Persistent Nonunion Research Articles

Applications of the Medial Femoral Condyle Free Flap for Foot and Ankle Reconstruction

Avascular necrosis (AVN) or persistent nonunion occurs in situations of poor vascular supply. Some specific situations that plague the foot and ankle surgeon are talus nonunion, talus AVN, navicular AVN, and failed ankle arthrodesis with bone loss. The medial femoral condyle (MFC) flap has emerged as a popular source of vascularized corticocancelous bone. We present a series of cases demonstrating the versatility of the MFC flap in complex foot and ankle pathology. A retrospective review was completed of all MFC flaps used in the foot and ankle over the past 5 years. Five patients were identified (average age 48). Surgical indications included talar AVN and ankle arthritis, talar nonunion, and navicular AVN. All patients had undergone conventional bone grafting techniques, which failed, prior to being treated with a MFC free flap; this series of patients did not possess significant medical comorbidities. Fixation techniques included compression screw fixation, plate osteosynthesis, or fine wire external fixation. The average follow-up was 20 months (range 8 to 40 months). There was a 100% flap success rate with no returns to the operating room for thrombosis. The volume of the bone flaps was 5.6 cm(3) (range 1 cm(3) to 12 cm(3)). The average follow-up time was 20 months (range 8 to 40 months). All cases resulted in union, and full weight bearing status was achieved at a mean of 23.8 weeks (range 10 to 52 weeks) postoperatively. Vascularized bone transfer in the form of the MFC free flap was a valuable method for foot and ankle reconstruction. The MFC flap provided an alternative for those defects that were smaller then 3 cm in length. In our experience, for small bone defects requiring vascularized bone, the MFC flap is currently the ideal donor location supplanting the iliac crest. Level IV, retrospective case series.

Congenital pseudoarthrosis of the tibia

This preliminary report is on two patients with congenital pseudoarthrosis of the tibia who had a persistent nonunion following intramedullary rodding and bone grafting. We do not advocate repeated surgery to achieve union. When limb length discrepancy becomes greater than 5 cm, we proceeded with an Ilizarov procedure with the primary aim of equalizing limb length rather than achieving union. Healing of the pseudoarthrosis occurred in both patients after lengthening over the intramedullary rod without compression of the nonunion site. We believe that union occurs because of hyperaemia during the lengthening. This approach minimizes the repeated surgeries that are usually needed and thus ensures a more normal childhood without frequent hospitalizations.

Outcome of locking compression plates in humeral shaft nonunions

Background:Nonunion of diaphyseal fractures of the humerus are frequently seen in clinical practice (incidence of up to 15% in certain studies) and osteosynthesis using dynamic compression plates, intra medullary nails and Ilizarov fixators have been reported previously. Locking compression plates (LCP) are useful in the presence of disuse osteoporosis, segmental bone loss and cortical defects that preclude strong fixation. We report a prospective followup study of the outcome of the use of LCP for humeral nonunion following failed internal fixation in which implants other than LCP had been used.Materials and Methods:Twenty four patients with nonunion of humeral shaft fractures following failed internal fixation were included in the study. The mean followup period was 3.4 years (range: 2.4 to 5.7 years) and the minimum followup period was 2 years. Mean age of the patients was 41.04 years (range: 24 to 57 years). All 24 patients underwent osteosynthesis using LCP and autologous bone grafting (cortico-cancellous iliac crest graft combined with or without fibular strut graft). Main outcome measurements included radiographic assessment of fracture union and pre and postoperative functional evaluation using the modified Constant and Murley scoring system.Results:23 out of 24 fractures united following osteosynthesis. Average time to union was 16 weeks (range: 10 to 28 weeks). Complications included delayed union (n = 2), transient radial nerve palsy (n = 2) and persistent nonunion (n = 1). Functional evaluation using the Constant and Murley score showed excellent results in 11, good in 10, fair in two and poor outcome in one patient.Conclusions:Locking compression plating and cancellous bone grafting is a reliable option for achieving union in humeral diaphyseal nonunion with failed previous internal fixation and results in good functional outcome in patients with higher physiological demands.

