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Affiliation(s)
- Ruth Christine Schäfer
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tübingen, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany.
| | - Andreas Nusche
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tübingen, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany
| | - Anna Einzmann
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tübingen, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany
| | - Claudius Illg
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tübingen, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany
| | - Adrien Daigeler
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tübingen, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany
| | - Katarzyna Rachunek
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tübingen, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany
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Bone Morphogenic Protein 2 Use for the Surgical Treatment of Acute Scaphoid Fractures and Scaphoid Non-unions. Plast Reconstr Surg 2022; 150:608e-612e. [PMID: 35791268 DOI: 10.1097/prs.0000000000009416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Bone morphogenic protein 2 (BMP-2) has demonstrated promise as an adjunct to surgically treating fractures. Its reported use in the upper extremity is limited. Questions/purpose: This study reports union rates, outcomes, and complications of scaphoid fractures treated with adjunctive BMP-2 to further characterize BMP-2 use in the hand and wrist. METHODS Retrospective review of scaphoid fractures treated surgically in one region of the military health system from 2009 to 2019 was conducted to identify cases employing BMP-2. Fracture healing was determined by computed tomography. Primary outcomes were union rate, time to union, and complications. Secondary outcomes included union rates for prior non-unions, union rates at 4 & 6 weeks, and functional outcomes. RESULTS Fourteen patients met inclusion criteria. Non-unions accounted for 50% of included fractures. The total union rate was 93%. Mean time to union was 6.2 weeks. All acute fractures healed with mean time to union of 4.8 weeks. Non-unions had a union rate of 86% with mean time to union of 7.7 weeks. Four patients (29%) developed radiographic heterotopic ossification (HO); however, there was no significant decrease in motion was appreciated. Thirteen patients (93%) resumed the push-ups portion of the military fitness test. No major complications were identified during follow up. CONCLUSIONS Adjunctive use of BMP-2 in operative fixation of scaphoid fractures resulted in desirable union rates without major complications. Larger, prospective studies are needed to assess if adjunctive BMP-2 use in scaphoid fractures provides significant benefit versus other treatments.
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Papatheodorou LK, Papadopoulos DV, Graber MM, Sotereanos DG. Dorsal capsular-based vascularized distal radius graft for proximal pole scaphoid nonunion with avascular necrosis. Injury 2021; 52:3635-3639. [PMID: 33902867 DOI: 10.1016/j.injury.2021.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/18/2021] [Accepted: 04/04/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Scaphoid nonunion involving the proximal pole with the presence of avascular necrosis is difficult to reconstruct. We aimed to determine the efficacy of surgical treatment of proximal pole scaphoid nonunion with avascular necrosis using a dorsal capsular-based vascularized distal radius graft. METHODS Between 2000 and 2018, 64 patients with established proximal pole scaphoid nonunion with avascular necrosis were treated using a dorsal capsular-based vascularized distal radius graft. This graft was harvested from the dorsal aspect of the distal radius with its dorsal wrist capsule attachment. Fixation of the scaphoid nonunion was performed with a small cannulated screw, followed by insertion of the vascularized graft into the dorsal trough at the scaphoid nonunion site. In the last 47 patients of this series, a micro suture anchor was placed into the scaphoid to augment graft fixation. RESULTS Union rate was 86% (55 of 64 scaphoid nonunions with avascular necrosis) at a mean time of 12 weeks. Persistent non-union was noted in eight patients and fibrous union in one patient. No patients developed donor site morbidity. No graft dislodgment was noted. There was significant improvement of the wrist functional outcomes at the final follow up. CONCLUSIONS The dorsal capsular-based vascularized distal radius graft is a safe and effective treatment in patients with scaphoid nonunion with avascular necrosis of the proximal pole. This pedicle vascularized bone graft is derived from a location that can easily reach the proximal third of the scaphoid avoiding microsurgical dissection or anastomosis.
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Affiliation(s)
- Loukia K Papatheodorou
- University of Pittsburgh School of Medicine, Department of Orthopaedic Surgery, Orthopaedic Specialists - UPMC, 9104 Babcock Blvd, 5th floor, Pittsburgh, PA 15237, USA.
| | - Dimitrios V Papadopoulos
- University of Pittsburgh School of Medicine, Orthopaedic Specialists - UPMC, 9104 Babcock Blvd, 5th floor, Pittsburgh, PA 15237, USA.
| | - Micaela M Graber
- Orthopaedic Specialists - UPMC, 9104 Babcock Blvd, 5th floor, Pittsburgh, PA 15237, USA.
| | - Dean G Sotereanos
- University of Pittsburgh School of Medicine, Department of Orthopaedic Surgery, Orthopaedic Specialists - UPMC, 9104 Babcock Blvd, 5th floor, Pittsburgh, PA 15237, USA.
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Rancy SK, Wolfe SW, Jerome JTJ. Predictors of Failure for Vascularized and Nonvascularized Bone Grafting of Scaphoid Nonunions: A Systematic Review. J Hand Microsurg 2021; 14:322-335. [DOI: 10.1055/s-0041-1735349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Abstract
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.
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Affiliation(s)
- Schneider K. Rancy
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, United States
| | - Scott W. Wolfe
- Division of Hand and Upper Extremity, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, United States
| | - J. Terrence Jose Jerome
- Department of Orthopedics, Hand & Reconstructive Microsurgery, Olympia Hospital & Research Centre, Trichy, Tamil Nadu, India
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Foissac R, Piereschi S, Camuzard O. Vascularized pisiform graft for the treatment of scaphoid nonunion: An anatomical study. HAND SURGERY & REHABILITATION 2021; 40:433-438. [PMID: 33798753 DOI: 10.1016/j.hansur.2021.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 01/21/2021] [Accepted: 02/01/2021] [Indexed: 10/21/2022]
Abstract
Scaphoid fracture can evolve into scaphoid nonunion leading to wrist arthritis. Vascularized bone flaps used to treat scaphoid nonunion are supplied by delicate, small, or short arteries that are not always reliable. The pisiform bone has never been considered as a possible treatment of scaphoid nonunion since the traditionally harvested pedicle is too short. This study aimed to characterize the vascularization of the pisiform with the goal of developing a method of harvesting it with a longer pedicle that can be used as a graft to treat scaphoid nonunion. A cadaver study on 30 upper limbs was done in two parts: firstly, we dissected 20 cadaver specimens and documented the pisiform's vascularization (size, length, and articular surface) as well as anatomical characteristics of the dorsal ulnar artery; secondly, we used 10 cadaver specimens to study an experimental surgical procedure in which a vascularized pisiform graft is used to treat an artificially created nonunion and confirm its feasibility. The pisiform artery originated from the dorsal ulnar artery in all 20 dissections. Its average length of 4.036cm could be increased by 11% by ligating the upstream collateral branches from the dorsal ulnar artery. The pedicled vascularized pisiform flap was grafted to the scaphoid in 10 experimental procedures performed on fresh cadavers. The vascularized pisiform graft consists of a reliable vascular pedicle and well vascularized multi-cortical bone with a cartilaginous surface. However, more studies are needed to confirm the feasibility of this flap as an alternative for treating unstable scaphoid nonunion.
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Affiliation(s)
- R Foissac
- Plastic and Reconstructive Surgery Unit, Polyclinique Saint George, Nice, France.
| | - S Piereschi
- Plastic and Reconstructive Surgery Unit, Hospital Pasteur 2, Nice, France
| | - O Camuzard
- Plastic and Reconstructive Surgery Unit, Hospital Pasteur 2, Nice, France
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Spies CK, Ayache A, Löw S, Langer MF, Hohendorff B, Müller LP, Oppermann J, Unglaub F. [Revision surgery after failed (partial-) arthrodesis of the wrist]. DER ORTHOPADE 2020; 49:784-796. [PMID: 32809041 DOI: 10.1007/s00132-020-03967-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
(Partial) arthrodeses of the wrist have been proven cornerstones to treat many lesions for decades, especially in the case of revision surgery. Four-corner, scapho-trapezo-trapezoidal (STT), radio-scapho-lunate (RSL) and total wrist fusions are very common techniques in hand surgery. However, even these proven surgical procedures have significant non-fusion rates. Prior to revising a failed arthrodesis, it is essential to analyse the latter failure precisely. A technically adequate revision is only feasible when based on a correct and meticulous analysis. The understanding of the biological processes and technical aspects of the implants are the basis for solving this issue.
