Scaphoid Waist Nonunion Research Articles

Arthroscopic treatment of scaphoid nonunion with humpback deformity and DISI with corticocancellous bone grafting: Technical note

For two decades, scaphoid nonunion has been treated arthroscopically. However, compressed cancellous bone graft does not have the same mechanical properties as corticocancellous bone graft for reducing the scaphoid humpback deformity and DISI tilt. Here, we describe an arthroscopic technique to treat Alnot stage IIB scaphoid nonunion. We treated a 27-year-old male patient for scaphoid waist nonunion with humpback deformity and DISI. A 8×8×10 mm cylindrical corticocancellous bone graft was harvested from the dorsal aspect of the radius using a single-use osteochondral autograft transfer system (OATS®, Arthrex Inc., Naples, USA). It was inserted in the nonunion site through an arthroscopic volar approach. Bone union was obtained at 3 months with lasting correction of the scaphoid humpback deformity and DISI. The functional result at 6 months was excellent. There were no complications. Scaphoid nonunion with humpback deformity and DISI may be treated arthroscopically with a corticocancellous bone graft.

TREATMENT OF SCHAPHOID NONUNION WITH VOLAR LOCKED PLATE.

ABSTRACTObjective:To assess and compare radiographic, tomographic and functional pre and postoperative parameters of patients submitted to treatment of nonunion of the scaphoid waist with locked plate for scaphoid.Methods:This is a case series of scaphoid waist nonunion, operated from March 2017 to March 2018 at the Institute of Orthopedics and Traumatology of HCFMUSP, using the technique of Fisk-Fernandez and osteosynthesis with locked plate for scaphoid APTUS®Hand from Medartis. The patients were submitted to radiographs, computed tomography and functional evaluation by the occupational therapy team in the pre and postoperative periods.Results:There was consolidation of the scaphoid waist nonunion in all cases, improvement in the parameters of carpal alignment in the imaging examinations, but functionally we observed reduction of the range of motion and grip strength in relation to the contralateral limb.Conclusions:The treatment of the scaphoid waist nonunion with locked plate was effective, with a high index of consolidation and improvement of the carpal alignment in the imaging tests, although with a reduction in the range of motion and grip strength in relation to the contralateral limb when evaluated with 12 weeks postoperatively. Level of Evidence IV, Case series.

Treatment of scaphoid waist nonunion by one, two headless compression screws or plate with or without additional extracorporeal shockwave therapy.

Scaphoid nonunion remains challenging for hand surgeons. Several treatmentoptions are available such as: non-vascularized or vascularized bone grafting, with or without additional stabilization. In the last few decades, extracorporeal shockwave therapy (ESWT) has become an established procedure for treating delayed and nonunions. Purpose of this retrospective follow-up study was (a) to investigate union rate and clinical outcome of the different implants [either one/two headless compression screws (HCS) or a plate] and (b) union rate and clinical outcome using only surgery, or a combination of surgery and ESWT. The study included 42 patients with scaphoid nonunions of the waist with a mean follow-up of 52months. All patients received a non-vascularized bone graft from the iliac crest and stabilization was achieved by using one, two HCS or a plate. ESWT was performed with 3000 impulses, energy flux density per pulse 0.41mJ/mm2 within 2weeks after surgery. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, Disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O'Brien (Mayo) Wrist Score. In addition, each patient had a CT scan of the wrist. A total of 33/42 (79%) patients showed union at the follow-up investigation. Patients treated with additional ESWT showed bony healing in 21/26 (81%) and without ESWT in 12/16 (75%). Patients that were stabilized using one HCS showed bony healing in 6/10 (60%), with two HCS 10/12 (83%) and by plate 17/20 (85%). The ESWT group had a significantly lower pain score according to the VAS and better modified Green O'Brien (Mayo) Score. No differences could be found in respect of ROM, grip strength, functional outcome score depending of which stabilization method was used. Stabilization of scaphoid waist nonunions with two HCS or plate showed higher union rates than a stabilization using only one HCS. In addition, ESWT combined with a nonvascularized bone graft from the iliac crest seems a suitable option for treating scaphoid nonunions.

Clinical and Radiologic Outcomes of the Matti-Russe Technique for Scaphoid Nonunions in Pediatric Patients.