Chronic Thrombosis in the Descending Genicular Artery during Harvest of a Medial Femoral Condyle Corticocancellous Flap: A Case Report

Since its original description [10], the vascularized medial femoral condyle (MFC) corticoperiosteal free flap has gained increased popularity due to its versatility and reliability. While the flap was initially proposed for small bone nonunions [5], its favorable characteristics and osteogenic potential have led to its application in long bone nonunions [4]. The advantages of this flap include minimal donor side morbidity, a long noncritical vascular pedicle, and relatively reliable anatomy [7]. To date, there have been few disadvantages or complications of this flap reported in the literature. Those cited include persistent nonunion, seroma formation, knee pain, flap failure, and femur fracture [1, 3]. We present the case of a chronic arterial thrombosis in the descending genicular artery (DGA) identified during the harvest of a MFC corticocancellous flap for a humeral nonunion.

Vascularized Scapular Free Bone Graft after Nonunion of a Tarsal Navicular Stress Fracture: A Case Report

Nonunion of a tarsal navicular stress fracture, although relatively uncommon, is often amenable to open reduction and internal fixation. Furthermore, avascular necrosis of the navicular whether intact or occurring after fracture is rare, secondary to the adequate blood supply it receives. However, persistent nonunion after primary surgical repair in conjunction with avascular necrosis often results in limited treatment options. Thus, the purpose of the present case report is to describe the surgical approach and complications of a vascularized scapular free bone graft for augmentation of revision talonavicular and naviculocuneiform arthrodesis.

Distal Femur Allograft Prosthetic Composite Reconstruction for Short Proximal Femur Segments following Tumor Resection

Short metaphyseal segments remaining after distal femoral tumor resection pose a unique challenge. Limb sparing options include a short stemmed modular prosthesis, total endoprosthetic replacement, cross-pin fixation to a custom implant, and allograft prosthetic composite reconstruction (APC). A series of patients with APC reconstruction were evaluated to determine functional and radiologic outcome and complication rates. Twelve patients were retrospectively identified who had a distal femoral APC reconstruction between 1994 and 2007 to salvage an extremity with a segment of remaining bone that was less than 20 centimeters in length. Seventeen APC reconstructions were performed in twelve patients. Eight were primary procedures and nine were revision procedures. Average f/u was 89 months. Twelve APC reconstructions (71%) united and five (29%) were persistent nonunions. At most recent followup 10 patients (83%) had a healed APC which allowed WBAT. One pt (8%) had an amputation and one pt (8%) died prior to union. Average time to union was 19 months. Four pts (33%) or five APC reconstructions (29%) required further surgery to obtain a united reconstruction. Although Distal Femoral APC reconstruction has a high complication rate, a stable reconstruction was obtained in 83% of patients.

Behandling av skafoidfrakturar i eit lokalsjukehus

Scaphoid fractures are common, but can easily be overlooked clinically. The purpose of this study was to determine the incidence of this injury and the treatment outcome for patients with scaphoid fractures in our department. All patients with scaphoid fractures who were treated in the Orthopaedic Section of Haugesund Hospital from 1987 up to and including 2011 were included in the study. Data was gathered through review of patient records. 415 patients were included. 302 (73%) were men, and the average age was 35. The final outcome was known for 385 patients (93%), and only these were included in the analysis of the results. Cast immobilisation resulted in radiographic union in 281 of 308 cases (91%), and 26 follow-up operations brought the number healed up to 302 (98%). Seventeen patients received surgical primary treatment because of extensive displacement. After a maximum of two reoperations, all fractures were healed. Fractures were healed in 319 (98%) of a total of 325 patients who received appropriate primary treatment. 60 patients went without treatment for a long time. Fractures were healed in 41 (68%) of patients who had cast immobilisation followed by surgery in 38 cases. Non-union was found in a total of 66 patients (17%). 50 of the 66 non-union patients underwent surgery; the fractures of 84% of them were healed. The final outcome was healing of 360 of 385 patients (93%). 25 patients (7%) developed persistent non-union. The result of plaster casting and surgery was satisfactory. The prognosis for scaphoid fractures that receive appropriate primary treatment is good, but many such fractures are only discovered at a late stage.

Free Vascularized Iliac Crest Bone Graft for the Treatment of a Pediatric Lateral Humeral Condyle Fracture Nonunion: A Case Report.

