Bone Grafting For Scaphoid Nonunion Research Articles

Non-vascularized iliac bone grafting for scaphoid nonunion with avascular necrosis.

IV.

Outcomes of Scaphoid Nonunion with Segmental Defect Treated with Plate Fixation and Autogenous Cancellous Graft: First Clinical Report

There is no financial information to disclose. Treatment of scaphoid nonunion with segmental defect presents a challenging clinical problem. Various techniques have been proposed, usually involving vascularized bone grafting with or without structural bone. Outcomes of these complex procedures have been inconsistent in the medical literature. The authors hypothesize that similar or perhaps better clinical and radiographic outcomes are possible with a relatively simplified technique of volar plate fixation augmented with autogenous pure cancellous graft. The authors performed a retrospective chart review of 49 consecutive patients with scaphoid nonunion with segmental defect treated with plate fixation and pure cancellous bone grafting. Surgical management included a single volar incision, reduction, insertion of bone graft from ipsilateral olecranon and/or distal radius, and application of a volar locking plate. Post-operative outcome measures included time to union based on computerized tomography (CT), return to work, patient-reported pain and disability scores, grip strength, and range of motion (ROM). The average patient was 31 years old and treated an average of 28 months after initial injury. Twenty-nine patients (59.0%) were treated for nonunion at the scaphoid waist, 19 (38.8%) at the proximal pole, and 1 (2.0%) at the distal pole. 13 patients (26.5%) were treated specifically for avascular necrosis confirmed with magnetic resonance imaging (MRI). Mean follow-up was 18.9 months (range, 12-34). Union was achieved in all patients and average time to union was 78 +/- 18.4 days post-operatively. Complications included symptomatic hardware that required plate removal for 1 patient. Mean DASH score improved from 13.4 +/- 0.5 pre-operatively to 41.4 +/- 3.7 post-operatively. Mean visual analogue scale (VAS) improved from 7.0 +/- 0.7 pre-operatively to 2.1 +/- 0.7 post-operatively. All employed patients returned to work, although 5 (13.9%) did not return to full capacity. Grip strength improved from 79.9% of the non-operative side pre-operatively, to 93.5% post-operatively. At final follow-up, ROM including wrist flexion, extension, ulnar deviation, and radial deviation improved 128%, 173%, 112%, and 164%, respectively, compared to pre-operative ROM. •The combination of scaphoid plate fixation and pure cancellous bone grafting for scaphoid nonunions with segmental defects yields reliable union rates and good patient outcomes.•Autogenous cancellous bone grafting is a reliable alternative to more technically demanding or morbid grafting procedures for the treatment of scaphoid nonunions with segmental bone defects.•In cases of avascular necrosis, outcomes of volar locked plating with pure cancellous grafting appear to be similar, if not superior, to those reported for vascularized bone grafting techniques.

A Critical Appraisal of Vascularized Bone Grafting for Scaphoid Nonunion.

Background Vascularized bone grafting (VBG) has the potential to yield reliable results in scaphoid nonunion; however, results across studies have been highly variable. This study critically evaluates surgical techniques, fracture location, and patient selection in relation to radiographic, clinical, and patient-centered outcomes after VBG for scaphoid nonunion. Methods We conducted a systematic review of the literature for the use of VBG in scaphoid nonunion. Physical examination, radiographic, and patient-centered outcomes were assessed. Four substratifications were performed: the location of scaphoid nonunion, pedicled versus free technique, Kirschner wire (K-wire) versus screw fixation, and VBG done as a primary versus revision procedure. Results A total of 41 publications were included in final analysis. VBG had an 84.7% union rate at 13 weeks after surgery. On an average, 89% of patients returned to preinjury activity levels by 18 weeks after surgery and 91% of patients reported satisfaction with the procedure. Proximal pole nonunions demonstrated similar union rates but lower functionality scores compared with nonunions across all regions of the scaphoid. Pedicled techniques demonstrated slightly improved range of motion compared with free technique. K-wire versus screw fixation demonstrated significantly higher union rates and faster union times. There were no differences in outcomes for VBG done as a primary versus revision procedure. Conclusion VBG serves as a viable option for the treatment of scaphoid nonunion, with consistent union rates in addition to significantly improved postoperative patient functionality. The fixation of these vascularized bone grafts with K-wires versus screw fixation may result in superior radiologic outcomes. Level of Evidence Therapeutic, Level III, systematic review.

Non-vascularized bone grafting in scaphoid nonunion: principles and type of fixation.