Scaphoid fractures are a common injury, and a known complication is nonunion. One option to treat this nonunion is with the Matti-Russe technique, which takes a corticocancellous graft and fits it into the defect without internal fixation. The advent of modern methods of fixation has led the classic Matti-Russe technique to fall out of favor. In this study, we describe the classic technique and evaluate the results of the Matti-Russe method for treatment of scaphoid nonunions specifically for the pediatric population. Our purpose was to evaluate the long-term clinical and radiologic outcomes after surgery for scaphoid nonunion using the Matti-Russe technique in the pediatric population. A retrospective review was performed of patients less than 17 years of age, with a scaphoid nonunion that was treated with the Matti-Russe technique. This technique consisted of open reduction with intercalated bone graft and no internal fixation with hardware. Union was determined by radiographic evaluation. Computed tomography was obtained in 7 of 10 patients in this series and showed bony bridging in more than 50% of the scaphoid width in 3 different views. Intrascaphoid, scapholunate, and radiolunate angles were calculated. We reviewed wrist range of motion and complications. We obtained postoperative Mayo and Disabilities of the Arm, Shoulder and Hand (DASH) scores. There were 10 patients who underwent the Matti-Russe technique. The average age was 14.7 years old (±1.34, range: 13-17). All 10 of these patients had a scaphoid waist nonunion. There were 9 males and 1 female with an average follow-up of 13 months. The average amount of time to surgery from the date of injury was 12.3 months. All 10 patients went on to radiographic union at or before 6 months from surgery. Preoperative intrascaphoid, scapholunate, and radiolunate angles were 29° (±5.38), 62° (±18.28), and 20° (±9.22). Postoperative intrascaphoid, scapholunate, and radiolunate angles improved to 16° (±6.89), 38° (±8.50), and 10° (±4.69), which was significant. Seven out of 10 patients completed postoperative outcomes measures. The average postoperative Mayo wrist score was 87.9 (±14.10, range: 60-100). The average postoperative DASH score was 1.9 (±2.03, range: 0-4.5). There were no associated complications nor reoperations. The Matti-Russe technique is a safe and effective treatment for scaphoid nonunion in the pediatric population. It facilitates scaphoid union without the need for screw fixation and avoiding potential complications with hardware.

Results of percutaneous fixation and distal radius core decompression in scaphoid waist non-unions treated without grafting

Scaphoid non-union management is still a challenge in clinical practice for orthopaedic surgeons. Though several treatment methods have been described, there is an ongoing debate about optimum management. Based on new concepts about avascular conditions, promising results were reported with metaphyseal decompression of the distal radius by increasing the vascularization of the radial column of the carpus. We aimed to evaluate the clinical, radiological, and functional outcomes of distal radius core decompression and fixation with palmar percutaneous cannulated compression screws without grafting in patients with scaphoid waist fracture non-union. Twenty-nine patients with scaphoid non-union were included in this prospective study. There were 27 male and 2 female patients with an average age of 29 years (range 18–45 years). Mean time from the injury to surgery was 18.3 months. The Slade and Geissler classification was used to classify the non-unions. Wrist range of motion (ROM), pain based on a visual analog scale (VAS), and the Mayo wrist score were used to assess the clinical outcomes. Postoperative radiographs and CT-scans were reviewed to assess fracture union, carpal alignment and screw position. The average clinical follow-up was 76 weeks (range: 74–87 weeks) postoperatively. Mean time to union was 11 weeks (range: 7–18 weeks). There was no humpback/no DISI in any of the cases. Twenty-six patients healed successfully with no additional procedures. Three patients with failed union underwent revision surgery with grafting. At the final follow-up, average wrist ROM was 61° (range: 30–80) in extension and 61° (range: 35–80) in flexion, the average Mayo wrist score was 66±20 (range: 20–90), and the mean VAS was 2±2 (range: 0–7). Percutaneous fixation without grafting associated with distal radius core decompression can provide satisfactory outcomes in surgical management of scaphoid non-unions. Level of evidenceII.

Treatment of the scaphoid humpback deformity – is correction of the dorsal intercalated segment instability deformity critical?