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Affiliation(s)
- C K Spies
- Handchirurgie, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Deutschland.
| | - A Ayache
- Handchirurgie, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Deutschland
| | - S Löw
- Praxis für Handchirurgie und Unfallchirurgie, Bad Mergentheim, Deutschland
| | - M F Langer
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - B Hohendorff
- Abteilung für Hand‑, Ästhetische und Plastische Chirurgie, Elbe Klinikum Stade, Stade, Deutschland
| | - L P Müller
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln, Köln, Deutschland
| | - J Oppermann
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln, Köln, Deutschland
| | - F Unglaub
- Handchirurgie, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Deutschland.,Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
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Shoji KE, Simeone FJ, Ozkan S, Mudgal CS. Outcomes of Local Bone Graft and Fixation of Proximal Pole Scaphoid Nascent Nonunions and Nonunions. J Wrist Surg 2020; 9:203-208. [PMID: 32509423 PMCID: PMC7263866 DOI: 10.1055/s-0040-1701512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 12/20/2019] [Indexed: 10/25/2022]
Abstract
Background Fractures of the proximal pole of the scaphoid have an increased risk of nonunion due to its tenuous blood supply. The optimal treatment of proximal pole scaphoid nonunions remains controversial. Objectives To review a single surgeon's experience with proximal pole scaphoid nascent nonunions (delayed unions) and nonunions that underwent surgical fixation with a cannulated headless compression screw and local autologous bone graft from the distal radius. Patients and Methods After obtaining Institutional Review Board approval, the electronic medical record of one tertiary care center was queried for patients with the diagnosis of "proximal pole scaphoid fractures" who underwent surgical fixation by a single surgeon over an 11-year period (2006-2017). Fifteen patients met initial query criteria; upon review of records, four patients were excluded due to the acute nature of the fracture, and one was excluded as surgical fixation included a vascularized bone graft. Results The final study cohort consisted of 10 patients with a total of 10 proximal pole scaphoid nonunions. Almost all of the patients in this study were male (9/10 [90%]), and sporting activities were the most common mechanism of injury (8/10 [80%]). Volumetric measurements of the scaphoid fractures on computed tomography (CT) revealed that the mean total volume of the scaphoid was 2.4 ± 0.48 cm 3 and the mean volume of the proximal pole fragment was 0.38 ± 0.15 cm 3 . Postoperative CT scans were performed at a mean of 12.4 weeks (range: 8-16 weeks), with seven (7/10 [70%]) showing signs of complete union and three (3/10 [30%]) demonstrating partial union. None of the patients required additional procedures and there were no complications. Conclusions Our results suggest that proximal pole scaphoid fractures with delayed union and nonunion treated with surgical fixation and autologous local bone graft heal without the need for more complex vascularized procedures. The volume of the proximal pole fragment did not correlate with increased risk of ongoing nonunion after the index procedure. Level of Evidence This is a Level IV, case series study.
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Affiliation(s)
- Kristin E. Shoji
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, Massachusetts
| | - F. Joseph Simeone
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sezai Ozkan
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chaitanya S. Mudgal
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Combined Pedicled Vascularized and Wedge Nonvascularized Bone Graft for Treating Scaphoid Waist Nonunion With Humpback Deformity. Tech Hand Up Extrem Surg 2020; 23:155-159. [PMID: 31738737 DOI: 10.1097/bth.0000000000000244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pedicled vascularized bone graft (VBG) is a useful method in treating the scaphoid fracture nonunion, especially when the avascular necrosis exists. Humpback deformity is an important issue that we have to correct it during the treatment. We describe a method by using combined wedge non-VBG to correct the nonunion deformity when treating scaphoid nonunion with pedicled VBG. The wedge bone graft was harvested just proximal to the 2,3 intercompartmental supraretinacular artery VBG and was used as an inlay at the volar site to correct the humpback deformity, whereas the VBG was set at the dorsal site for bone bridging and blood supply. We also present our results of 10 patients with scaphoid fracture nonunion and humpback deformity treated with this method. Bone healing was achieved and the lateral intrascaphoid angles could be improved in all the 10 patients. Functional outcomes, including the Visual Analog Pain Scale for pain during activity, grip strength, the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), and the modified Mayo Wrist Scores, were significantly improved.
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Keller M, Kastenberger T, Anoar AF, Kaiser P, Schmidle G, Gabl M, Arora R. Clinical and radiological results of the vascularized medial femoral condyle graft for scaphoid non-union. Arch Orthop Trauma Surg 2020; 140:835-842. [PMID: 32124031 PMCID: PMC7244456 DOI: 10.1007/s00402-020-03386-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION This study evaluated the use of a free vascularized bone graft with and without cartilage from the medial femoral condyle (MFC) in patients with recalcitrant scaphoid non-union, with a special focus on union rates and the osteochondral graft for proximal pole destruction. MATERIALS AND METHODS Thirty-eight avascular scaphoid non-unions in 37 patients who were treated with a free osteoperiosteal or osteochondral MFC graft were retrospectively evaluated (mean follow-up 16 months). Bone union, the scapholunate and the radiolunate angles were evaluated on X-ray images. The range of motion, grip strength, VAS, DASH and PRWE scores were evaluated clinically. RESULTS The overall union rate was 95%. Bone union was achieved in 27 out of 29 (93%) scaphoids treated with a free osteoperiosteal MFC grafts and in 9 out of 9 (100%) scaphoids treated with a free osteochondral MFC graft. The range of motion remained almost unchanged, while grip strength increased significantly (34 kg vs. 44 kg) and the VAS (22-5), DASH (59-19) and PRWE (62-30) score decreased significantly. The scapholunate (71°-65°) and radiolunate (28°-18°) angle decreased. No major donor site morbidity was observed. Postoperative complications were observed in eight cases (21%). CONCLUSIONS The vascularized medial femoral bone graft leads to a good functional outcome in the treatment of scaphoid non-unions. The graft provides adequate blood supply and structural stability to the scaphoid. A proximal pole destruction can be replaced using an osteochondral graft with promising short-term results preventing carpal osteoarthritis and collapse.
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Affiliation(s)
- Marco Keller
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria ,grid.440128.b0000 0004 0457 2129Department of Orthopaedics and Traumatology, Kantonsspital Baselland, Rheinstrasse 26, 4410 Liestal, Switzerland
| | - Tobias Kastenberger
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Anizar Faizi Anoar
- grid.412516.50000 0004 0621 7139Department of Orthopaedics and Traumatology, Kuala Lumpur Hospital, Jalan Pahang, 50586 Kuala Lumpur, Malaysia
| | - Peter Kaiser
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Gernot Schmidle
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Markus Gabl
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Rohit Arora
- grid.5361.10000 0000 8853 2677Department of Trauma Surgery, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
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Abstract
Many hand surgeons argue that vascularized bone grafting is indicated in proximal pole avascular necrosis, prior failed surgery, or long-standing scaphoid nonunion. However, the available evidence does not support improved treatment outcomes for vascularized bone grafting rather than traditional nonvascularized techniques. This article addresses the available evidence and examines the role of vascularized bone grafting in scaphoid nonunion treatment. It also identifies important factors that influence healing, clarifies the decision-making algorithm, and proposes areas for further research.
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Affiliation(s)
- Schneider K Rancy
- College of Medicine, SUNY Downstate Medical Center, 1160 Ocean Avenue, Apt 5F, Brooklyn, NY 11230, USA
| | - Gernot Schmidle
- Department of Trauma Surgery, Medical University Innsbruck, Anichstraße 35, Innsbruck 6020, Austria
| | - Scott W Wolfe
- Hand and Upper Extremity Service, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY 10021, USA.
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11
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Kollitz KM, Pulos N, Bishop AT, Shin AY. Primary medial femoral condyle vascularized bone graft for scaphoid nonunions with carpal collapse and proximal pole avascular necrosis. J Hand Surg Eur Vol 2019; 44:600-606. [PMID: 30049241 DOI: 10.1177/1753193418789329] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This study aimed to determine the outcome of free vascularized medial femoral condyle bone grafts in the primary treatment of scaphoid nonunions with scaphoid foreshortening or carpal collapse and intraoperatively documented avascular necrosis. Thirty-two patients (28 male, four female) met the inclusion criteria. Median time from injury to surgery was 70 weeks. Thirty of 32 patients healed at a median of 12 weeks. There was significant improvement from preoperative to postoperative lateral intrascaphoid angle, scapholunate angle, and radiolunate angle. Two scaphoids failed to unite; one patient underwent scaphoidectomy and four-corner fusion 15 months postoperatively after suffering a subsequent injury. Another patient underwent 1,2-intercompartmental supraretinacular artery-based vascularized bone grafting at 4 months postoperatively and then scaphoid excision with four-corner fusion 4 years later. The free vascularized medial femoral condyle bone graft restores scaphoid vascularity and architecture while promoting union in a subset of scaphoid nonunions that has historically been a clinical challenge. Level of evidence: IV.
