Bone Grafting For Scaphoid Nonunion Research Articles

The Outcomes and Complications of 1,2-Intercompartmental Supraretinacular Artery Pedicled Vascularized Bone Grafting of Scaphoid Nonunions

The Outcomes and Complications of 1,2-Intercompartmental Supraretinacular Artery Pedicled Vascularized Bone Grafting of Scaphoid Nonunions

The Outcomes and Complications of 1,2-Intercompartmental Supraretinacular Artery Pedicled Vascularized Bone Grafting of Scaphoid Nonunions

Over the past decade vascularized bone grafts that use a 1,2-intercompartmental supraretinacular artery (1,2-ICSRA) pedicle have gained popularity in the treatment of scaphoid nonunions. The purpose of this study was to evaluate critically the outcome, complications, and failures of 1,2-ICSRA-based vascularized bone grafting at our institution to understand better the appropriate indications, methods, and possible contraindications. From January 1994 through July 2003, 50 scaphoid nonunions in 49 patients were treated with 1,2-ICSRA-based vascularized bone grafts. A retrospective review of the clinical and radiographic information was performed. Two patients were lost to follow-up study. Nine female and 38 male patients averaging 24 years of age were followed-up for an average of 7.8 months. Thirty-four scaphoid nonunions went on to union at an average of 15.6 weeks after surgery. Complications occurred in 8 patients and consisted of graft extrusion, superficial infection, deep infection, and failure of fixation. Univariate risk factors for failure included older age, proximal pole avascular necrosis, preoperative humpback deformity, nonscrew fixation, tobacco use, and female gender. Although previous researchers have concluded that vascularized bone grafts based on the 1,2-ICSRA are efficacious in the treatment of scaphoid nonunions, we determined that a successful outcome is not universal and depends on careful patient and fracture selection and appropriate surgical techniques. Therapeutic, Level IV.

Vascularized Bone Graft for Scaphoid Nonunions

Scaphoid fracture nonunion remains a challenging problem that may persist despite traditional methods of bone grafting and internal fixation. The alteration of wrist mechanics created by nonunion as well as the development of avascular necrosis leads to degenerative change of the radiocarpal joint accompanied by loss of motion and pain. The use of a vascularized bone graft has the theoretical benefit of increased blood flow that exceeds that of nonvascularized grafts. Numerous sources of vascularized bone graft have been described, including those from remote sites as well as from the carpus and distal radius. Knowledge of the blood supply to the distal radius has allowed for development of several vascularized bone graft harvest sites. The results of vascularized bone grafting from the distal radius have been encouraging, with numerous authors reporting the successful treatment of scaphoid nonunions.

Vascularized Bone Graft for Scaphoid Nonunion

The management of recalcitrant nonunion of the scaphoid can be frustrating. Recent understanding of the vascular anatomy of the distal radius has helped in the management of these problems. Vascularized bone grafting for scaphoid nonunion has improved the union rates. Consequently, familiarity with this procedure is an important tool for any surgeon who treats scaphoid nonunion. Although there are numerous publications discussing both the vascular anatomy of the distal radius and the scaphoid, little is written about the surgical technique. This study reviews the literature on scaphoid nonunion and outlines the authors' experience with this procedure.

Femoral Neck Stress Fractures and Metabolic Bone Disease

To determine whether metabolic bone disease plays a role in the cause of femoral neck stress fractures. Twenty-three patients with femoral neck stress fractures were enrolled prospectively in the study. Examination included computed tomography bone densitometry, trace mineral analysis, and histomorphometric analysis of the iliac crest in thirteen patients who underwent surgical treatment of their stress fractures. A control group of fifteen patients undergoing iliac crest bone grafting for scaphoid nonunions underwent similar examinations. Tertiary military medical center. Patients with femoral neck stress fractures had lower bone mineral density than did control patients (p = 0.010), but no trace mineral deficiencies or consistent histomorphometric differences were noted. Bone mineral density is decreased in patients with femoral neck stress fractures. Despite observations of decreased bone mineral density in the stress fracture group, osteoporosis, as determined by histomorphometry, is not a consistent finding.

Vascular Pedicled Bone Graft for Scaphoid Non-union

Vascular Pedicled Bone Graft for Scaphoid Non-union

Vascularized Bone Grafting for Scaphoid Nonunion

Vascularized Bone Grafting for Scaphoid Nonunion

Revision of failed bone grafting for nonunion of the scaphoid. Treatment options and results.