Treatment of scaphoid fractures has been focused mainly on achieving union, with less attention to restoring normal scaphoid shape and orientation. Malalignment of one carpal bone will disrupt the kinetics of the entire wrist. The dorsal intercalated segment instability deformity associated with scaphoid waist nonunion is a nondissociative form of carpal instability. It has to be reduced in the treatment of scaphoid waist nonunions to avoid kinetic problems that will lead to arthritic changes. Computerized tomography scanning has become indispensable to visualize the humpback deformity clearly. Different techniques may be used to restore the normal anatomy of scaphoid, from non-vascularized graft to arthroscopic bone grafting, and also the option of vascularized bone grafting.

Treatment of Scaphoid Waist Non-Union with A Modified Matti-Russe Technique: Our Experience Giuseppe

Amongst the different techniques for scaphoid non-union, the Matti-Russe procedure is a simple method where a cortico-cancellous bone graft from the iliac crest is packed in the scaphoid...

Greffe spongieuse et fixation par vis de compression sans tête dans les pseudarthroses du scaphoïde carpien

PurposeScaphoid fracture commonly occurs around the mid-third of the scaphoid, and nonunion of this fracture has several treatment options. The authors performed autologous cancellous bone graft from the iliac crest and headless compression screw fixation for the treatment of Mack–Lichtman type II scaphoid waist nonunion. The purpose of this study was to determine whether this procedure was effective in achieving bony union and restoration of alignment. MethodsMedical records and radiographs of 30 patients who underwent cancellous bone graft and headless compression screw fixation for nonunion of scaphoid waist fracture were retrospectively reviewed. There were 28 men and 2 women, with a mean age of 32.8 years (range, 21–63). The mean time to surgery was 10 months (range, 3–25) and mean follow-up was 37.5 months (range, 15–52). The authors analyzed bony union, lateral intrascaphoid angle, scapholunate angle, radiolunate angle and scaphoid length on radiographs and evaluated the modified mayo wrist score (MMWS) as a functional outcome. ResultsBony union was achieved in all cases. The lateral intrascaphoid angle improved from 40° to 32° (P<0.001). The scapholunate angle also improved from 61° to 56° (P=0.009). The radiolunate angle decreased from 8° to 4° (P=0.048) and scaphoid length increased from 22mm to 26mm (P<0.001) postoperatively. Wrist motion and MMWS improved significantly at last follow-up. However, there were no significant differences between scaphoid deformity correction angle and pre to postoperative difference in MMWS. ConclusionsNonstructural autologous cancellous bone graft from the iliac crest and headless screw fixation provided reliable results and can be one of the effective treatment options for patients with symptomatic Mack–Lichtman type II nonunion in the mid-third of the scaphoid. Level of evidenceLevel III.

The Result of Percutaneous Screw Fixation without Bone Grafting for Scaphoid Waist Nonunion under Local Anesthesia

The Result of Percutaneous Screw Fixation without Bone Grafting for Scaphoid Waist Nonunion under Local Anesthesia

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.

Non-Structural Cancellous Bone Graft and Headless Compression Screw Fixation for Treatment of Scaphoid Waist Nonunion

Non-Structural Cancellous Bone Graft and Headless Compression Screw Fixation for Treatment of Scaphoid Waist Nonunion

Hybrid Russe Procedure for Scaphoid Waist Fracture Nonunion With Deformity

To assess the results of a hybrid Russe procedure using a corticocancellous strut, cancellous autologous nonvascularized bone graft, and cannulated headless compression screw to reduce the deformity reliably from a collapsed scaphoid nonunion, provide osteoinductive stimulus, and stabilize the fracture for predictable union. A hybrid Russe procedure was performed for scaphoid waist fracture nonunions with humpback deformity and no evidence of avascular necrosis. A volar distal radius autologous bone graft was harvested and a strut of cortical bone was fashioned and placed into the nonunion site to restore length and alignment. We packed cancellous bone graft in the remainder of the nonunion site and fixed the scaphoid was with a headless compression screw. Union was determined by radiographs or computed tomography, and intrascaphoid, scapholunate, and radiolunate angles were calculated on final radiographs. We recorded wrist range of motion, grip strength, pinch strength, pain, and complications. Fourteen male and 3 female patients (average age, 32 years; range, 16-78 years), with a mean follow-up of 32 months, were examined clinically and radiographically. All 17 scaphoids united with a mean time for union of 3.6 months. The mean postoperative intrascaphoid angle was significantly reduced from 65° preoperatively to 35° postoperatively. The mean radiolunate angle was significantly improved from 20° from neutral (lunate tilted dorsally) preoperatively to 0° postoperatively. The scapholunate angle also demonstrated significant improvement from 70° preoperatively to 56° postoperatively. Grip strength improved from 70% of the contralateral hand to 89% after the procedure. All patients were satisfied with the functional outcome and no donor site morbidity or hardware issues were identified. This straightforward hybrid Russe technique predictably restored radiolunate, scapholunate, and intrascaphoid angles with a 100% union incidence. The technique provides excellent functional results in patients with a challenging clinical problem, and we recommend it for scaphoid fracture waist nonunions with dorsal intercalated segment instability deformity. Therapeutic IV.