Fractures of the lateral humeral condyle are the second most common pediatric elbow fracture1, and they account for 15% of all pediatric elbow fractures2. In lateral humeral condyle fractures that were treated closed, 28.5% developed nonunion, while all fractures that were treated open healed2,3. These fractures are one of the few in children in which nonunion is a relatively common complication2,3. The algorithm for treating an established nonunion includes open reduction and internal fixation (ORIF) with bone-grafting4. To our knowledge, there is no literature demonstrating the percentage of treated nonunions that remain ununited, although this has been reported as a complication5. It is our experience that if the persistent nonunion is not treated, it can lead to progressive cubitus valgus deformity, elbow instability, and pain in adolescence and adulthood, without surgical options to treat this problem in adulthood6. This case report describes a successful option for providing union of the lateral humeral condyle in a patient with continued nonunion after ORIF and bone-grafting. The patient was informed that data concerning her case would be submitted for publication, and both the patient and her mother provided consent. A ten-year-old right-hand-dominant girl presented to our institution with symptoms of increasing pain and valgus deformity in the left elbow. Eight years prior, she had fallen on an outstretched arm and sustained a lateral humeral condyle fracture, which was treated nonoperatively. The fracture did not heal, and she had developed pain and deformity in the elbow. One year prior to presentation to us, an orthopaedic surgeon had performed a traditional in situ ORIF with iliac crest bone-grafting. On presentation to us, she had tenderness over the lateral humeral condyle. Elbow motion was 0° to 140°, pronation …

Judet osteoperiosteal decortication for treatment of non-union: The Cornwall experience

BackgroundThe treatment of non union can be challenging with a variety of surgical options available to achieve bone consolidation. Robert Judet first described a method of osteo-periosteal decortication in 1963. He stated that by elevating cortical chips that remain attached to the periosteum and overlying soft tissues surrounding the site of non-union, combined with mechanical support, the bone consolidated. Despite excellent results presented in 2008 of 99% union rates with a mean delay of 8 months, the technique has not yet become popularised. We aim to show that Judet's method of decortication can achieve good results in the management of failure of union in a hospital other than Judet's. MethodsRetrospective analysis was performed from December 2002 to December 2008 of 40 cases in 39 patients of osteoperiosteal decortication for fracture non-union. Concurrent stabilisation was with internal fixation only. All procedures were performed by one surgeon (MN) using the Judet technique after learning the technique in the originators hospital. A preoperative non union scoring system was also used to assess its use in predicting persistent non-union. ResultsUnion was successfully achieved in 36 of the 39 surviving cases (92.3%) after a median delay of 8 months (range 3–47, SD 9.2) Twenty-six patients (65%) achieved union following the decortication procedure without subsequent operations. Factors such as open fracture and smoking did not have a statistically significant effect on union. The mean number of procedures following decortication was 0.68 (range 0–4). Metalwork failure occurred in 11 cases (28%), the majority in femoral decortications (n=9, 82%). The femur was the site of all persistent non unions in the series. Three patients had superficial infections and two had deep infections. The pre-operative non union scoring system (0–100) means were noticeably worse for the persistent non union group 42.0 (20–46) compared with the union group 31.0 (range 4–52). ConclusionsOsteoperiosteal decortication remains a highly effective surgical technique in the management of failed fracture union. The non union scoring system is a reliable predictor of persistent non union after this type of surgery. Clinical relevanceRelevant to general trauma orthopaedic surgeon and specialist orthopaedic surgeons with an interest in fracture non-union.

Gap nonunion of tibia treated by Huntington′s procedure

Background:Gap nonunion that may occur following trauma or infection is a challenging problem to treat. The patients with intact or united fibula, preserved sensation in the sole, and adequate vascularity, were managed by tibialization (medialization) of the fibula (Huntington's procedure), to restore continuity of the tibia. The goal of this retrospective analysis study is to report the mid-term results following the Huntington's procedure.Materials and Methods:22 patients (20 males and two females) age 16-34 years with segmental tibial loss more than 6 cm were operated for tibialization of fibula. The procedure was two-staged in seven and single-staged in the rest 15 patients, where the lateral aspect of the leg was relatively supple. In the two-staged procedure, the distal tibiofibular synostosis was performed six-to-eight weeks after the proximal procedure. Weightbearing (protected) was started in a long leg cast after six-to-eight weeks of the second stage and continued for six-to-eight months, followed by the use of a brace.Results:The fibula started showing signs of hypertrophy within the first year after the procedure and it was more than double in breath after the four-year period. Full and unprotected weightbearing on the operated leg was achieved at an average time of 16 months. At the final followup, ten patients were very satisfied, seven satisfied, and five fairly satisfied. One patient had persistent nonunion at the proximal synostotic site even after bone grafting and secondary fixation.Conclusion:Huntington's procedure is a safe and simple salvage procedure and remains an excellent option for treating difficult infected nonunion of the tibia in the selected indications.

