Pedicled Vascularized Bone Graft Research Articles

Pedicled Vascularized Bone Grafts for Posterior Lumbosacral Fusion: A Cadaveric Feasibility Study and Case Report

Study DesignCadaveric feasibility study and case report. ObjectiveTo determine if it is feasible to rotate pedicled vascularized bone graft (VBG) from L1 to S1 via a posterior approach. Summary of Background DataVBG has been used to successfully augment fusion rates in various skeletal pathologies. Pedicled VBG has numerous advantages over free-transfer VBG, including the maintenance of a robust vascular supply to the graft without the need for vascular anastomoses. Pedicled VBG options have not been well described for posterior lumbosacral fusion. MethodsA multidisciplinary team of plastic surgeons and neurosurgeons hypothesized that it is feasible to rotate pedicled VBG from L1 to S1 via a posterior approach. In six cadavers, two VBG donor sites were evaluated: posterior element (PE-VBG) and iliac crest (IC-VBG). A single case report of a patient with lumbar Charcot joint treated with IC-VBG is also presented. ResultsFor the PE-VBG, the laminae and spinous processes were mobilized en bloc via Gill laminectomy on a unilateral sacrospinalis pedicle. Mean ± standard deviation (SD) length × width graft dimensions were 2.8±0.48 cm × 2.2±0.81 cm. The inter–transverse process (inter-TP) distance was less than the corresponding lamina length at all levels. For the IC-VBG, iliac crest was mobilized on a quadratus lumborum pedicle. Mean±SD length × width × thickness graft dimensions were 7.7±1.28 cm × 2.2±0.69 cm × 1.5±0.79 cm. The IC-VBGs reached from L1 (T12–S1) to S1 (S1–S3), and all IC-VBGs were able to cover three levels. ConclusionsThis feasibility cadaveric study and the case report are the first demonstrations that pedicled VBGs can be successfully applied to posterior lumbosacral spinal arthrodesis. Patients at high risk for nonunion may benefit from these strategies. Further clinical experience with these techniques is warranted. Level of EvidenceLevel IV.

Clinical and functional outcomes of vascularized bone graft in the treatment of scaphoid non-union.

IntroductionScaphoid 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.MethodsPatients 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.ResultsForty-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.ConclusionSurgical 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.

Lessons learned from volar plate fixation of scaphoid fracture nonunions.

IV.

Vascularized Pedicle Bone-Grafting from the Cuboid for Talar Osteonecrosis: Results of a Novel Salvage Procedure.

Osteonecrosis of the talar body represents a complex clinical challenge with treatment options currently limited to core decompression, vascularized and nonvascularized bone-grafting, total talar replacement, and hindfoot arthrodesis. Vascularized pedicle bone-grafting from the cuboid to the talus is a potential alternative to contemporary operative options for replacement of necrotic talar tissue with viable bone. We aimed to analyze functional and radiographic outcomes of vascularized pedicle bone-grafting from the cuboid for the treatment of talar osteonecrosis in a consecutive series of patients spanning a 12-year period. Patients with osteonecrosis of the talar body and dome who underwent vascularized pedicle bone-grafting from the cuboid to the talus at our institution between 2003 and 2014 were retrospectively identified. All patients had preoperative radiographs and magnetic resonance imaging (MRI) scans and were monitored postoperatively with serial radiographs and MRI. For generic health-related quality-of-life (HRQoL) assessment, patients were given the preoperative Medical Outcomes Study Short Form-12 (SF-12) and postoperative 36-Item Short Form (SF-36) from which Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were derived and compared before and after surgery. Thirteen patients were identified and sequentially followed for 2 to 12 years (mean, 6 years). Two patients had failure of treatment and subsequently underwent total ankle replacement, 1 patient had arthroscopic debridement for soft-tissue impingement, and no other patient required secondary surgery. The average PCS score (and standard deviation) significantly improved by 23.3 ± 18.9 points with surgery (p = 0.006), and the average MCS score significantly increased by 39.4 ± 10.1 points (p < 0.001). HRQoL outcomes suggest that vascularized pedicle bone-grafting from the cuboid combined with bracing for 1 year may be a viable treatment option for osteonecrosis of the talus that provides good pain relief and improved physical function without necessitating a secondary procedure for the majority of patients. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical outcomes of scaphoid nonunions treated with 1,2 intercompartmental supraretinacular artery pedicled vascularized bone graft and headless compression screw