Treatment of Scaphoid Waist Nonunion Using Olecranon Bone Graft and Stryker Asnis Micro Cannulated Screw: A Retrospective Study-80 Case Studies and 6 Years of Follow-Up.

Background Screw fixation and bone grafting are the gold standard for scaphoid waist nonunion without avascular necrosis. Question/Purpose Assesses the scaphoid waist nonunion healing rate with use of an uncommon cancellous bone graft (olecranon) and an unusual fixation system (Asnis Micro Cannulated Screw System; Stryker Inc., Kalamazoo, MI, USA). Material and Methods A series of 102 consecutive patients were treated for scaphoid waist nonunion (without deformity). Of these, 80 patients subjected to clinical (Modified Mayo Wrist Score (MMWS), Jamar hydraulic dynamometer) and radiographic examination before and after surgery were evaluated. Ipsilateral olecranon cancellous bone graft and the ASNIS Micro 3.0-mm diameter screw, were used. The average follow up was 6 years (min 3; max 10). Results Radiographic consolidation was achieved in 90% of patients; dorsal intercalated segment instability (DISI) deformities were corrected in 71.4% of cases. Ninety percent improved the range of motion of the wrist and grip strength. All patients showed a significant reduction of peak force in the operated hand. In 6.25% we observed clinical and radiographic screw head-trapezium impingement. Twenty-six patients developed a degenerative wrist sign. The MMWS yielded 68 optimal, 8 good, and 4 bad results. Conclusions To treat scaphoid waist nonunions without misalignment, low-profile headed screw and olecranon bone graft allowed a high consolidation rate with positive results to long-term follow-up. The Asnis Micro 3.0 mm diameter screw may be a suitable option for treating scaphoid waist nonunion. Level of Evidence IV.

Pure Cancellous Iliac Bone grafting for the Treatment of Scaphoid Waist Nonunions with Humpback Deformity

The scaphoid is the most commonly fractured carpal bone, accounting for approximately 60% of all carpal fractures, and continue to present diagnostic and therapeutic challenges. Early diagnosis and adequate primary treatment are important to provide healing and prevent late complications. The symptoms can often be misinterpreted as a sprain both by the patient and the doctor, and acute fractures may be difficult to see on ordinary X-rays. Despite scaphoid fractures are primarily recognized and treated appropriately, nonunion may occur in 5% to 15%. According to the recent report, most case series report an approximate 10% nonunion rate. More recent data reported that fracture displacement (usualPure Cancellous Iliac Bone grafting for the Treatment of Scaphoid Waist Nonunions with Humpback Deformity