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Affiliation(s)
| | - Nicholas Pulos
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Allen T Bishop
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alexander Y Shin
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN, USA
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Tanner C, Johnson T, Majors A, Hentz VR, Husak L, Walker Gallego E, Christ B, Hoekzema N. The Vascularity and Osteogenesis of a Vascularized Flap for the Treatment of Scaphoid Nonunion: The Pedicle Volar Distal Radial Periosteal Flap. Hand (N Y) 2019; 14:500-507. [PMID: 29357702 PMCID: PMC6760070 DOI: 10.1177/1558944717751191] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Vascularized periosteal flaps from the distal radius have been previously proposed. The purpose of this study was to investigate the vascularity and osteogenic potential of a vascularized volar distal radial periosteal flap for the treatment of scaphoid nonunion. Methods: In 5 fresh frozen cadavers, a rectangular periosteal flap was elevated from the distal radius with the pedicle just proximal to the watershed line. Latex dye was injected into the radial artery proximally and the vascularity of the flap characterized by microscopic evaluation. Patients with scaphoid nonunion were then treated with open reduction, internal fixation, and distal radius cancellous bone graft. Two groups of patients with midwaist nonunion scaphoid were then evaluated. The first group received the vascularized periosteal flap and the second group received a nonvascularized periosteal flap. A third group of proximal pole nonunions also received the vascularized flap. Results: Cadaveric dissections revealed that all of the injected flaps demonstrated vascularity to the distal edge of the flap. Vascularized flaps formed visible bone on imaging in 55% of cases. None of the nonvascularized flaps formed visible bone. In group 1, 12/12 midwaist nonunions united. In group 2, union was achieved in 6/6 of patients who completed the follow-up. In group 3, 6/7 proximal pole fractures united. Conclusions: Previously proposed vascularized periosteal flaps from the distal radius appear to possess notable osteogenic potential that may be of interest to surgeons treating scaphoid nonunion.
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Affiliation(s)
- Cary Tanner
- Sierra Pacific Orthopedics Center,
Fresno, CA, USA,University of California, San Francisco,
Fresno, CA, USA,Cary Tanner, Sierra Pacific Orthopedics
Center, 1630 E Herdon Avenue, Fresno, CA 93720, USA.
| | - Toby Johnson
- Sierra Pacific Orthopedics Center,
Fresno, CA, USA,University of California, San Francisco,
Fresno, CA, USA
| | - Alex Majors
- Sierra Pacific Orthopedics Center,
Fresno, CA, USA,University of California, San Francisco,
Fresno, CA, USA
| | | | - Lisa Husak
- University of California, San Francisco,
Fresno, CA, USA
| | | | - Brad Christ
- University of California, San Francisco,
Fresno, CA, USA
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Overstuffing of Unstable Scaphoid Nonunions: A Radiographic Analysis of Carpal Parameters. J Hand Surg Am 2019; 44:423.e1-423.e6. [PMID: 30301646 DOI: 10.1016/j.jhsa.2018.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 06/04/2018] [Accepted: 07/25/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to radiographically evaluate scaphoid length and carpal parameters before and after reconstruction of nonunions with interposition vascularized medial femoral condyle (MFC) bone graft to determine if the scaphoid was overstuffed or if normal anatomy was restored and to determine the effect on ulnar carpal translocation when the volar radiocarpal ligaments were left unrepaired. METHODS Thirty-nine patients with established scaphoid nonunions with carpal collapse were reconstructed by interposition vascularized MFC bone grafts without repair of the volar radiocarpal ligaments. Pre- and postoperative radiographs and computed tomography scans of the 39 patients were reviewed. The scaphoid length, capitate-ulnar distance ratio (CUDR), modified carpal height ratio (MCHR), radiolunate (RL) and scapholunate (SL) angles were measured before and 3 months after surgery. Thirteen of these patients had contralateral wrist radiographs that were used for analysis of scaphoid length restoration. RESULTS No significant changes were observed for CUDR and MCHR before and after surgery. The length of the scaphoid significantly improved after reconstruction from 21.9 ± 3.3 to 23.7 ± 3.4 mm on posteroanterior x-ray views and from 24.0 ± 2.2 to 27.7 ± 2.8 mm on lateral views. The RL and SL angles also changed significantly after surgery from 19.5° ± 13.5° to 4.1° ± 16.9° and from 67.5° ± 12.5° to 56.0° ± 12.5°, respectively. Regarding the 13 patients with contralateral x-rays, no differences were seen on CUDR, MCHR, or scaphoid length on posteroanterior x-ray views. However, the scaphoid length on lateral x-ray views increased from 23.1 ± 2.40 to 27.6 ± 2.78 mm and was significantly longer than the contralateral side by 9.6%. The RL and SL angles were restored and comparable with the contralateral side. CONCLUSIONS The use of vascularized MFC bone graft increased scaphoid length by 9.6% and restored normal carpal alignment. Despite the increased scaphoid length compared with the contralateral side, the lack of repair of the volar radiocarpal ligaments did not cause ulnar carpal translocation in short-term follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Tsantes AG, Papadopoulos DV, Gelalis ID, Vekris MD, Pakos EE, Korompilias AV. The Efficacy of Vascularized Bone Grafts in the Treatment of Scaphoid Nonunions and Kienbock Disease: A Systematic Review in 917 Patients. J Hand Microsurg 2018; 11:6-13. [PMID: 30911206 DOI: 10.1055/s-0038-1677318] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 10/26/2018] [Indexed: 10/27/2022] Open
Abstract
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.
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Affiliation(s)
- Andreas G Tsantes
- Department of Orthopedics, University Hospital of Ioannina, Stavros Niarchos Ioannina, Greece
| | | | - Ioannis D Gelalis
- Department of Orthopedics, University Hospital of Ioannina, Stavros Niarchos Ioannina, Greece
| | - Marios D Vekris
- Department of Orthopedics, University Hospital of Ioannina, Stavros Niarchos Ioannina, Greece
| | - Emilios E Pakos
- Department of Orthopedics, University Hospital of Ioannina, Stavros Niarchos Ioannina, Greece
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Papatheodorou LK, Sotereanos DG. Treatment for proximal pole scaphoid nonunion with capsular-based vascularized distal radius graft. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 29:337-342. [PMID: 30474741 DOI: 10.1007/s00590-018-2329-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 10/16/2018] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Loukia K Papatheodorou
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Orthopaedic Specialists - UPMC, 9104 Babcock Blvd, 5th Floor, Pittsburgh, PA, 15237, USA
| | - Dean G Sotereanos
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Orthopaedic Specialists - UPMC, 9104 Babcock Blvd, 5th Floor, Pittsburgh, PA, 15237, USA.
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16
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Abstract
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.
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Affiliation(s)
- Ji Hyun Yeo
- Department of Orthopaedic Surgery, Dongguk University College of Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jin Young Kim
- Department of Orthopaedic Surgery, Dongguk University College of Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
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Pulos N, Kollitz KM, Bishop AT, Shin AY. Free Vascularized Medial Femoral Condyle Bone Graft After Failed Scaphoid Nonunion Surgery. J Bone Joint Surg Am 2018; 100:1379-1386. [PMID: 30106819 DOI: 10.2106/jbjs.17.00955] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Outcomes following revision surgery for scaphoid nonunions with osteonecrosis are guarded. We hypothesized that use of free vascularized medial femoral condyle (MFC) bone grafts can lead to healing of the nonunion, increase vascularity of the proximal pole, and restore scaphoid architecture, resulting in acceptable functional outcomes. METHODS We performed a retrospective review of 49 patients who were treated with an MFC bone graft, between May 2005 and September 2016, after prior failure of operative treatment for scaphoid nonunion. The mean time from the injury to the revision surgery with the MFC bone graft was 24 months, and the mean time from the prior, failed surgery was 15 months. Thirty-six of the 49 patients had had a prior bone graft procedure and 6 patients had had 2 previous surgical procedures for the nonunion. The initial internal fixation of the scaphoid fracture was with a scaphoid screw in 43 patients. All patients had documented osteonecrosis of the proximal pole at the time of our surgery. Carpal indices, time to union, pain scores, functional outcomes, and complications were recorded. RESULTS Forty-one (84%) of the 49 previously operated on scaphoid nonunions healed at a mean of 16 weeks (range, 9 to 31 weeks) after the MFC bone-grafting as confirmed on computed tomography (CT). Radiographs demonstrated significant improvement in carpal alignment following the surgery with the MFC bone graft. Comparison between preoperative and postoperative values showed a trend toward improved grip strength and no important change in total wrist range of motion. Subsequent procedures were performed in 29 patients, 21 of whom had planned Kirschner wire removal. All 24 patients in whom scaphoid union had been achieved and who were available for follow-up were able to work or attend school full-time, and 88% were satisfied or very satisfied with their wrist function. Age, smoking status, body mass index, time to surgery, and preoperative radiographic findings were not found to be significant predictors of failure. CONCLUSIONS MFC grafts increase vascularity and restore scaphoid architecture, promoting union in most patients with the combination of proximal pole osteonecrosis, carpal collapse, and failed prior scaphoid nonunion surgery. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nicholas Pulos
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Allen T Bishop