Modified Retrograde-Locked Nailing for Aseptic Femoral Supracondylar Nonunion With Severe Osteoporosis in Elderly Patients

Femoral supracondylar nonunions in elderly patients are uncommon. To date, there is no convincing technique for managing this condition. When the nonunion is associated with severe osteoporosis, treatment becomes even more complicated. We developed a modified retrograde-locked nailing technique to treat this complex lesion. Twenty-four aseptic femoral supracondylar nonunions with severe osteopenia in 24 elderly patients (aged ≥65 years) were treated. A retrograde femoral-locked nail was inserted in the dynamic mode. Next, the medial ½ to 2/3 marrow cavity in the nonunion site was filled with bone cement, and the lateral 1/3 to ½ marrow cavity received a cancellous bone graft with or without a bone graft substitute. A cylindrical brace was applied for 3 weeks postoperation. Early ambulation with a walker or wheelchair was encouraged. Twenty patients were followed up for an average period of 2.5 years (range, 1.1-4.5 years), and 18 nonunions healed. The union rate was 90.0% with an average union period of 4.9 months (range, 4-7 months). No deep infection or malunion was found. The two patients with persistent nonunions were advised to use a walker whenever necessary. The satisfactory rate for knee function improved from 0% preoperatively to 80.0% at the latest follow-up. The described technique may concomitantly provide sufficient stability and initiate osteogenic potential, thus facilitating bone union. This technique is simple with a low complication rate and thus should be considered as a useful alternative for treating this complex lesion.

Reconstructive Surgical Treatment Without Bone Grafting in Nonunions of Humeral Surgical Neck Fractures

To evaluate reconstruction surgery without bone grafting in humeral surgical neck nonunions using either a blade plate or the "Humerusblock" implant in small head fragments. Retrospective cohort study, Evidence-Based Medicine Level IV. Paracelsus Medical University Salzburg, Department of Traumatology and Sports Injuries. Fifty-five patients (mean age, 66.2 years) with symptomatic nonunion after humeral surgical neck fractures were subjected to surgical reconstruction. In 45 patients, open reduction and internal fixation using a blade plate was performed (Group 1). In 10 patients, the Humerusblock device was used (Group 2), because the head fragment of each of these patients was too small for plating. In no patients was bone grafting used. Shoulder function, level of pain, and bone healing. After a mean follow-up time of 74 months, the overall mean Constant score improved from 30.4% preoperatively to 83.2% postoperatively. The improvement was from 30.5% to 85.3% in Group 1 and from 32.2% to 75.4% in Group 2, which represented statistically significant improvements for both groups (P < 0.01). Radiologic bone healing was achieved in 51 patients (93%). The overall complication rate was high, 15%, and complications included plate loosening, avascular head necrosis, persistent nonunion, and infection. Nonunion of humeral surgical neck fractures can be successfully treated by surgical reconstruction without bone grafting using either a blade plate or the Humerusblock for small head fragments. However, an increased complication rate is associated with this challenging posttraumatic pathology.

Revision surgery for femoral shaft aseptic nonunion associated with broken distal locked screws

Abstract Purpose This retrospective study was to report the experience in treating femoral shaft aseptic nonunions associated with breakage of distal locked screws. Materials and Methods Thirty-two femoral shaft aseptic nonunions associated with breakage of both distal locked screws in 30 consecutive adult patients with 32 nonunions were treated. Eleven nonunions were concomitantly associated with at least 1.5 cm (1.5–3.5) shortening. These 11 nonunions were treated by one-stage nail exchange and femoral lengthening, static locked nailing stabilization, and corticocancellous bone graft supplementation, whereas other 21 nonunions were treated with less than 1.5 cm shortening, simple exchange nailing only. Results Twenty-eight nonunions were followed-up for a median of 3.8 (1.1–6.2) years and 26 fractures healed at a median of 4 (3–9) months. Either group had one persistent nonunion (p = 0.48) and was successfully treated with repeated exchange nailing or open cancellous bone grafting. Conclusions Using exchange locked nailing or one-stage femoral lengthening to treat femoral shaft aseptic nonunion associated with broken distal locked screws can achieve a high success rate. The key of the technique to remove broken screws is withdrawing the nail a little bit to release the incarcerated broken screw end. Then, the screw end is pushed out with a used Knowles’ pin or a smaller size screwdriver under the image intensifier guidance.