Scaphoid Waist Nonunions Treated with Illiac Crest or Vascularized Bone Grafts

We present the results of a retrospective study looking at postoperative outcomes of treatment of scaphoid nonunions following three different techniques: Palmar (nonvascularized) iliac crest, vascularized bone-grafts dorsal and palmar. The purpose is to present the consolidation rates and discover if range of motion, grip strength and pain differ using the different grafts. Methods: We evaluated 57 cases with a mean follow-up of 6.6 months. 24 patients had nonunion of the proximal scaphoid pole with avascular osteonecrosis. Operative technique were chosen based on the vascularity, location of non-union, previous operations, and pedicle availability. Conventional graft was used in 19 patients, palmar vascularized in 15 and dorsal vascularized graft in 23. We measured and compared clinical and radiological outcomes. Results: Out of 57 nonunions 46 united. No significant difference in rate of consolidation was found between the 3 treatment groups. Highest percentage of consolidation, 87%, was in patients treated with a palmar vascularized graft, whereas the consolidation rate of dorsal vascularized graft was 78% and of iliac crest graft 79%. Grip strength improved significantly. The most in iliac crest group (from 70% to 91%) and the least in dorsal vascularized graft group (from 81% to 83%). Best range of motion in flexion/-extension was in the iliac-crest group, although not being significantly. Average Mayo score was 82. 18 patients showed an excellent, 17 a good, 13 a satisfactory and 3 a poor result. No significant difference was found between the groups. Conclusion: Vascularized grafts had a comparable consolidation rate and outcome in Mayo score as the iliac crest group, even though these cases were more problematic due to the presence of avascular necrosis. Iliac crest grafts afforded the best results concerning grip strength and range of motion. The gain in grip strength and range of motion was less with vascularized grafts.

Scaphoid Waist Nonunion With Humpback Deformity Treated Without Structural Bone Graft

Conventional treatment of scaphoid nonunion with collapse deformity and bone loss involves the use of a structural corticocancellous bone graft. With internal screw fixation, we propose that length and alignment can be restored and maintained using only cancellous interposition graft. We describe 12 patients with established scaphoid waist nonunions. Average patient age was 22 years, all were male, and 8 cases involved the dominant wrist. Time from injury to treatment averaged 11 months. We performed open reduction through an anterior approach with correction of the deformity and placement of a distal to proximal screw. We then simply filled the resultant defect with cancellous autograft obtained from the ipsilateral distal radius. All patients underwent postoperative computed tomographic imaging to document union and degree of correction. At a minimum 2-year follow-up, all patients had a united scaphoid with significant improvement in wrist extension compared with preoperative values. Grip strength also improved significantly. Disabilities of the Arm, Shoulder, and Hand scores at follow-up averaged 4 ± 3 (range, 0-9), the Mayo wrist score averaged 88 ± 6 (range, 80-100), and the average lateral intrascaphoid angle improved from 49° to 32° (normal, < 35°). Pain at follow-up as measured on a 10-point visual analog scale averaged 0.3 (range, 0-2). With stable internal screw fixation, scaphoid waist nonunion with collapse and bone loss can be successfully treated using only cancellous bone graft. Advantages include marked simplification of surgical carpentry, the use of local autograft, and rapid incorporation of cancellous bone without compromise of scaphoid reduction and carpal alignment. Therapeutic IV.

Three-Dimensional Computed Tomographic Analysis of 11 Scaphoid Waist Nonunions

To virtually assess nonunions of the scaphoid waist using 3-dimensional computed tomography (CT) reconstruction for the amount of displacement of the distal fragment and the postfracture reduction position using the intact opposite scaphoid for reference. We generated 3-dimensional reconstructions for 11 nonunions of the scaphoid waist and the contralateral intact scaphoids based on CT. The mean age of the patients was 25 years and the time from injury to the CT scan was 2.4 years. We used the mirrored 3-dimensional model of the healthy scaphoid to guide virtual reduction of the nonunion and calculated the amount of displacement of the distal pole fragment from prereduction to postreduction. We compared the results with the intrascaphoid angles calculated using single CT slices. The scaphoid nonunions showed a mean flexion deformity of 23°, an ulnar deviation of 5°, and a pronation deformity of 10°. Mean translation was 0.9 mm volarward, 0.2 mm radialward, and 3.3 mm distalward. After reduction, all scaphoids showed a bony overlap on the dorsoradial side; the mean volume of this region was 3% of total bone volume. There was no correlation between the degree of displacement and the intrascaphoid angle measurements. Preoperative planning for scaphoid reconstruction is usually performed using conventional radiographs and single CT slices. However, by synthesizing the information from the CT into a 3-dimensional reconstruction, an exact analysis is possible. This method also allows quantification of prosupination displacement. The postreduction area of dorsal bone overlap may be due to appositional callus formation. Simple volar opening of the scaphoid allows correction of angulation deformities but results in lengthening of the scaphoid. Correct reduction of the scaphoid fragments is often only possible if the dorsal appositional callus is resected.