Clinical outcomes of scaphoid nonunions treated with 1,2 intercompartmental supraretinacular artery pedicled vascularized bone graft and headless compression screw

Treatment of Kienböck's disease using a fourth extensor compartmental artery as a vascularized pedicle bone graft

Vascularized bone grafts for the treatment of Kienböck's disease may facilitate revascularization and remodeling of the avascular lunate. The aim of this study was to evaluate the radiological and clinical results obtained when a fourth extensor compartmental artery (ECA) bone graft was used to treat Kienböck's disease. Between May 2009 and June 2012, 13 patients (6 men, 7 women) with Kienböck's disease were treated with placement of fourth ECA vascularized bone grafts. The mean patient age was 39.2 (20-58) years, and the mean follow-up period was 32.5 (12-72) months. At the time of surgery, One patient had Lichtman's stage II Kienböck's disease, 11 stage IIIA disease, and one stage IIIB disease. We measured the pre- and post-operative ranges of motion, pain, grip strength, and radiological parameters, including the carpal height ratio and the radioscaphoid angle. At the last follow-up, pain was significantly reduced, and grip strength had improved from 60.5% to 87.8% relative to that of the contralateral side. The mean range of motion for flexion had improved from 39° to 53° while that of wrist joint extension improved from 41° to 56°. There were little or no changes in either the carpal height ratio or the radioscaphoid angle (both p values>0.05). Placing of a fourth ECA vascularized bone graft is a reliable alternative to other revascularization procedures for treatment of Kienböck's disease. Such grafting is effective, minimally invasive, and associated with a low risk of pedicle kinking. Therapeutic/IV.

Scaphoid Plate Fixation and Volar Carpal Artery Vascularized Bone Graft for Recalcitrant Scaphoid Nonunions

We sought to evaluate the clinical and radiographic outcomes after treatment of symptomatic, recalcitrant scaphoid nonunions using a novel combination of volar scaphoid buttress plating with a pedicled vascularized bone graft. We retrospectively followed 9 patients with recalcitrant scaphoid waist nonunions, characterized by failed prior surgery, long duration of nonunion, avascular necrosis of the proximal pole, or considerable bone loss at the nonunion site. We treated these persistent nonunions through a single volar incision with a pedicled vascularized bone graft, based on the volar carpal artery, and a 1.5-mm precontoured, scaphoid-specific, volar buttress plate. Postoperatively, we assessed objective and subjective outcomes as well as radiographs and computed tomography scans. The median duration of nonunion was 15 months, ranging from 6 to 96 months. Postoperative follow-up ranged from 11 to 19 months. Computed tomography scans demonstrated union in 8 of 9 cases. Complications included 1 minor hematoma that spontaneously resolved. One scaphoid failed to unite, requiring revision surgery. Three patients experienced problems with the plate. One plate was removed from a patient who noted persistent clicking, and 2 plates have caused symptomatic clicking, likely requiring future removal. Eight of nine patients reported satisfaction with the procedure, with QuickDash scores averaging 8.2. We present a series of recalcitrant scaphoid nonunions treated with a novel technique of volar buttress plating and vascularized bone graft. In this series, we found a high rate of union, with consistent radiographic improvement and symptomatic relief. This procedure can be performed using a single incision and with minimal donor site morbidity. Volar plating of a scaphoid nonunion comes with the risk of articular prominence, but offers a new alternative to headless screw fixation. Our early results from this series are promising and support this protocol as a viable alternative for challenging nonunions. Therapeutic IV.