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Proximal Pole Scaphoid Nonunion Reconstruction With 1,2 Intercompartmental Supraretinacular Artery Vascularized Graft and Compression Screw Fixation. J Hand Surg Am 2018; 43:770.e1-770.e8. [PMID: 29426603 DOI: 10.1016/j.jhsa.2018.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/04/2017] [Accepted: 01/02/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To review the incidence of union of patients with proximal pole scaphoid fracture nonunions treated using a 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) vascularized graft and a small compression screw. METHODS This is a retrospective case series of 12 patients. Calculations of the size of the proximal pole fragment relative to the total scaphoid were performed using posteroanterior view scaphoid radiographs with the wrist in ulnar deviation and flat on the cassette. Analyses were repeated 3 times per subject, and the average ratio of proximal pole fragment relative to the entire scaphoid was calculated. We reviewed medical records, radiographs, and computed tomography (CT) scans of these 12 patients. The CT scans that were performed after an average of 12 weeks were ultimately used to confirm union of the scaphoid fractures. One patient was unable to have a CT so was excluded from the final calculation. RESULTS All 11 (100%) scaphoid fractures that were assessed by CT were found to be healed at the 12-week assessment point. The mean proximal pole fragment size was 18% (range, 7%-27%) of the entire scaphoid. CONCLUSIONS The 1,2 ICSRA vascularized graft and compression screw was an effective treatment for patients with proximal pole scaphoid fractures. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Rahimnia A, Rahimnia AH, Mobasher-Jannat A. Clinical and functional outcomes of vascularized bone graft in the treatment of scaphoid non-union. PLoS One 2018; 13:e0197768. [PMID: 29787613 PMCID: PMC5963744 DOI: 10.1371/journal.pone.0197768] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 05/08/2018] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Alireza Rahimnia
- Trauma Research center, Department of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | | | - Abdolkarim Mobasher-Jannat
- Chemical Injuries Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
- * E-mail:
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Schmidle G, Ebner HL, Klima G, Pfaller K, Fritz J, Hoermann R, Gabl M. Time-dependent changes in bone healing capacity of scaphoid fractures and non-unions. J Anat 2018; 232:908-918. [PMID: 29488208 PMCID: PMC5979627 DOI: 10.1111/joa.12795] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2018] [Indexed: 11/30/2022] Open
Abstract
The scaphoid is the most frequently fractured carpal bone and prone to non‐union due to mechanical and biological factors. Whereas the importance of stability is well documented, the evaluation of biological activity is mostly limited to the assessment of vascularity. The purpose of this study was to select histological and immunocytochemical parameters that could be used to assess healing potential after scaphoid fractures and to correlate these findings with time intervals after fracture for the three parts of the scaphoid (distal, gap and proximal). Samples were taken during operative intervention in 33 patients with delayed or non‐union of the scaphoid. Haematoxylin and Eosin (HE), Azan, Toluidine, von Kossa and Tartrate‐resistant acid phosphatase (TRAP) staining were used to characterise the samples histologically. We determined distribution of collagen 1 and 2 by immunocytochemistry, and scanning electron microscopy (SEM) was used to investigate the ultrastructure. To analyse the samples, parameters for biological healing status were defined and grouped according to healing capacity in parameters with high, partial and little biological activity. These findings allowed scoring of biological healing capacity, and the ensuing results were correlated with different time intervals after fracture. The results showed reduced healing capacity over time, but not all parts of the scaphoid were affected in the same way. For the distal fragment, regression analysis showed a statistically significant correlation between summarised healing activity scores and time from initial fracture (r = −0.427, P = 0.026) and decreasing healing activity for the gap region (r = −0.339, P = 0.090). In contrast, the analyses of the proximal parts for all patients did not show a correlation (r = 0.008, P = 0.969) or a decrease in healing capacity, with reduced healing capacity already at early stages. The histological and immunocytochemical characterisation of scaphoid non‐unions (SNUs) and the scoring of healing parameters make it possible to analyse the healing capacity of SNUs at certain time points. This information is important as it can assist the surgeon in the selection of the most appropriate SNU treatment.
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Affiliation(s)
- Gernot Schmidle
- Department of Trauma Surgery, Medical University Innsbruck, Innsbruck, Austria
| | | | - Günter Klima
- Division of Histology and Embryology, Medical University Innsbruck, Innsbruck, Austria
| | - Kristian Pfaller
- Division of Histology and Embryology, Medical University Innsbruck, Innsbruck, Austria
| | - Josef Fritz
- Department of Medical Statistics, Informatics and Health Economics, Medical University Innsbruck, Innsbruck, Austria
| | - Romed Hoermann
- Division of Clinical and Functional Anatomy, Medical University Innsbruck, Innsbruck, Austria
| | - Markus Gabl
- Department of Trauma Surgery, Medical University Innsbruck, Innsbruck, Austria
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21
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Schmidle G, Ebner HL, Klauser AS, Fritz J, Arora R, Gabl M. Correlation of CT imaging and histology to guide bone graft selection in scaphoid non-union surgery. Arch Orthop Trauma Surg 2018; 138:1395-1405. [PMID: 30006666 PMCID: PMC6132950 DOI: 10.1007/s00402-018-2983-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Indexed: 11/25/2022]
Abstract
INTRODUCTION For the treatment of scaphoid non-unions (SNU), different surgical techniques, including vascularized and non-vascularized bone grafts, are applied. Besides stability, vascularity, and the biological situation at the non-union site are important for healing and the appropriate choice of treatment. We assessed the healing potential of SNUs by histological parameters and compared it to CT parameters of bone structure and fracture location. Based on the results, we developed a CT classification and a treatment algorithm to impact graft selection in SNU surgery. PATIENTS AND METHODS Preoperative 2D-CT reformations of 29 patients were analyzed for trabecular structure, sclerosis, and fragmentation of the proximal fragment. The fracture location was assessed on 3D-CT reconstructions and grouped in three zones depending on the potential blood supply. Samples were taken during surgery for histological evaluation. Histological parameters of bone healing were defined and a bone healing capacity score (BHC), reflecting histological bone viability, was calculated. CT findings were compared to BHC, age of SNU, and time to union. RESULTS Cases with trabecular structure and without fragmentation showed a statistically significant higher BHC. Time to union was significantly faster if trabecular structure was present and sclerosis was absent. In intraarticular proximal pole non-unions, where no blood supply is assumed, the BHC was statistically significantly lower and time to union was longer compared to SNUs of the other locations. A statistically significant correlation between BHC and time to union was found in the proximal and distal fragment with higher BHC associated with faster healing. CONCLUSIONS CT parameters of bone structure and fracture location can reflect histological healing capacity of SNUs. This can guide bone graft selection in SNU surgery.
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Affiliation(s)
- Gernot Schmidle
- Department of Trauma Surgery, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria.
| | - Hannes Leonhard Ebner
- Department of Trauma Surgery, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Andrea Sabine Klauser
- Department of Radiology, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Josef Fritz
- Department of Medical Statistics, Informatics and Health Economics, Medical University Innsbruck, Schöpfstraße 41, 6020, Innsbruck, Austria
| | - Rohit Arora
- Department of Trauma Surgery, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Markus Gabl
- Department of Trauma Surgery, Medical University Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
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Kim J, Park JW, Chung J, Jeong Bae K, Gong HS, Baek GH. Non-vascularized iliac bone grafting for scaphoid nonunion with avascular necrosis. J Hand Surg Eur Vol 2018; 43:24-31. [PMID: 28893145 DOI: 10.1177/1753193417730657] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED We present the surgical outcomes of non-vascularized bone grafting taken from the iliac crest in 24 patients with scaphoid nonunion and avascular necrosis. The Fisk-Fernandez technique was used in 11 patients, and cancellous bone grafting was used in 13 patients. Bony union was achieved in 22 of the 24 patients. Non-vascularized iliac bone grafting can be used for the surgical management of scaphoid nonunion with avascular necrosis. Although revascularization of the proximal fragment after surgery was not evaluated, bony union was confirmed in nearly all patients. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jihyeung Kim
- Department of Orthopaedic Surgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Jin Woo Park
- Department of Orthopaedic Surgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Jeehyeok Chung
- Department of Orthopaedic Surgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Kee Jeong Bae
- Department of Orthopaedic Surgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Hyun Sik Gong
- Department of Orthopaedic Surgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Goo Hyun Baek
- Department of Orthopaedic Surgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
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Abstract
Kienbock disease (KD) is a disease of uncertain etiology, leading to chondral and osseous change in the lunate and wrist. Traditionally, Lichtman's classification of KD, based on radiographic appearances, has been used to direct treatment. Diagnostic wrist arthroscopy allows direct assessment of the lunate and surrounding articulations. Wrist arthroscopy can also serve as a therapeutic tool for performing debridement, resection, or arthrodesis procedures. The new Lichtman-Bain algorithm takes into consideration the status of the lunate, the effect on the wrist, and surgical and patient factors to guide management.