Failure of bone grafting in scaphoid nonunion presents the hand surgeon a perplexing set of problems. Controversy remains as to the best course of treatment in this difficult situation. The authors have retrospectively reviewed during a 5-year period the patients treated at the Mayo Clinic who have gone on to a second nonunion after a failed initial bone grafting procedure. Twenty-five patients were identified, 19 of whom had a second bone grafting procedure. Depending on the preoperative evaluation, 4 types of bone grafting procedures were performed: conventional Russe procedure, 4; Maltese cross bone graft procedure, 6; interpositional wedge graft, 5; and vascularized pedicle bone graft, 4. Twenty-two of 25 united (88%). Average followup at 57 months (range, 25-90 months), shows satisfactory results (16% very satisfied and 8% moderately satisfied), but varying degrees of pain. Results using a modification of the Mayo Wrist Score are somewhat disappointing with 3 excellent, 5 good, 10 fair, and 7 poor. It must be remembered, however, these wrists have had at least 2 surgeries, multiple long periods of immobilization, and often a delay in treatment with a prolonged period of abnormal carpal mechanics. It is thought that a second bone grafting attempt should be strongly considered. The key to success is matching the type of bone graft procedure to the specific unique features of scaphoid shortening, carpal instability, and proximal pole vascularity that each patient's wrist displays. A treatment algorithm is presented to help decision making in this difficult problem.

Biomechanical measurements on scaphoid bone screws in an experimental model

A number of screws commonly used for internal fixation in scaphoid bone fractures and non-unions are compared regarding biomechanical properties and clinical applicability. The experiments were carried out on models made of ash-wood, representing a reconstruction and fixation as is performed in a cortico-cancellous inlay bone graft for scaphoid non-union. For fixation use was made of 2.7 and 3.5 AO ASIF cortical screws respectively, 4.0 AO ASIF cancellous screws, Herbert screws, and a newly designed screw called the three components screw (D.K.S.). The models with implanted screws were tested for bending strength, tensile strength and torsion stability. No large differences between the various screws were found regarding the measured parameters, so that a small intra-osteal implant such as the Herbert screw and the D.K.S., which can be inserted easily and which gives a certain amount of interfragmentary compression, will be sufficient for osteosynthesis of the scaphoid bone. In case an intra-osteal implant is not available a single 3.5 AO ASIF cortical screw, inserted following lag-screw principles, is recommended.

Carpal alignment after different surgical approaches to the scaphoid: A comparative study

Thirty-seven patients with inlay bone grafting for scaphoid nonunion were evaluated before and after operation for wrist function and carpal alignment. There were 26 in whom a palmar approach had been used. The remaining 11 had been treated with a dorsal approach. The two procedures showed a similar union rate (around 80%). The palmar approach, however, caused a significant increase in the scapholunate angle (p less than 0.001) and in the lunocapitate angle (p less than 0.05) and consequently augmented carpal collapse. The dorsal approach did not affect carpal alignment. The surgical division of the palmar radiocarpal ligaments, which is necessary when using a palmar approach, may be responsible for these findings. Accordingly, a dorsal approach should be preferable to a palmar approach when a graft is used for treatment of a scaphoid nonunion.

The effect of avascular necrosis on Russe bone grafting for scaphoid nonunion

This article reports a prospective study of 45 patients with nonunion of the scaphoid treated with Russe bone grafting. The operative procedure contains modifications in the technique made by Russe subsequent to his 1960 article. The results strongly support Russe's contention that his operation is not likely to be successful if the proximal pole is totally avascular. Twenty-four (92%) of 26 patients with good vascularity in the proximal pole achieved solid union. In patients in whom the vascularity of the proximal pole was spotty or diminished, the rate of union dropped to 71% (10 of 14). Most important, none of the five patients in whom the proximal pole was totally avascular achieved successful union. True avascular necrosis is best determined by punctate bleeding points in cancellous bone found at operation, and cannot be accurately predicted by the appearance of preoperative radiographs.

The Surgical Approach and Source of Bone Graft for Symptomatic Nonunion of the Scaphoid

In 2 groups of patients treated by bone grafting for scaphoid nonunions, one group had a dorsal or dorsolateral surgical approach with a bone graft from the radius while the other group had a volar approach with an iliac graft. The best results were obtained with an iliac graft. Through the volar approach it is relatively easy to avoid damage to the scaphoid arterial supply. A small proximal vascular pole led to a failure rate of 36%.