Open reduction and internal fixation of clavicular nonunions with allograft bone substitute

Background:Biologic augmentation with allograft has shown equivalent healing rates to autograft in several nonunion models. No literature exists clearly demonstrating this in the clavicle. The purpose of this study was to evaluate the healing and complication rates of clavicle nonunions treated solely with open reduction and internal fixation (ORIF) and allograft.Materials and Methods:Nineteen clavicle nonunions treated with ORIF and allograft were evaluated retrospectively to assess healing rates and complications based on clinical symptoms and radiographic findings.Results:For the 19 patients included and treated with ORIF and allograft, clinical follow-up averaged 15 months. Seven patients were smokers. Although complete radiographic healing was achieved in only 68% of patients, clinical success occurred in 16 (84%) patients who demonstrated full range of motion and strength without pain. The three patients who did not demonstrate full radiographic healing were completely pain free. Five patients experienced complications (26%). Two underwent hardware removal due to persistent irritation after union. Three had a persistent painful nonunion. Each of these three patients was a smoker (P=0.08). Two proceeded to union after revision fixation. The other had hardware failure, which was removed, with a persistent nonunion and did not wish any further treatment.Conclusion:ORIF with allograft bone substitute is an acceptable treatment alternative to iliac crest bone graft for clavicle nonunions. However, we did not demonstrate equivalent healing rates to published results utilizing autograft. Smokers were identified to have a trend toward higher failure rates with ORIF augmented with allograft and therefore these patients may be better served by augmenting fixation with autograft.Level of Evidence:IV; retrospective comparative study.

Transfer of Ipsilateral Fibula on Vascular Pedicle for Treatment of Congenital Pseudarthrosis of the Tibia

Although the use of free vascularized fibula grafts has frequently been reported in the treatment of congenital pseudarthrosis of the tibia, the use of ipsilateral fibula graft on a vascular pedicle is uncommon. We reviewed the long-term results of this procedure in 11 patients. The records of 11 patients who underwent transfer of the ipsilateral fibula on a vascular pedicle between 2.1 and 10.8 years of age were retrospectively reviewed. Average follow-up was 11 years after the index procedure. Seven patients had reached skeletal maturity. Clinical records and radiographs were reviewed to determine patient demographics, surgical parameters, union rate, refracture rate, residual deformity, and functional outcome. Eight patients (73%) achieved union at an average of 20.1 months. Additional bone grafting procedures were required in 4 patients with distal nonunions. There were 3 refractures (38%). Four patients eventually underwent amputation, and 1 patient had a persistent nonunion at final follow-up. Residual deformity included tibial valgus and procurvatum deformities, limb length discrepancy, and ankle valgus. Use of the ipsilateral fibula did not seem to increase the risk of ankle valgus. Functional outcomes were good in all but one patient. Use of the ipsilateral fibula as a pedicle graft provides reasonable results in healing congenital pseudarthrosis of the tibia. Patients should be monitored for the sequelae of this condition, including nonunion, refracture, shortening, and angular deformity, and treated accordingly. Therapeutic Level IV.

Judet osteo-periosteal decortication for treatment of non- and mal-union: the Cornwall experience

The treatment of nonunion is challenging providing the surgeon with a variety of different surgical options in order to encourage and achieve bone consolidation. Despite excellent results presented in 2008 of 99% union rates, Judet Osteo-Periosteal Decortication does not seem to be popular at present with bone grafting and distraction osteo-modelling being the favoured option. Retrospective analysis was performed from December 2002 to December 2008 of 46 cases of osteoperiosteal decortication(Judet technique) for failure of fracture union. Union was successfully achieved in 39 of the 45 patients(85%) after a mean delay of 10.7 months(range 3-39 months). Thirty patients(65%) achieved union following the decortication procedure without subsequent operations. The mean number of procedures following decortication was 0.6(range 0-4) mostly being performed for metalwork failure. Metal work failure occurred in 13 cases(28%) with the majority occurring in decortications of the femur(n=11,85%). The femur was the location of all persistent non unions in the series. The nonunion scoring system(0-100,Calori et al 2008) means were noticeably worse for the persistent nonunion group(41.67, range 34-46) compared to the union group(29, range 4-52). Osteoperiosteal decortication remains a highly effective surgical technique in the management of failed fracture union.