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Affiliation(s)
- Simon B M MacLean
- Department of Orthopaedic Surgery, Flinders University, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Karim Kantar
- Department of Orthopaedic Surgery, Flinders University, Flinders Medical Centre, Adelaide, South Australia, Australia.
| | - Gregory I Bain
- Department of Orthopaedic Surgery, Flinders University, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David M Lichtman
- Uniformed Services University, Bethesda, MD, USA; Department of Orthopaedic Surgery, University of North Texas, Health Science Center, Fort Worth, TX, USA
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Ditsios K, Konstantinidis I, Agas K, Christodoulou A. Comparative meta-analysis on the various vascularized bone flaps used for the treatment of scaphoid nonunion. J Orthop Res 2017; 35:1076-1085. [PMID: 27018317 DOI: 10.1002/jor.23242] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 03/17/2016] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Konstantinos Ditsios
- 1st Orthopaedic Department of Aristotle University of Thessaloniki, "Georgios Papanikolaou" General Hospital, Exohi 57010, Thessaloniki, Greece
| | - Ioannis Konstantinidis
- 1st Orthopaedic Department of Aristotle University of Thessaloniki, "Georgios Papanikolaou" General Hospital, Exohi 57010, Thessaloniki, Greece
| | | | - Anastasios Christodoulou
- 1st Orthopaedic Department of Aristotle University of Thessaloniki, "Georgios Papanikolaou" General Hospital, Exohi 57010, Thessaloniki, Greece
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Alluri RK, Yin C, Iorio ML, Leland H, Wong J, Patel K. Vascularized Bone Grafting in Scaphoid Nonunion: A Review of Patient-Centered Outcomes. Hand (N Y) 2017; 12:127-134. [PMID: 28344522 PMCID: PMC5349405 DOI: 10.1177/1558944716643080] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Ram K. Alluri
- University of Southern California, Los Angeles, USA,Ram K. Alluri, Keck Medical Center of University of Southern California, 1200 N. State Street, GNH 3900, Los Angeles, CA 90033, USA.
| | | | | | - Hyuma Leland
- University of Southern California, Los Angeles, USA
| | | | - Ketan Patel
- University of Southern California, Los Angeles, USA
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Sander AL, Sommer K, Schäf D, Braun C, Marzi I, Pohlemann T, Frank J. Clinical outcome after alternative treatment of scaphoid fractures and nonunions. Eur J Trauma Emerg Surg 2017; 44:113-118. [PMID: 28243717 DOI: 10.1007/s00068-017-0773-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 02/08/2017] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- A L Sander
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe-University, Frankfurt/Main, Germany. .,Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
| | - K Sommer
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe-University, Frankfurt/Main, Germany
| | - D Schäf
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe-University, Frankfurt/Main, Germany
| | - C Braun
- Department of Trauma, Hand and Reconstructive Surgery, St.-Antonius-Hospital, Kleve, Germany
| | - I Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe-University, Frankfurt/Main, Germany
| | - T Pohlemann
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Medical Center, Homburg, Germany
| | - J Frank
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Johann Wolfgang Goethe-University, Frankfurt/Main, Germany
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Han SH, Lee HJ, Hong IT, Kim U, Lee SJ. Non-structural cancellous bone graft and headless compression screw fixation for treatment of scaphoid waist non-union. Orthop Traumatol Surg Res 2017; 103:89-93. [PMID: 27939913 DOI: 10.1016/j.otsr.2016.10.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 08/23/2016] [Accepted: 10/06/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE Scaphoid fracture commonly occurs around the mid-third of the scaphoid, and non-union of this fracture has several treatment options. The authors performed autologous cancellous bone graft from the iliac crest and headless compression screw fixation for the treatment of Mack-Lichtman type II scaphoid waist non-union. The purpose of this study was to determine whether this procedure was effective in achieving bony union and restoration of alignment. METHODS Medical records and radiographs of 30 patients who underwent cancellous bone graft and headless compression screw fixation for non-union of scaphoid waist fracture were retrospectively reviewed. There were 28 men and 2 women, with a mean age of 32.8 years (range: 21-63). The mean time to surgery was 10 months (range: 3-25) and mean follow-up was 37.5 months (range: 15-52). The authors analyzed bony union, lateral intrascaphoid angle, scapholunate angle, radiolunate angle and scaphoid length on radiographs and evaluated the Modified Mayo wrist score (MMWS) as a functional outcome. RESULTS Bony union was achieved in all cases. The lateral intrascaphoid angle improved from 40° to 32° (P<0.001). The scapholunate angle also improved from 61° to 56° (P=0.009). The radiolunate angle decreased from 8° to 4° (P=0.048) and scaphoid length increased from 22mm to 26mm (P<0.001) postoperatively. Wrist motion and MMWS improved significantly at last follow-up. However, there were no significant differences between scaphoid deformity correction angle and pre- to post-operative difference in MMWS. CONCLUSIONS Non-structural autologous cancellous bone graft from the iliac crest and headless screw fixation provided reliable results and can be one of the effective treatment options for patients with symptomatic Mack-Lichtman type II non-union in the mid-third of the scaphoid. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- S H Han
- Department of orthopaedic surgery, CHA Bundang medical center, school of medicine, CHA university, 463-712 Seong-nam, Republic of Korea.
| | - H J Lee
- Department of orthopaedic surgery, CHA Bundang medical center, school of medicine, CHA university, 463-712 Seong-nam, Republic of Korea
| | - I T Hong
- Department of orthopaedic surgery, CHA Bundang medical center, school of medicine, CHA university, 463-712 Seong-nam, Republic of Korea
| | - U Kim
- Department of orthopaedic surgery, CHA Bundang medical center, school of medicine, CHA university, 463-712 Seong-nam, Republic of Korea
| | - S J Lee
- Department of orthopaedic surgery, CHA Bundang medical center, school of medicine, CHA university, 463-712 Seong-nam, Republic of Korea
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Schuind F, Moungondo F, El Kazzi W. Prognostic factors in the treatment of carpal scaphoid non-unions. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 27:3-9. [DOI: 10.1007/s00590-016-1886-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 10/24/2016] [Indexed: 01/22/2023]
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Bain GI, MacLean SBM, Tse WL, Ho PC, Lichtman DM. Kienböck Disease and Arthroscopy: Assessment, Classification, and Treatment. J Wrist Surg 2016; 5:255-260. [PMID: 27777814 PMCID: PMC5074828 DOI: 10.1055/s-0036-1584546] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 05/17/2016] [Indexed: 10/21/2022]
Abstract
The assessment and management of Kienböck Disease (KD) has always been a conundrum. The Lichtman classification has traditionally been used to guide treatment based on imaging. Arthroscopy provides a direct visualization of the articular surface, allows probing of the surfaces, and enables minimally invasive techniques to be performed. The Lichtman-Bain classification is a new classification that takes into account the osseous, vascular, and cartilage aspects of the lunate and the secondary effects on the wrist. It identifies the important prognostic factors including age, the status of the lunate, and the status of the wrist. With arthroscopy, the articular surfaces of the lunate can be assessed to better understand the status of the lunate. The lunate can be defined as intact, compromised, or not reconstructable. If the lunate is intact then lunate decompression (forage) and arthroscopic assisted bone grafting can be performed. If the lunate facet and capitate are functional, then a proximal carpectomy can be performed. This can be performed as an arthroscopic procedure. Assessment of the wrist includes assessment of the adjacent articular surfaces of the central column articulations (radiocarpal and midcarpal articulations). Instability of the proximal carpal row can also be assessed. The radioscaphoid articulation is often preserved except in late KD, which allows the scaphocapitate fusion to be a good surgical option. This can now be performed as an arthroscopic procedure. Once the radioscaphoid articulation is degenerate, a salvage procedure is required.
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Affiliation(s)
- Gregory I. Bain
- Department of Orthopaedic Surgery, Flinders University, Adelaide, South Australia, Australia
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Simon B. M. MacLean
- Flinders Medical Centre, Adelaide, South Australia, Australia
- Department of Orthopaedics, Flinders University, Adelaide, South Australia, Australia
| | - Wing-Lim Tse
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Pak-Cheong Ho
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - David M. Lichtman
- Uniformed Services University, Bethesda, Maryland
- Department of Orthopaedic Surgery, University of North Texas, Health Science Center, Fort Worth, Texas
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Malizos KN, Dailiana Z, Varitimidis S, Koutalos A. Management of scaphoid nonunions with vascularized bone grafts from the distal radius: mid- to long-term follow-up. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 27:33-39. [DOI: 10.1007/s00590-016-1867-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 10/09/2016] [Indexed: 10/20/2022]
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Kalb K. Freies gefäßgestieltes Femurknochentransplantat bei Skaphoidpseudarthrose. DER ORTHOPADE 2016; 45:966-973. [DOI: 10.1007/s00132-016-3334-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Rhee PC, Jones DB, Shin AY, Bishop AT. Evaluation and Treatment of Scaphoid Nonunions: A Critical Analysis Review. JBJS Rev 2016; 2:01874474-201407000-00004. [PMID: 27490062 DOI: 10.2106/jbjs.rvw.m.00074] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Peter C Rhee
- Division of Hand Surgery, Department of Orthopedic Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905
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Bain GI, Yeo CJ, Morse LP. Kienböck Disease: Recent Advances in the Basic Science, Assessment and Treatment. ACTA ACUST UNITED AC 2016; 20:352-65. [PMID: 26387994 DOI: 10.1142/s0218810415400079] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Kienböck disease is a disorder of impaired lunate vascularity which ultimately has the potential to lead to marked degeneration of the wrist and impaired wrist function. The aetiology of the avascular necrosis is uncertain, but theories relate to ulnar variance, variability in lunate vascularity and intraosseous pressures. Clinical symptoms can be subtle and variable, requiring a high index of suspicion for the diagnosis. The Lichtmann classification has historically been used to guide management. We present a review of Kienböck disease, with a focus on the recent advances in assessment and treatment. Based on our understanding thus far of the pathoanatomy of Kienböck's disease, we are proposing a pathological staging system founded on the vascularity, osseous and chondral health of the lunate. We also propose an articular-based approach to treatment, with an arthroscopic grading system to guide management.