The use of pedicled vascularized bone graft from the dorsum of distal radius for the treatment of scaphoid nonunion

Background The use of vascularized bone grafts from the dorsum of the distal radius for the treatment of scaphoid nonunion. Poor reduction or neglect of an unstable carpal scaphoid fracture may lead to scaphoid nonunion with or without avascular necrosis. When preoperative suggestion of avascular necrosis of the proximal pole is confirmed with intraoperative evaluation, conventional bone graft is not enough and a vascularized bone graft is strongly recommended. Patients and methods From May 2011 to September 2014, 12 patients with nonunited fracture of the scaphoid were treated with pedicled vascularized bone graft from the dorsum of the distal radius using of the 1,2 intercompartmental supraretinacular artery. Presurgical and postsurgical clinical evaluation included pain, range of motion, and grip strength. Radiographic evaluation included plain radiographs and MRI. The average follow-up period was 26 months (range = 12-40 months). Results At a mean follow-up period of 26 months, all patients clinically improved. Nine patients (75%) reported the absence of any discomfort, two patients (16%) reported slight discomfort after hard work, and only one case (8%) reported pain with light work. The wrist range of motion improved significantly, and the hand grip strength also improved. According to the modified Mayo wrist scoring chart, clinical results were rated as excellent in eight cases, good in three cases, and fair in one case. Radiographically, in eight of the 12 patients, union was achieved within 12 weeks after surgery, and in the other four patients trabecular bridging of the scaphoid fracture was achieved 16 weeks after the procedure. Conclusion 1,2 Intercompartmental supraretinacular artery is superficial to the extensor retinaculum and is a proper pedicle of vascularized bone graft due to the ease of visibility and dissection. The functional results and union rates were satisfactory in our study.

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.

Scaphoid nonunion volar pedicle vascularized graft versus volar peg graft

Background Scaphoid fracture nonunion often presents a therapeutic challenge. This is because the vascular supply of the scaphoid renders the proximal pole in many of these fractures avascular. Russe reported the use of an anterior inlay graft and, since then, other techniques of bone grafting have been devised. More recently, vascularized bone grafts for scaphoid nonunion have gained increasing popularity and many methods have been described on the basis of different pedicles. Aim of the study This study performs a comparison of the results of the treatment of scaphoid nonunion fractures using a volar radial vascularized pedicle bone graft and a volar peg graft. Patients and methods In a prospective study, 45 patients with nonunions scaphoid fractures were divided randomly into two equal groups: a group treated using a volar radial vascularized pedicle bone graft and a group treated using a volar bone peg graft technique. Results The final end result was assessed according to the Cooney score scale; in group A (volar peg graft), bone union was achieved in 15 patients (68.20%). There were five excellent, seven good, three fair, and seven poor results. In group B (volar vascularized graft), bone union was achieved in all patients (100%). There were 10 excellent, 10 good, and three fair results. Conclusion A volar vascularized pedicle bone graft is a viable option for the treatment of scaphoid nonunion that leads to rapid union and consolidation of proximal pole scaphoid nonunion, with better both clinical and radiological results.

Treatment of scaphoid nonunion: Pedicled vascularized bone graft vs. traditional bone graft

The clinical results of the application of pedicled vascularized bone graft (VBG) from Lister's tubercle vs. traditional bone graft (TBG) were evaluated and compared. Thirteen cases of symptomatic scaphoid nonunion were treated between January 2011 and December 2012, including 7 cases subject to VBG and the rest 6 cases to TBG, respectively. Outcomes were assessed by modified Mayo wrist score system. All cases were followed up for an average period of 3.5 months after operation. The results showed that total scores in VBG group were 86.4±9.4 after operation with excellent result in 4 cases, good in 2 and acceptable in one, and those in TBG group were 71.7±9.3 after operation with good result in 2 cases, acceptable in 3 and disappointing in one. Total score of wrist function was significantly improved in VBG group as compared with TBG group (P<0.05). Our study suggests that VBG method is more effective for treating scaphoid nonunion than TBG method.

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.

Functional results and quality of life after bilateral scaphoid reconstruction: a case series

Unilateral scaphoid non-union remains a major problem, which can lead to major functional limitations. Until now there is no evidence of outcome of the rare case of bilateral scaphoid non-unions and in how far two-stage bilateral reconstruction affects functional results and the quality of life. Between 1997 and 2010, altogether four bilateral scaphoid non-unions were treated in the centre and retrospectively analyzed. The mean follow-up was performed 36.8 months after reconstruction. The measures included analysis of patient data, analysis of functional measures and quality of life after follow-up. The reconstructions were performed with implantation of a free, non-vascularized iliac crest bone graft (4), osteosynthesis with implantation of a pedicled vascularized bone graft (3) and osteosynthesis with cancellous bone graft (1). The mean range of motion of the wrist was extension/flexion 111.3°. The average grip strength by JAMAR dynamometer showed right versus left sight 32.7 kg (±3.5) versus 33.7 (±2.9). The evaluation of the DASH score resulted in 11.6 (±12.5), the SF36 scale in 87.1 (±9.2) points. The present case series for the first time demonstrated functional mid-term results of the rare event of bilateral scaphoid reconstruction after non-union. With respect to the impact on one affected hand, functional results, DASH score and quality of life are excellent and thus justify good prognosis in patient education after injury.