In scaphoid fractures, delayed diagnosis and nonunion are fairly common as a result of several factors, including the difficulty of radiographic diagnosis of non-displaced fractures and underestimation of the injury by the patient. Main factors to consider when deciding treatment are the type of fracture and fracture stability. In the stable nonunion (Type D1 according to the Filan and Herbert classification, or linear type of Ikeda's classification), percutaneous screw fixation without bone graft is recommended. The indications of non-vascularized bone grafting are as follows: (1) arthroscopic cancellous bone graft in type D1 and cystic type of Ikeda's classification. (2) tricortical bone graft from the iliac crest in type D2 or D3 if the possibility of avascular necrosis of the proximal fragment is excluded. In this paper, our non-vascularized bone grafting for scaphoid nonunion would like to be described mainly about principles and type of fixation.

Scaphoid Nonunion With Poor Prognostic Factors: The Role of the Free Medial Femoral Condyle Vascularized Bone Graft.

Background: To report on the results of free medial femoral condyle (MFC) vascularized bone graft for scaphoid nonunions with 1 or more poor prognostic factors. Methods: We have used the free MFC vascularized bone graft for scaphoid nonunions that have 1 or more factors associated with a poor prognosis. These were, a delay in presentation of over 5 years, a proximal pole nonunion, the presence of avascular necrosis (AVN), or previous nonunion surgery. We used this technique on 20 patients over a 4.5-year period. Results: Our overall union rate was 88.5% (17 of 19 patients), with 1 patient failing to attend for follow-up. Our mean union time was 7 months (2-18). All patients had at least 1 poor prognostic factor and over half had 2 or more. Of those with AVN with or without other factors, the union rate was 85% (11 of 13). There were 2 donor site complications that required a further procedure and 2 patients with residual wrist pain that required a scapho-trapezio-trapezoid joint fusion and a radial styloidectomy, respectively. Both nonunions were offered further surgery, and 1 elected to undergo successful revision surgery. Conclusions: Overall, this technique showed good results, in a subgroup of patients that typically have poorer outcomes, with a low incidence of donor site morbidity. Our union rate compares favorably with other techniques for this difficult subset of patients with 1 or more poor prognostic factors, although results are clearly not as good as those of studies using the MFC graft for all scaphoid nonunions. We continue to reserve this technique for nonunions with 1 or more poor prognostic factors, and we believe that this technique should at least be considered in these patients.

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

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

The 1,2-Intercompartmental Supraretinacular Artery Vascularized Bone Graft for Scaphoid Nonunion: Management and Clinical Outcome

To evaluate the clinical outcome of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft for scaphoid nonunion (SN). A retrospective study was performed to evaluate patients with SN and treated with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft between 1997 and 2010. Functional measures, quality of life by Short Form SF-36 questionnaire, and analysis of risk factors were included. Out of 39 patients who were eligible for the study, 11 were lost to follow-up. Out of the remaining 28 patients, union was achieved in 21 (75%). The mean length of follow-up was 63 ± 45 months. In hands with scaphoid union, the grip strength and the radioulnar active range of motion were less than the contralateral side but greater compared with patients with nonunion. Active extension-flexion was less compared with the noninjured hand but similar to patients with nonunion. Disabilities of the Arm, Shoulder and Hand (DASH) score decreased from 58 to 23 in dominant hands and from 46 to 13 in nondominant hands. Smoking was found to be a risk factor for nonunion. Patients with scaphoid union tended to higher scores in 8 domains of SF-36-Item Health Survey quality of life without significant difference. Surgical treatment of SN with 1,2-intercompartmental supraretinacular artery pedicled vascularized bone graft provided a union rate comparable with other vascularized bone graft techniques. Previous scaphoid reconstruction with standard iliac crest bone graft was not associated with higher risk for secondary nonunion. There was an upward tendency seen in DASH score and quality of life after scaphoid union. Therapeutic IV.

Wrist & Hand

The June 2013 Wrist & Hand Roundup360 looks at: whether size is a limitation; cancellous bone grafting in scaphoid nonunion; the Kienböck’s dichotomy; late displacement of the distal radius; flexor slide for finger contracture; aesthetic syndactyly; flexor tendon repair; and fixation of trapeziometacarpal cups.