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Affiliation(s)
- Gregory Ian Bain
- * Flinders University, Flinders Medical Centre, Adelaide, South Australia, Australia.,† Department of Orthopaedics and Trauma, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Chong Jin Yeo
- ‡ Hand&Microsurgery Section, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
| | - Levi Philip Morse
- * Flinders University, Flinders Medical Centre, Adelaide, South Australia, Australia.,† Department of Orthopaedics and Trauma, Flinders Medical Centre, Adelaide, South Australia, Australia
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Dehghani M, Soltanmohamadi M, Tahririan MA, Moezi M, Daneshpajouhnejad P, Zarezadeh A. Management of scaphoid nonunion with avascular necrosis using 1,2 intercompartmental supraretinacular arterial bone graft. Adv Biomed Res 2014; 3:185. [PMID: 25250299 PMCID: PMC4166208 DOI: 10.4103/2277-9175.140094] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 08/28/2013] [Indexed: 12/02/2022] Open
Abstract
Background: 1,2 ICSRA, introduced by Aidembery et al., is a well-established technique, with up to 100% union rate among different studies. The purpose of our study was to evaluate the outcome of scaphoid nonunion undergoing 1,2 ICSRA bone graft in Iran. Materials and Methods: All participants who presented sequentially over a period of 24 months between 2010 and 2013 with nonunion scaphoid fracture with AVN in proximal pole were included in the study. Anteroposterior and lateral view plain radiographs of carpal bones were obtained for diagnosis of nonunion, and a diagnosis of avascular necrosis was made by MRI of the scaphoid. Subjects underwent 1,2 ICSRA bone graft surgery. Patients were assessed based on radiographs and the Mayo Wrist Score (MWS) questionnaire on before and after surgery. Data were analyzed using SPSS ver. 18 by paired t test. Results: Overall, 16 patients (100% male) were included in the study. Mean age of subjects was 27.50 ± 5.86 (18 to 38). Mean Mayo score was 36.63 ± 8.92 and 83.75 ± 9.22 before and 6 month after surgery, respectively, and the difference was statistically significant (P < 0.001). after 8 weeks, 10 (62.5%) had union, and after 12 weeks, all subjects had union. Nine (56.25%) of our patients had excellent functional outcome, 5 (31.25%) had good and 2 (12.5%) had satisfactory functional outcome. Conclusion: 1,2 ICSRA 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.
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Affiliation(s)
- Mohamad Dehghani
- Department of Orthopedic, Orthopedic Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohamad Soltanmohamadi
- Department of Orthopedic, Orthopedic Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Ali Tahririan
- Department of Orthopedic, Orthopedic Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehdi Moezi
- Department of Orthopedic, Orthopedic Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Abolghasem Zarezadeh
- Department of Orthopedic, Orthopedic Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
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Al-Jabri T, Mannan A, Giannoudis P. The use of the free vascularised bone graft for nonunion of the scaphoid: a systematic review. J Orthop Surg Res 2014; 9:21. [PMID: 24690301 PMCID: PMC3976175 DOI: 10.1186/1749-799x-9-21] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 03/12/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fractures of the scaphoid are well known to be problematic especially when complicated by avascular necrosis, nonunion and carpal collapse. Fixation techniques have involved nonvascularised bone grafting; however, in the presence of avascular necrosis, generally poor union rates (47%) occur as identified by a meta-analysis performed by Merrell et al. The introduction of pedicled vascularised bone grafts showed further improvement; however, in the presence of carpal collapse, union rates as low as 50% have been reported by Chang et al. amongst others using the 1,2-intercompartmental supraretinacular artery pedicled graft. The difficulty lies in having a short pedicle with limited manoeuvrability to correct a humpback deformity and insert into the scaphoid cavity. Prior trauma to the soft tissues or distal radius may prohibit the use of pedicled grafts. The aim of this systematic review is to examine the published evidence for the use of free vascularised bone grafts in cases of scaphoid nonunion. METHODS A systematic review was performed with the following defined search strategy on MEDLINE and Google Scholar: ((scaphoid nonunion) OR scaphoid pseudarthrosis) AND bone graft. Articles were reviewed and data compiled into tables for analysis. Statistical analysis was performed with determination of descriptive statistics, and differences between the groups were calculated using categorical variables and chi-square test. A p value of 0.05 or less was considered to be statistically significant. RESULTS Two hundred and sixty-three articles were identified with a total of 12 articles meeting the inclusion criteria. Two hundred and forty-five cases of scaphoid nonunion were identified through the articles included in this systematic review. Fifty-six patients underwent free vascularised bone grafts from the medial femoral condyle with a 100% union rate and correction of humpback deformity, and 188 patients underwent free vascularised bone grafting from the iliac crest with an 87.7% union rate. The difference between the two similar groups was statistically significant (p = 0.006). CONCLUSIONS The promising data suggests that the medial femoral condylar free graft based on the descending genicular vessels can be considered in cases of proximal pole avascular necrosis and humpback deformity or in situations where other flaps are precluded or deemed unlikely to cause union.
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Affiliation(s)
- Talal Al-Jabri
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK.
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Mehrban N, Bowen J, Vorndran E, Gbureck U, Grover LM. Structural changes to resorbable calcium phosphate bioceramic aged in vitro. Colloids Surf B Biointerfaces 2013; 111:469-78. [DOI: 10.1016/j.colsurfb.2013.06.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 05/27/2013] [Accepted: 06/11/2013] [Indexed: 11/30/2022]
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Ting JWC, Rozen WM, Niumsawatt V, Baillieu C, Leung M, Leong JC. Developments in image-guided deep circumflex iliac artery flap harvest: a step-by-step guide and literature review. J Oral Maxillofac Surg 2013; 72:186-97. [PMID: 23993225 DOI: 10.1016/j.joms.2013.06.219] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Revised: 06/26/2013] [Accepted: 06/27/2013] [Indexed: 11/18/2022]
Abstract
PURPOSE The deep circumflex iliac artery (DCIA) flap has evolved significantly over time in the intricacies of flap design and breadth of surgical application. This has been facilitated by advances in preoperative imaging and planning, in particular, computed tomographic angiography. Studies have highlighted that advanced imaging modalities and other technologies such as image-guided stereolithographic biomodeling can substantially improve flap planning, flap harvest, and operative outcomes. PATIENTS AND METHODS The present report comprises a combined literature review and clinical cohort study of 20 consecutive patients to assess the modern technologies applied to DCIA flap planning and harvest. We have also described a step-by-step guide for the implementation of these techniques into clinical practice. RESULTS The protocol for a single, standardized technique of computed tomographic angiography scanning is presented and was applied to a range of techniques in the preoperative planning of DCIA flaps. These include 1) bony and vascular imaging analysis of both donor and recipient sites, 2) stereolithographic "biomodeling" of both donor and recipient bony and vascular anatomy, and 3) the use of preoperative "virtual surgery" with image-guided stereotactic navigation. The application and role of each technique was explored. CONCLUSIONS Modern imaging and stereolithographic techniques are innovations that can substantially improve surgical outcomes in DCIA flap surgery, such as has been highlighted in our clinical experience and in published studies. Notably, few outcome studies have been reported, and the need for larger case series and comparative studies is apparent.
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Affiliation(s)
- Jeannette W C Ting
- Plastic and Reconstructive Surgical Registrar, Department of Plastic and Reconstructive Surgery, Dandenong Hospital, Southern Health, Dandenong, Victoria, Australia; Department of Surgery, Monash University Faculty of Medicine, Clayton, Victoria, Australia.