Vascularized Pedicle Bone Grafting for Nonunions of the Tarsal Navicular

Osteonecrosis and nonunions of the tarsal navicular remain a challenging clinical problem. This article presents a series of patients treated with local vascularized pedicle bone grafting to the navicular. The purpose of this study was to determine the early clinical and radiographic outcomes of this technique. Patients who underwent local vascularized pedicle bone grafting for osteonecrosis of the navicular from 2002 to 2007 were included in this study. The Ankle Osteoarthritis Scale (AOS), the Revised Foot Function Index (FFI-R), and the Short-Form 36 (SF-36) outcomes questionnaires were administered at most recent followup. Postoperative imaging was reviewed for evidence of healing. Eight patients with a mean age of 47.5 (range, 18 to 68) years were included in this study. The mean followup time was 61 (range, 32 to 72) months. Two patients underwent concomitant talonavicular arthrodesis. Two patients underwent additional procedures to address continued nonunion of the navicular. Neither patient elected to complete the outcomes questionnaires. The mean postoperative FFI score was 35.2 (range, 16.6 to 59). SF-36 subscales were as follows: bodily pain, 53; general health, 55; mental health, 75; physical function, 56; role emotional, 61; role physical, 37.5; social function, 71; and vitality, 56. The mean postoperative AOS pain score was 27.9 (range, 0 to 46.2) and the average disability score was 31.4 (range, 0 to 78.2). Postoperative imaging revealed consolidation and full healing in six of eight patients. Vascularized pedicle bone grafting is a treatment option for patients with chronic nonunion or osteonecrosis of the navicular. Additionally, it may serve as an adjunct procedure to provide increased vascularity to talonavicular arthrodesis in cases of navicular osteonecrosis and talonavicular arthritis.

Revascularization Procedures forKienböckDisease

The goals of treatment in Kienböck disease include preservation of wrist function, maintaining normal wrist kinematics, and revascularization of the necrotic lunate when and if possible. A variety of pedicled vascularized bone graft options exist and include but are not limited to pedicled grafts from the volar radius, dorsal radius, metacarpal heads or bases, and pisiform. Of the various treatment options, pedicled vascularized bone grafts from the dorsal distal radius based on the fourth and fifth extensor compartment arteries has been successful in the revascularization of the necrotic lunate at our institution. Vascularized bone grafting is an attractive alternative to conventional bone grafting by improving the local biological environment and thereby promoting revascularization. Recent advances in the anatomy and physiology of vascularized pedicled bone grafts have increased our ability to apply them to the treatment of Kienböck disease. The purpose of this article is to describe the various types of pedicled vascularized bone graft available, to detail the vascular anatomy of the dorsal distal radius, and to describe the surgical technique of our preferred vascularized bone graft (the fourth+fifth extensor compartment artery graft). In addition, the indications, contraindications, and outcomes are described.

Scaffolds Combined with Stem Cells and Growth Factors in Healing of Pseudotumoral Lesions of Bone

Reconstructions of large lesions or defects often require a bone graft or a bone substitute to promote healing. In common practice the reconstruction of a bone defect is dependent on the site and size of the lesion: in long bones intercalary defects may be managed with Ilizarov technique of bone transport and distraction osteogenesis or the use of a free or pedicled vascularized bone graft, or with Masquelet technique. For cavitary defects the available surgical options include autograft, allograft or xenograft or the use of synthetic scaffolds to promote bone regeneration. In order to promote a faster bone healing tissue engineering proposed the application of enriched graft to fill bone defects. The employment of enriched bone graft has been our choice in the last years to fill contained defects following curettage of a pseudotumoral lesion of bone. We report our clinical experience in terms of safety and success of these procedures at a long-term follow up.