2,3 Intercompartmental Supraretinacular Artery Pedicled Vascularized Bone Graft for Scaphoid Nonunions

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

Erratum to: Local distal radius bone graft versus iliac crest bone graft for scaphoid nonunion: a comparative study

Erratum to: Local distal radius bone graft versus iliac crest bone graft for scaphoid nonunion: a comparative study

Free Medial Femoral Condyle Vascularized Bone Grafting for Scaphoid Nonunions with Proximal Pole Avascular Necrosis and Carpal Collapse

Treating scaphoid nonunions complicated by avascular necrosis and collapse with humpback deformity has proven challenging. Conventional nonvascularized interposition grafts restore the structural architecture, but fail to restore the vascular supply to the scaphoid. Pedicled inlay grafts restore blood flow, but fail to correct the humpback deformity or restore scaphoid length. Restoration of both vascularity and geometry is critical for promoting bony union. The free vascularized medial femoral condyle bone graft provides both and has proven successful in treating this problematic subset of scaphoid nonunions. The rationale, indications, contraindications, anatomical basis, and technique of scaphoid preparation, bone graft harvest, insetting, fixation, and microvascular anastomosis are presented for the treatment of scaphoid nonunions with avascular necrosis and carpal collapse.

Current Innovations in Wrist Arthroscopy

It has become clear that the stability of the scapholunate joint does not depend wholly on the scapholunate interosseous ligament, but rather on both primary and secondary stabilizers, which form a scapholunate ligament complex. Each case of scapholunate instability is unique and should be treated with tissue-specific repairs, which may partly explain why one procedure cannot successfully restore joint stability in every case. Wrist arthroscopy has a pivotal role in both the assessment and treatment of the scapholunate ligament complex derangements. Tears of the foveal attachment of the triangular fibrocartilaginous complex can be an underdiagnosed cause of distal radioulnar joint instability, because the foveal fibers cannot be visualized using the standard radiocarpal arthroscopy portals. Distal radioulnar joint arthroscopy allows for direct visualization and assessment of these fibers, which in turn has spawned a number of open and arthroscopic repair methods. Wrist arthroscopy has gained wider acceptance as a method to fine-tune articular reduction during open and percutaneous fixation of distal radius fractures, and simplifies intra-articular osteotomies for malunion. It can facilitate percutaneous bone grafting of scaphoid nonunions and has a role in the diagnosis and treatment of associated soft tissue lesions. These and other recent developments will be discussed in the following article.

The utility of the technique for bone graft for scaphoid nonunion with distal intercalated segmental instability according to preoperative planning based on conventional radiography

The utility of the technique for bone graft for scaphoid nonunion with distal intercalated segmental instability according to preoperative planning based on conventional radiography

Vascularized Bone Grafting of Scaphoid Nonunions

Scaphoid fractures represent the most common carpal fracture and must always be included in the differential diagnosis for wrist pain in the athlete. In the short-term, nonunions may result in mild discomfort; however, the long-term sequelae of nonunions result in a predictable descent into wrist arthrosis. Athletes with excellent compensatory ability and multiple incentives to continue in sport may neglect these injuries until significant disruption of the scaphoid blood supply or arthritic changes have already occurred. The restoration and evaluation of scaphoid vascularity represent a challenging and important area of hand surgery. Magnetic resonance imaging and computed tomography (CT) scans have important roles in evaluating these injuries before and after surgery. Stable fixation and the use of local pedicled bone grafting or free vascularized grafts are the mainstays of treatment. Although technically more complex, better results have been reported with vascularized bone grafting and fixation compared with fixation and nonvascularized grafting alone, especially in cases of proximal pole avascular necrosis.

A Qualitative Evaluation of Scaphoid Remodeling in Bone-Grafted Scaphoid Nonunions

The purpose of this case series is to identify and illustrate the phenomenon of scaphoid remodeling in skeletally mature subjects following bone grafting for scaphoid nonunion. Nine patients with scaphoid nonunions were treated with interpositional bone grafting (with iliac crest bone graft) and K-wire fixation. The mean length of follow-up was 28.6 ± 9months. Radiographs and CT scans were reviewed and assessed for degree of union and a qualitative assessment of scaphoid architecture. Following surgery, there was marked distortion of the scaphoid. Once healed, the contour of the scaphoid was still significantly distorted in all nine patients. Remodeling then became evident along the articular surfaces between 8 and 12months. By 3years, the scaphoid was completely recontoured and the normal architecture was completely restored in all nine patients. We conclude that the articular surface of the scaphoid remodels over time in skeletally mature subjects.