| | - Warren M Rozen
- Plastic and Reconstructive Surgical Registrar, Department of Plastic and Reconstructive Surgery, Dandenong Hospital, Southern Health, Dandenong, Victoria, Australia; Department of Surgery, Monash University Faculty of Medicine, Clayton, Victoria, Australia
| | - Vachara Niumsawatt
- Plastic and Reconstructive Surgical Registrar, Department of Surgery, Monash University Faculty of Medicine, Clayton, Victoria, Australia
| | - Charles Baillieu
- Plastic and Reconstructive Surgical Consultant, Department of Plastic and Reconstructive Surgery, Dandenong Hospital, Southern Health, Dandenong, Victoria, Australia; Department of Surgery, Monash University Faculty of Medicine, Clayton, Victoria, Australia
| | - Michael Leung
- Plastic and Reconstructive Surgical Consultant, Department of Plastic and Reconstructive Surgery, Dandenong Hospital, Southern Health, Dandenong, Victoria, Australia; Department of Surgery, Monash University Faculty of Medicine, Clayton, Victoria, Australia
| | - James C Leong
- Plastic and Reconstructive Surgical Consultant, Department of Plastic and Reconstructive Surgery, Dandenong Hospital, Southern Health, Dandenong, Victoria, Australia; Department of Surgery, Monash University Faculty of Medicine, Clayton, Victoria, Australia
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Park HY, Yoon JO, Jeon IH, Chung HW, Kim JS. A comparison of the rates of union after cancellous iliac crest bone graft and Kirschner-wire fixation in the treatment of stable and unstable scaphoid nonunion. Bone Joint J 2013; 95-B:809-14. [DOI: 10.1302/0301-620x.95b6.31259] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This study was performed to determine whether pure cancellous bone graft and Kirschner (K-) wire fixation were sufficient to achieve bony union and restore alignment in scaphoid nonunion. A total of 65 patients who underwent cancellous bone graft and K-wire fixation were included in this study. The series included 61 men and four women with a mean age of 34 years (15 to 72) and mean delay to surgery of 28.7 months (3 to 240). The patients were divided into an unstable group (A) and stable group (B) depending on the pre-operative radiographs. Unstable nonunion was defined as a lateral intrascaphoid angle > 45°, or a radiolunate angle > 10°. There were 34 cases in group A and 31 cases in group B. Bony union was achieved in 30 patients (88.2%) in group A, and in 26 (83.9%) in group B (p = 0.439). Comparison of the post-operative radiographs between the two groups showed no significant differences in lateral intrascaphoid angle (p = 0.657) and scaphoid length (p = 0.670) and height (p = 0.193). The radiolunate angle was significantly different (p = 0.020) but the mean value in both groups was < 10°. Comparison of the dorsiflexion and palmar flexion of movement of the wrist and the mean Mayo wrist score at the final clinical visit in each group showed no significant difference (p = 0.190, p = 0.587 and p = 0.265, respectively). Cancellous bone graft and K-wire fixation were effective in the treatment of stable and unstable scaphoid nonunion. Cite this article: Bone Joint J 2013;95-B:809–14.
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Affiliation(s)
- H. Y. Park
- Asan Medical Center, Department
of Orthopedic Surgery, University of Ulsan
College of Medicine, 88, Olympic
road 43-Gil, Songpa-Gu, Seoul, Korea
| | - J. O. Yoon
- Asan Medical Center, Department
of Orthopedic Surgery, University of Ulsan
College of Medicine, 88, Olympic
road 43-Gil, Songpa-Gu, Seoul, Korea
| | - I. H. Jeon
- Asan Medical Center, Department
of Orthopedic Surgery, University of Ulsan
College of Medicine, 88, Olympic
road 43-Gil, Songpa-Gu, Seoul, Korea
| | - H. W. Chung
- Asan Medical Center, Department
of Orthopedic Surgery, University of Ulsan
College of Medicine, 88, Olympic
road 43-Gil, Songpa-Gu, Seoul, Korea
| | - J. S. Kim
- Asan Medical Center, Department
of Orthopedic Surgery, University of Ulsan
College of Medicine, 88, Olympic
road 43-Gil, Songpa-Gu, Seoul, Korea
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Abstract
INTRODUCTION This is single centre retrospective review of a consecutive series of patients with scaphoid nonunion (SNU) treated using the Ilizarov technique without bone graft. Fifteen of the original 18 patients were available for clinical and radiological examination at a minimum follow-up of 5 years (range 5-10 years). An evaluation was made of the late functional results, satisfaction scores, residual symptoms, grip strength and the presence of radiocarpal and scaphoid degenerative changes. METHODS The series consisted of 15 patients; 14 males; 1 female, with a mean SNU duration of 15.7 months, and a mean age of 23.6 years. Patients with carpal instability, humpback deformity, carpal collapse, avascular necrosis or marked degenerative change, were excluded from this treatment method. Following frame application the treatment consisted of three stages: distraction, compression and immobilisation. The technique is detailed herein. RESULTS Radiographic (CT) and clinical bony union was achieved in all 15 patients after a mean of 88 days (70-130 days). Mean modified Mayo wrist scores initially improved from 21 preoperatively to 86 at previous review, and were 96 at a mean follow-up of 81 months (62-120 months), with excellent results in 10, and good results seen in 5 patients. At latest review the mean grip strengths had returned to 96% of the uninjured hand, and 7 patients had regained full strength; mean wrist flexion/extension arc of motion had also continued to improve to 136° from 131°. All patients returned to their pre-injury occupations and levels of activity at a mean of 117 days. Three patients suffered superficial K-wire infections, which resolved with oral antibiotics. One patient continues to suffer intermittent mild aching in the wrist. No patient suffered loss of scaphoid height, humpback deformity, DISI instability or collapse of the regenerate bone. CONCLUSION In these selected patients this technique safely achieved bony union without the need to open the SNU site and without the need for bone graft. These patients also had the capacity to continually improve their wrist function beyond 3 years following their treatment.
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Affiliation(s)
- Marko Bumbasirevic
- University of Belgrade, School of Medicine, Institute for Orthopaedic Surgery and Traumatology, Clinical Center of Serbia, Belgrade, Serbia.
| | - Henry D Atkinson
- Department of Trauma and Orthopaedics, North Middlesex University Hospital and London Sports Orthopaedics, Sterling Way N18 1QX, UK
| | - Aleksandar Lesic
- University of Belgrade, School of Medicine, Institute for Orthopaedic Surgery and Traumatology, Clinical Center of Serbia, Belgrade, Serbia
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Derby BM, Murray PM, Shin AY, Bueno RA, Mathoulin CL, Ade T, Neumeister MW. Vascularized bone grafts for the treatment of carpal bone pathology. Hand (N Y) 2013; 8:27-40. [PMID: 24426890 PMCID: PMC3574491 DOI: 10.1007/s11552-012-9479-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Primary bone healing fails to occur in 5-15 % of scaphoid bones that undergo fracture fixation. Untreated, occult fractures result in nonunion up to 12 % of the time. Conventional bone grafting is the accepted management in the treatment algorithm of scaphoid nonunion if the proximal pole is vascularized. Osteonecrosis of the proximal scaphoid pole intuitively suggests a need for transfer of the vascularized bone to the nonunion site. Scaphoid nonunion treatment aims to prevent biological and mechanical subsidence of the involved bone, destabilization of the carpus, and early degenerative changes associated with scaphoid nonunion advanced collapse. Pedicled distal radius and free vascularized bone grafts (VBGs) offer hand surgeons an alternative treatment option in the management of carpal bone nonunion. VBGs are also indicated in the treatment of avascular necrosis of the scaphoid (Preiser's disease), lunate (Kienböck's disease), and capitate. Relative contraindications to pedicled dorsal radius vascularized bone grafting include humpback deformity, carpal instability, or collapse. The free medial femoral condyle bone graft has offered a novel treatment option for the humpback deformity to restore geometry of the carpus, otherwise not provided by pedicled grafts. In general, VBGs are contraindicated in the setting of a carpal bone without an intact cartilaginous shell, in advanced carpal collapse with degenerative changes, and in attempts to salvage small or collapsed bone fragments. Wrist salvage procedures are generally accepted as the more definitive treatment option under such circumstances. This manuscript offers a current review of the techniques and outcomes of VBGs to the carpal bones.
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Affiliation(s)
- Brian M. Derby
- />Institute for Plastic Surgery, Southern Illinois University School of Medicine, 747 North Rutledge 3rd Floor, P.O. Box 19653, Springfield, IL 62794 USA
| | - Peter M. Murray
- />Department of Orthopedic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Alexander Y. Shin
- />Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905 USA
| | - Reuben A. Bueno
- />Institute for Plastic Surgery, Southern Illinois University School of Medicine, 747 North Rutledge 3rd Floor, P.O. Box 19653, Springfield, IL 62794 USA
| | | | - Tim Ade
- />Institute for Plastic Surgery, Southern Illinois University School of Medicine, 747 North Rutledge 3rd Floor, P.O. Box 19653, Springfield, IL 62794 USA
| | - Michael W. Neumeister
- />Institute for Plastic Surgery, Southern Illinois University School of Medicine, 747 North Rutledge 3rd Floor, P.O. Box 19653, Springfield, IL 62794 USA
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El-Sallakh S, Mousa W, Aly T. Intercalated bone PEG in the treatment of non-united scaphoid fractures. HAND SURGERY : AN INTERNATIONAL JOURNAL DEVOTED TO HAND AND UPPER LIMB SURGERY AND RELATED RESEARCH : JOURNAL OF THE ASIA-PACIFIC FEDERATION OF SOCIETIES FOR SURGERY OF THE HAND 2013; 18:27-33. [PMID: 23413846 DOI: 10.1142/s0218810413500056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Untreated ununited scaphoid fractures will almost inevitably progress to radiographic and symptomatic osteoarthritis of the wrist. This may lead to subsequent morbidity and lifelong disability especially in young males in which the fracture scaphoid is more common. PATIENTS AND METHODS Twenty-one patients presenting non-united fracture scaphoid were operated upon by using disto-proximal bone peg technique with average time between injury and operation as 11 months (6-18 months). All of them male with average age of 26 years (17-35 years). There were 17 patients with fracture waist (80.9%) and four patients with fracture proximal pole (19.1%). RESULTS Anatomy of the wrist was restored and radiological healing confirmed in 17/21, partial healing in 3/21 and non-union in 3/21 patients. Eighteen patients (85.7%) were graded as satisfactory, 5 patients (23.8%) were graded as excellent, ten patients (47.6%) were graded as good, and three patients (14.3%) were graded as fair. The remaining three patients (14.3%) were graded as unsatisfactory. CONCLUSION We conclude that the disto-proximal bone peg technique of taking the graft from the ipsilateral ulna without using any metal work for fixing scaphoid non-union fracture is a reliable, easy, and inexpensive alternative method. However, we would not recommend it for the non-union of the scaphoid proximal pole fracture. Also we find the time lag before operation is one of the most important factors to achieve union in non-united fractures of the scaphoid. LEVEL OF EVIDENCE Therapeutic case series, level 1V.