Vascularized bone grafting from the dorsal distal radius for Kienböck's disease: Technique, indications and review of the literature

The goals of surgical procedures in Kienböck's disease are to preserve wrist function, revascularize the necrotic lunate and maintain normal wrist kinematics when possible. Of the various treatment options, pedicled vascularized bone grafts from the dorsal distal radius permit the transfer of vascularized osseous tissue to the necrotic lunate in order to revascularize it. Vascularized bone grafting is an attractive alternative to conventional bone grafting by improving the local biological environment and thereby promoting revascularization. Recent advances in the anatomy and physiology of vascularized pedicled bone grafts have increased our ability to apply them to the treatment of Kienböck's disease. The purpose of this article is to describe the detailed vascular anatomy of the dorsal distal radius, the surgical technique, indications as well as contraindications of our preferred method of pedicled vascularized bone grafts of Kienböck's disease.

Treatment of Hawkins Type II Fractures of Talar Neck by a Vascularized Cuboid Pedicle Bone Graft and Combined Internal and External Fixation: A Preliminary Report on Nine Cases

Fractures of the talar neck are relatively uncommon. The reported rates of avascular necrosis in Hawkins type II fractures vary from 34% to 50%. Various strategies have been adapted to prevent the occurrence of avascular necrosis. We retrospectively reviewed the records of nine patients with Hawkins type II fractures. Open reduction and internal fixation with percutaneous cannulated screws were performed, and external fixation was used to unload the talus. A vascularized cuboid pedicle bone graft based on the lateral tarsal artery is adapted to improve the blood supply to the talar body. Postoperative radiographs were used to evaluate the adequacy of the reduction and the process of fracture healing. Osteonecrosis was defined on plain radiographs as any area of increased density of the talar dome relative to the adjacent structures. The postoperative global foot function was assessed using the Maryland Foot Rating Score. The average length of follow-up was 39 months (range, 16-58 months). The mean time to fixation was 54.4 hours. In all of the cases, the wound was closed primarily, and there were no postoperative infections or skin necrosis. Fractures healed uneventfully in all the patients with an average time to union as 15.6 weeks (range, 13-18 weeks). The avascular necrosis rate of talus was 0%. Hawkins sign was seen in one patient at 8 weeks after surgery in the anteroposterior view. According to the Maryland Foot Rating Score, excellent result (90-100) in seven cases and good result (75-89) in two cases were seen. The use of a vascularized cuboid pedicle bone graft and combined internal and external fixation can effectively prevent avascular necrosis of the talus in preliminary study. Further randomized control research is necessary to clarify the effectiveness of this technique.

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

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

The Use of Vascularized Grafts From the Distal Radius for the Treatment of Preiser’s Disease

To examine the outcome of vascularized bone grafts (VBGs) used for the treatment of Preiser's disease. Over a 10-year period (1993-2003) 8 pedicled VBGs were performed as the primary treatment for Preiser's disease. All patients had preoperative magnetic resonance imaging (MRI) scans that confirmed the diagnosis of avascular necrosis of the scaphoid. Bone revascularization was evaluated by examining preoperative and postoperative MRIs. All patients had a reverse-flow pedicled VBG from the distal radius. The average patient age was 40 years and the mean follow-up period was 36 months. Postoperative evaluation included range of motion, grip strength, pain evaluation, and Mayo wrist scores. All MRIs showed evidence of revascularization, with improvement in T2 and/or T1 signal; however, a consistent finding on MRI was incomplete revascularization of the entire proximal pole. Wrist motion averaged 55% of the unaffected side after surgery. Grip strength remained stable. Seven patients had long-term improvement in pain. The average Mayo wrist score was 68, with 1 patient rated as excellent, 1 as good, 5 as fair, and 1 as poor. There was 1 reconstructive failure that resulted in a proximal row carpectomy less than 1 year after the surgery. In this series VBGs led to reduced pain levels and preserved the radiocarpal wrist motion in most patients. Inability to revascularize the proximal pole of the scaphoid and ongoing wrist arthritis appear to persist despite revascularization attempts. VBGs for Preiser's disease should be limited to patients with early stage disease (Herbert stages I or II) without evidence of radiocarpal arthritis and no evidence of carpal instability. Therapeutic, Level IV.