MFC Bone Graft for Scaphoid Nonunion, Osteonecrosis, and Failed Prior Surgery: Three Strikes But Not Necessarily Out: Commentary on an article by Nicholas Pulos, MD, et al.: "Free Vascularized Medial Femoral Condyle Bone Graft After Failed Scaphoid Nonunion Surgery".

Abstract

Commentary Patients with a nonunion of the scaphoid with a proximal fracture line, osteonecrosis of the proximal pole, and a previously unsuccessful attempt at achieving surgical union present the orthopaedic surgeon with a difficult clinical decision. Some surgeons might advocate nonoperative treatment, with the expectation that a salvage procedure (scaphoid excision and 4-corner fusion, proximal row carpectomy, total wrist arthrodesis, or total wrist arthroplasty) might eventually be required to relieve pain and maintain motion. Others might recommend repeat open reduction and internal fixation using either vascularized or nonvascularized local bone, whereas those who are experienced with microsurgical techniques might attempt, on the basis of the data presented in this article, a vascularized medial femoral condyle (MFC) bone graft in order to achieve union and restore vascularity (and therefore mitigate against eventual collapse) of the proximal pole. The authors give us an honest appraisal and have made an important iterative contribution to the care of young patients with this challenging clinical problem. They acknowledged an almost 20% rate of additional surgery (apart from scheduled surgery for the removal of Kirschner wires) and also reported a 1-in-6 rate of persistent nonunion. Even though these results are a reason for reflection and discussion, this surgical procedure is an attempt to restore preinjury anatomy, which is, in my opinion, a worthy goal for these young, physically active patients. Whether the main issue is carpal collapse and humpback deformity in an SNAC (scaphoid nonunion advanced collapse) wrist following scaphoid fracture with proximal pole osteonecrosis (and an initial attempt at achieving surgical union), or pain and tenderness over the proximal pole due to fragmentation and collapse as well as the development of osteoarthritis between the distal scaphoid pole and the radial styloid, remains open to discussion. Also, this article did not address specifically whether the goal of restoration of scaphoid length by means of an MFC graft is directly related to the restoration of carpal alignment. It would seem so; however, this point is really only academic since proximal pole fractures and nonunions do not routinely lead to arthrosis between the proximal pole of the scaphoid and the distal radial articular surface as is seen in chronic SLAC (scapholunate advanced collapse) wrists. Although 1 patient had a subsequent radial styloid excision, the distal pole was not excised, presumably because of the condition of either the proximal pole or the scapholunate ligament, or both. Several caveats outlined in the article bear repetition. First, patients frequently lost wrist motion following this procedure, and this was manifested by several patients’ inability to return to push-up exercises. This is not an unimportant point, especially in patients with specific functional requirements related to their employment. Second, there were some sports-related difficulties as well as persistent discomfort that compromised the outcomes. My mention of this is not meant to denigrate the procedure or the results, but rather to encourage the surgeon to set realistic expectations—i.e., of results that are either similar to or slightly better than those achievable with salvage procedures in terms of pain relief, motion, and strength with (hopefully) longer-term durability. The cases presented in this article are seen infrequently, and the patients often expect a full return to sports and vocational activities. Preoperative counseling and the setting of achievable goals are to be stressed. The surgical results in this retrospective study suggest that, in the infrequent situation where a young patient presents with “3 strikes” (nonunion, osteonecrosis, and prior unsuccessful surgery), he/she might not necessarily be “out.”