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Holm J, Vangelisti G, Remmers J. Use of the medial femoral condyle vascularized bone flap in traumatic avascular necrosis of the navicular: a case report. J Foot Ankle Surg 2012; 51:494-500. [PMID: 22726653 DOI: 10.1053/j.jfas.2012.04.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Indexed: 02/03/2023]
Abstract
The medial femoral condyle vascularized bone flap has a high success rate in published literature regarding its use in nonunions and avascular necrosis of the upper and lower extremities. It is reported to have minimal donor site morbidity and the ability to provide structural support and torsional strength to load-bearing areas. The flap has found particular success in the treatment of scaphoid nonunions. The tarsal navicular, similar to the scaphoid, is largely articular cancellous bone with little surface area for vascular inflow. These anatomic features make the navicular prone to nonunion and avascular necrosis in traumatic scenarios. We describe a case of nonunion and avascular necrosis of the tarsal navicular occurring as sequelae of a high-impact midfoot injury sustained in an automobile accident. After an initial attempt at open reduction and internal fixation with midfoot bridge plating, subsidence and nonunion resulted. An attempt at arthrodesis of the talonavicular and naviculocuneiform joints was then undertaken. This too failed, leading to the development of additional collapse and avascular necrosis. The site was treated with a medial femoral condyle vascularized bone flap. In this single case, the patient returned to pain-free ambulation and reported excellent outcomes and functional capacity. Although we present a successful case, a larger case series is necessary to establish the use of this flap as a reliable option for the treatment of nonunion and avascular necrosis of the tarsal navicular.
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Affiliation(s)
- Janson Holm
- Legacy Health/Kaiser Permanente Podiatric Surgical Residency, Portland, OR, USA
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Buijze GA, Ochtman L, Ring D. Management of scaphoid nonunion. J Hand Surg Am 2012; 37:1095-100; quiz 1101. [PMID: 22541157 DOI: 10.1016/j.jhsa.2012.03.002] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2011] [Accepted: 03/01/2012] [Indexed: 02/02/2023]
Abstract
The primary risk factor for nonunion of the scaphoid is displacement/instability, but delayed or missed diagnosis, inadequate treatment, fracture location, and blood supply are also risk factors. Untreated nonunion leads to degenerative wrist arthritis-the so-called scaphoid nonunion advanced collapse wrist. However, the correlation of symptoms and disease is poor; the true "natural history" is debatable because we evaluate only symptomatic patients presenting for treatment. It is not clear that surgery can change the natural history, even if union is attained. The diagnosis of nonunion is made on radiographs, but computed tomography or magnetic resonance imaging scans can be useful to assess deformity and blood supply. Treatment options vary from percutaneous fixation to open reduction and internal fixation with vascularized or nonvascularized bone grafting to salvage procedures involving excision and/or arthrodesis of carpals.
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Affiliation(s)
- Geert A Buijze
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Jones DB, Rhee PC, Shin AY. Vascularized bone grafts for scaphoid nonunions. J Hand Surg Am 2012; 37:1090-4. [PMID: 22483177 DOI: 10.1016/j.jhsa.2012.03.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 03/01/2012] [Indexed: 02/02/2023]
Abstract
Scaphoid fractures that fail to unite are at risk of developing avascular necrosis and progressive structural collapse, thereby complicating attempts at revision surgical treatment. Vascularized bone grafts have demonstrated utility in promoting consolidation in the treatment of scaphoid nonunions complicated by avascular necrosis. Numerous pedicled and free vascularized grafts have been described with variable, but generally favorable, outcomes. Understanding the indications for different grafts is critical to the successful application of these techniques and grafts in the treatment of challenging scaphoid nonunions.
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Affiliation(s)
- D B Jones
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Lamas C, Proubasta I, Natera L, Moldovan R, Almenara M. Injerto óseo vascularizado y fijación con mini-acutrak® en las pseudoartrosis de escafoides con necrosis del polo proximal. Rev Esp Cir Ortop Traumatol (Engl Ed) 2011. [DOI: 10.1016/j.recot.2011.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Jaminet P, Werdin F, Pfau M, Götz M, Manoli T, Rahmanian-Schwarz A, Schaller HE. [Treatment algorithm for scaphoid nonunion : retrospective case-control study of 208 patients]. Unfallchirurg 2011; 115:994-9. [PMID: 21465239 DOI: 10.1007/s00113-011-1956-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION We present a retrospective study on different treatment options for scaphoid nonunion. The results are compared to the literature and a treatment algorithm is proposed. MATERIALS AND METHODS Based on a retrospective case-control study, 208 patients suffering from scaphoid nonunion were treated between 2000 and 2006. The patients were grouped depending on the localization of the nonunion: proximal (n=10), middle (n=105), or distal (n=93) third. In the presence of a small avascular proximal fragment, a vascularized bone graft from the distal radius was added (n=53). The determination of scaphoid healing was achieved by conventional radiographs or CT scans. RESULTS Overall scaphoid healing occurred in 89.9% (n=187). For small proximal scaphoid fragments (n=93), we could show healing rates up to 83% (n=77). Using a vascularized bone graft from the distal radius, scaphoid consolidation was achieved in 81% for avascular proximal fragments and recurrent scaphoid nonunion (n=53). CONCLUSION Using sophisticated treatment options, the prognosis of scaphoid nonunions is very good.
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Affiliation(s)
- P Jaminet
- Klinik für Hand-, Plastische, Rekonstruktive und Verbrennungschirurgie, Berufsgenossenschaftliche Unfallklinik, Eberhard-Karl-Universität Tübingen, Schnarrenbergstraße 95, 72076, Tübingen, Deutschland.
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Lamas C, Proubasta I, Natera L, Moldovan R, Almenara M. Vascularised bone graft with mini-acutrak® fixation in scaphoid pseudoarthrosis with proximal pole necrosis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2011. [DOI: 10.1016/s1988-8856(11)70304-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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48
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Allieu Y. [Past, present and future of vascularised bone transfers in the hand and wrist]. CHIRURGIE DE LA MAIN 2010; 29 Suppl 1:S3-S10. [PMID: 21075663 DOI: 10.1016/j.main.2010.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The author specifies the aims and indications for simple or compound pedicle or free vascularised bone and bone and joint grafts (VBGs and VBJGs). He relates the history of VBGs whose indications for the wrist are often many and varied for the treatment of scaphoid non-union and Kienböch's disease. Within the hand the indication for compound VBGs is dominated by thumb reconstruction (skin and bone grafts). Compound VBGs and VBJGs used in an emergency for hand trauma, harvested from another irrecoverable long finger (bank finger) are extremely varied and adapted to each particular case. For secondary joint reconstruction in the adult, VBJGs must be discussed along with prosthetic arthroplasties (radio-carpal, lower radio-ulnar, trapezo-metacarpal, interphalangeal). For children VBJGs with an included growth plate maintain their indication. The immediate future of VBGs is that of a better knowledge of bone necrosis and bone innervation as well as an improvement in surgical techniques: microsurgery and robotics, mini-invasive surgery (wrist arthroscopy). The near future for VBGs is to control bone consolidation thanks to progress in the bio-engineering of bone tissue, which may make them obsolete and, for VBJGs, vascularised joint allografts, thanks to progress in immunosuppressant treatments. Although the immediate future and this near future may be envisaged according to the current advances, the same is not true for the distant future which remains totally unforeseeable, although this might involve regeneration and construction of organs by man himself.
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Affiliation(s)
- Y Allieu
- Institut montpelliérain de chirurgie de la main et du membre supérieur, clinique Clémentville, 25 rue Clémentville, Montpellier, France.
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Malizos KN, Dailiana ZH, Innocenti M, Mathoulin CL, Mattar R, Sauerbier M. Vascularized bone grafts for upper limb reconstruction: defects at the distal radius, wrist, and hand. J Hand Surg Am 2010; 35:1710-8. [PMID: 20888511 DOI: 10.1016/j.jhsa.2010.08.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Accepted: 08/03/2010] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Konstantinos N Malizos
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessalia, Larissa, Greece.
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Free-Vascularized Medial Femoral Condyle Bone Transfer in the Treatment of Scaphoid Nonunions. Plast Reconstr Surg 2010; 125:1176-1184. [DOI: 10.1097/prs.0b013e3181d1808c] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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