Outcome After Vascularized Bone Grafting of Scaphoid Nonunions With Avascular Necrosis

Vascularized bone grafting has been proposed as a treatment for scaphoid nonunions with avascular necrosis of the proximal pole. The purpose of this investigation is to report the results of vascularized bone graft and internal fixation for established scaphoid nonunions with proximal pole avascular necrosis as measured by validated outcome instruments. From 1996 to 2004, 30 consecutive patients with established scaphoid nonunion, proximal pole avascular necrosis, and no prior surgery were treated with open reduction and internal fixation in addition to a vascularized bone graft based on 1,2 intercompartmental supraretinacular artery. A total of 19 patients had nonunions of the scaphoid waist and 11 had nonunions of the proximal pole of the scaphoid. Preoperative and postoperative evaluation included measurement of clinical (grip strength and range of motion), radiographic (scapholunate angle, scaphoid height-to-length ratio, and radioscaphoid arthritis), function (Disabilities of the Arm, Shoulder, and Hand questionnaire) and satisfaction parameters. We recorded union and return to activity and analyzed data both in the aggregate and stratified by nonunion location. Union rate was 28 of 30 (93%) and time to union was 5.1 months (+/-2.4). Significant improvements were found for grip strength, Disabilities of the Arm, Shoulder, and Hand score, satisfaction score, and scaphoid height-to-length ratio (p < .01). No significant difference was found for composite wrist range of motion. Two patients experienced complications and required a second procedure to achieve union. A total of 28 of 30 (93%) of patients returned to work or sports activity at their preinjury level. The results of this investigation support the use of a vascularized bone graft for the treatment of scaphoid nonunions with avascular necrosis of the proximal pole.

Surgical outcome of conventional bone graft for scaphoid nonunions

Surgical outcome of conventional bone graft for scaphoid nonunions

Bone Grafting of Scaphoid Non-Unions: A Simple Distraction Technique to Optimise Fracture Exposure

Bone Grafting of Scaphoid Non-Unions: A Simple Distraction Technique to Optimise Fracture Exposure

The Detailed Anatomy of the 1,2 Intercompartmental Supraretinacular Artery for Vascularized Bone Grafting of Scaphoid Nonunions

To describe the configuration of the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA), including the location of the perforators, and to discuss the clinical use of the 1,2 ICSRA for vascularized bone grafting of scaphoid nonunions. Thirteen fresh-frozen cadaveric forearms were used to evaluate the variations in the anatomy of the 1,2 ICSRA. After injection of red latex, the 1,2 ICSRA and its perforators were characterized and measured. Pedicle length and distal reach of the transposed 1,2 ICSRA pedicle was evaluated. We noted the relationship of the 1,2 ICSRA to the dorsal scaphoid branch of the radial artery. Another 10 specimens were injected, frozen, and sectioned to evaluate vascular penetration into the dorsal distal radius. The 1,2 ICSRA branched from the radial artery 1.9 mm proximal to the tip of the radial styloid (range -6.3-3.2 mm), on average. The average pedicle length was 22.5 mm (range 15-31 mm), which permits its application for both dorsal and volar scaphoid. The relationship between the origin of the 1,2 ICSRA and the dorsal scaphoid branch was categorized into 3 types, including--separate, combined, and shared. The average number of perforating vessels arising from the pedicle was 5.5 (range 3-7), with an average of 2.75 (range 1-7) perforators overlying a 1 by 0.5 cm block of the distal radius bone graft. A graft located between 8-18 mm proximal to the articular surface of distal radius would incorporate the greatest numbers of perforators. The most notable vascular penetration of the distal radius was demonstrated at 10.0 mm proximal to the radial styloid. The detailed anatomy of the 1,2 ICSRA presented in this study may guide in planning and dissection to maximize the vascularity of a pedicled bone graft based on this vessel for the management of scaphoid nonunions.

Free Medial Femoral Condyle Bone Grafting for Scaphoid Nonunions With Humpback Deformity and Proximal Pole Avascular Necrosis

Treatment of scaphoid nonunions remains a challenging problem, especially in the setting of proximal pole avascular necrosis or humpback deformity. Conventional bone grafting techniques have demonstrated unpredictable results in the setting of collapse deformities, whereas pedicled dorsal distal radius vascularized bone grafts have recently been reported to have nearly a 50% failure rate when used in scaphoid nonunions with proximal pole nonunion. Free vascularized medial femoral condyle bone grafting is one option for the treatment of scaphoid nonunions with proximal pole avascular necrosis associated with a humpback deformity. The indications, contraindications, and technique of free vascularized medial femoral condyle bone grafting are presented for the treatment of scaphoid nonunions associated with proximal pole avascular necrosis and humpback deformities.