Treatment of Nonunion of Scaphoid Waist with Ni-Ti Shape-Memory Alloy Connector and Iliac Bone Graft

After fracture, the unique anatomy and blood supply of the scaphoid itself predisposes to nonunion. Scaphoid nonunion presents a formidable challenge to surgeons because of the difficulties for fixation, and the high failure rate after treatment. The Ni-Ti shape-memory alloy can provide compressive stress at the nonunion site, which is the key point for bone healing. Hence, we designed a shape-memory bone connector named arched shape-memory connector (ASC). We conducted a retrospective study looking at the union rate and complications and correlating the outcome of treatment with this device. The study reviewed a cohort of six consecutive patients presenting with scaphoid waist nonunion, who were treated with ASC and iliac cancellous bone grafting at our center from August 2002 to December 2007. The patients with nonunion achieved a 100% union rate. All the patients who achieved union had good pain relief and improved function. Our study demonstrates that scaphoid waist nonunions can be successfully treated by ASC and iliac bone grafting.

Analysis of Carpal Malalignment Caused by Scaphoid Nonunion and Evaluation of Corrective Bone Graft on Carpal Alignment

To clarify the correlation between a scaphoid deformity and carpal malalignment in patients with scaphoid waist nonunion and to investigate how accurately a corrective bone graft improves carpal malalignment according to the preoperative plan. A total of 38 patients were analyzed retrospectively. Surgery was performed according to the anterior wedge bone graft method described by Fernandez. The scaphoid deformity and carpal malalignment were evaluated by the changes in the intrascaphoid angle (ISA) and axial length (AL) and by the changes in the radiolunate angle (RLA) and scapholunate angle (SLA), respectively, compared with the uninjured side by using standardized x-rays. Each variable was measured at 1 year after surgery. By performing multiple regression analysis, the correlation between the scaphoid deformity and carpal malalignment and between the correction of the scaphoid deformity and the change in carpal alignment were analyzed. Compared with the uninjured side, the mean respective changes in the ISA, AL, RLA, and SLA were 11°, -1.3 mm, 14°, and 11°, preoperatively. The changes in the RLA and SLA correlated with the change in the ISA, but not with the change in the AL. The mean postoperative corrections of the ISA and AL were 15° from full extension and 1.7 mm, and the changes in the RLA and SLA were 18° and 12° from full extension, respectively. The change in the RLA correlated with the corrections of the ISA and AL. Although the change in the SLA did not correlate with either of them, the mean postoperative SLA was not significantly different from the mean value of the uninjured side. The degree of humpback deformity of the scaphoid correlated with the degree of carpal malalignment. The corrective bone graft resulted in the expected recovery of carpal alignment according to the preoperative plan. Prognostic IV.

Treatment of Scaphoid Waist Nonunions with an Avascular Proximal Pole and Carpal Collapse

Surgically, it is difficult to achieve union of a scaphoid nonunion that is associated with osteonecrosis of the proximal pole, and those with carpal collapse are especially difficult to treat. A variety of vascularized bone grafts can be used. The purpose of this study was to compare the effectiveness of two types of vascularized bone graft -- a distal radial pedicle graft and a free vascularized medial femoral condyle graft -- in the treatment of scaphoid waist nonunions associated with proximal pole osteonecrosis and carpal collapse. A retrospective review was conducted at two institutions to identify all patients with a scaphoid waist nonunion associated with an avascular proximal pole and carpal collapse. Between January 1994 and June 2006, twenty-two such nonunions were identified in twenty-two patients. Ten were treated with a distal radial pedicle vascularized graft and twelve, with a free vascularized medial femoral condyle graft. Patient demographics were similar between the groups, and the duration of follow-up averaged twelve months. Union was determined with use of plain radiographs and computed tomography or trispiral tomograms. In addition, carpal angles, time to union, union rates, and complications were recorded. Four of the ten nonunions treated with the distal radial pedicle graft healed, at a median of nineteen weeks, and all twelve nonunions treated with the free medial femoral condyle graft healed, at a median of thirteen weeks. The rate of union was significantly higher (p = 0.005) and the median time to healing was significantly shorter (p < 0.001) for the nonunions treated with the medial femoral condyle graft. A vascularized interposition graft from the medial femoral condyle is the recommended vascularized bone graft for the surgical treatment of scaphoid waist nonunion with avascularity of the proximal pole and carpal collapse.