Corticoperiosteal flap in the treatment of nonunions and small bone gaps: Technical details and expanding possibilities

The corticoperiosteal flap from the medial femoral condyle (CP) has proved to be highly reliable in the management of persistent, recurrent nonunion. However, much of the related literature has focussed on the flap aspects of the procedure and not so much on bone work-up. We present a series of 25 patients with nonunions and small bone gaps irresponsive to conventional therapy that were successfully treated with a CP with/without the addition of non-vascularised bone graft from the iliac crest. Different technical options of bone reconstruction are possible and discussed: CP plus non-structural bone chips, CP plus structural bi/tricortical struts or CP plus vascularised cancellous bone from the femoral condyle. A stable internal fixation was performed in all cases. Clinical and radiological evidence of healing was obtained in all the patients. Donor-site complications were few and transient (suture intolerance, seroma and numbness in the saphenous territory). No fracture of the femur, knee instability or stiffness has been observed. The corticoperiosteal flap from the femoral condyle is an excellent source of vascularisation and osteogenic stimulus to the nonunion site and highly effective in the management of persistent nonunions and small bone gaps. When needed, a structural corticocancellous strut from the iliac crest (along with a stable internal fixation) provides the greatest stability and the possibility of a prompt rehabilitation and functional recovery. The corticoperiosteal flap has succeeded in revascularising these highly demanding grafts and in allowing a 100% union rate.

One-stage management of infected nonunion using granulated cancellous bone autografting after debridement

To investigate the curative effect of treating infected nonunion with debridement and granulated cancellous bone autografting in a one-stage procedure. Between 1999 and 2005, 38 cases of infected nonunion were treated with immediate granulated cancellous bone autografting after debridement. At a mean follow-up of 44 months (range: 12 to 93), 33/38 (86.8%) had an excellent outcome, 5 (13.2%) developed infectious recurrent and/or persistent nonunion (1 case with infectious recurrence and persistent nonunion). Two patients suffered refracture after removing external fixator. The success rate of treating infected nonunion with debridement and granulated cancellous bone autografting in one-stage is high.

Long-term follow-up of the surgical management of neuropathic arthropathy of the spine

Background Context No studies have discussed the long-term surgical management and outcomes of Charcot arthropathy of the spine. This case series presents nine patients treated over 30 years. The study hypothesis was that surgery would reduce instability, pain, recurrence, and the need for revision surgery in the long-term, given previous study findings of successful fusion of Charcot spine in the short-term. Purpose To evaluate the long-term outcomes of surgery for Charcot spine. Study Design/Setting Retrospective case series. Cases took place at Stanford University Medical Center and Santa Clara Valley Medical Center. Methods All patients had either complete paraplegia or dense paraparesis with both major motor and sensory deficits. Seven patients developed Charcot spine after spinal instrumentation for trauma, one after scoliosis repair for meningomyelocele, and one after spinal instrumentation for neuromuscular scoliosis caused by birth injury resulting in C6–C7 quadraplegia. Average time between initial instrumentation and development of Charcot spine was 7.6 years. Two patients underwent posterior fusion alone, six had anterior-posterior fusion, and one was managed with thoracolumbar orthosis. Results Average follow-up was 14.3 years. Revisions were necessary in 75% (6 of 8) of patients for complications including nonunion, new Charcot joints, recurrent hardware failure, and osteomyelitis. Achieving fusion often required multiple operations, and there were no deaths or neurologic complications. Conclusions Long-term follow-up showed a high rate of revision surgery. Solid fusions often resulted in late breakdown or new junctional Charcot arthropathies. Patients initially fused to the lumbar spine instead of the sacrum or pelvis had a higher rate of developing another Charcot joint. Fusion was often difficult with persistent nonunions and functional deficits because of decreased mobility. We recommend that Charcot spine well tolerated without skin, seating problems, or dysreflexia should be cautiously observed with conservative management. For surgical care, we recommend three-column stabilization with either combined anterior-posterior or all posterior approaches with anterior support to obtain and secure greater long-term stability.

Free vascularised iliac bone graft for recalcitrant avascular nonunion of the scaphoid

We report the use of a free vascularised iliac bone graft in the treatment of 21 patients (19 men and 2 women) with an avascular nonunion of the scaphoid in which conventional bone grafting had previously failed. The mean age of the patients was 32 years (23 to 46) and the dominant wrist was affected in 14. The mean interval from fracture to the vascularised bone grafting was 39 months (9 to 62). Pre-operative MRI showed no contrast enhancement in the proximal fragment in any patient. Fracture union was assessed radiologically or with CT scans if the radiological appearances were inconclusive. At a mean follow-up of 5.6 years (2 to 11) union was obtained in 16 patients. The remaining five patients with a persistent nonunion continued to experience pain, reduced grip strength and limited range of wrist movement. In the successfully treated patients the grip strength and range of movement did not recover to match the uninjured side. Prevention of progressive carpal collapse, the absence of donor site morbidity, good subjective results and pain relief, justifies this procedure in the treatment of recalcitrant nonunion of the scaphoid.