Treatment Of Scaphoid Nonunion Research Articles

Evaluation of Carpal Malalignment Before and After Interpositional Bone Grafting for Treating Scaphoid Nonunion

Background: Carpal malalignment following the treatment of scaphoid nonunion increases the risk of Dorsal Intercalated Segment Instability (DISI) and progressive radiocarpal arthrosis. Objectives: In this study, we aimed to investigate the outcome of interpositional bone grafting without preplanning to correct carpal malalignment in treating scaphoid nonunion. Methods: Patients and Methods: In a retrospective study, 96 patients who underwent surgery to treat scaphoid nonunion (interpositional bone grafting without correction of carpal malalignment) were included. Indices of carpal malalignment, including the lunocapitate and scapholunate angles, were assessed before and one year after the surgery. A lunocapitate angle of more than15º and a scapholunate angle of more than 60º were considered a sign of DISI. Results: The study population included 93 men (96.9%) and three women (3.1%) with a Mean±SD age of 26.1±3.1 years. The mean±SD time from fracture to nonunion surgery was 8.6±4.2 months. The Mean±SD lunocapitate angle was 15.2±13.1º before and 14.4±11º one year after the surgery (P=0.48). The Mean±SD scapholunate angle was 63.9±15.2º before and 64.5±14.6º after the surgery (P=0.69). DISI was present in 67 patients (69.8%) before and 66 (68.8%) after the surgery. This difference was not statistically significant, too (P=0.89). Conclusion: Correction of carpal malalignment should be preoperatively planned to treat scaphoid nonunion to reduce the risk of postoperative DISI and subsequent radiocarpal arthrosis.

A prospective study of radiological and functional outcome of non union scaphoid fractures treated by pronator quadratus muscle pedicle bone graft

Scaphoid fractures are common, but present unique challenges because of the particular geometry of the fractures and the tenuous vascular pattern of the scaphoid. Delays in diagnosis and inadequate treatment for acute scaphoid fractures can lead to nonunions and subsequent degenerative wrist arthritis. Scaphoid nonunions can present with or without avascular necrosis of the proximal pole, and may show a humpback deformity on the radiograph. If left untreated, scaphoid nonunions can progress to carpal collapse and degenerative arthritis. Surgical treatment is directed at correcting the deformity with open reduction and internal fixation with bone grafting. Recently, vascularized bone grafts have gained popularity in the treatment of scaphoid nonunions, particularly in cases with avascular necrosis. This study gives us a radiological and functional outcome of 10 cases operated by pronator quadratus based muscle pedicle bone graft for scaphoid non unions at waist level.

Free Vascularized Medial Femoral Condyle Bone Graft for Scaphoid Nonunion with Poor Prognosis Factors

Purpose: Authors attempt to evaluate the clinical and radiographic results of the treatment of scaphoid nonunion with poor prognostic factors with the free vascularized medial femoral condyle bone graft. Methods: We operated on eight patients with avascular necrosis or prolonged nonunion of the scaphoid between January 2016 and July 2019. Wrist motion in terms of flexion, extension, and ulnar and radial deviation, a visual analogue scale (VAS), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the modified Mayo wrist score, scapholunate angle, and carpal height index were collected in the clinic setting preoperatively and at the latest follow-up in all patients Results: Eight patients with union achieved correction and maintenance of both scapholunate angle and carpal height index. The VAS pain scores significantly improved from 5.1 preoperatively to 3.3 postoperatively. There was a statistically significant improvement in the average DASH score at the final follow-up. Scapholunate relationships in the reconstructed wrists remained almost unchanged, with average scapholunate angles of 49.7° before surgery and 47.0° at the latest postoperative follow-up. There was no statistical significance between the number of poor prognosis factors and the time to union, but there was a positive correlation.Conclusion: It could help surgeons manage the scaphoid nonunion associated with poor prognostic factors such as avascular necrosis, carpal collapse (posttraumatic arthritis), prolonged nonunion, and failed prior scaphoid nonunion surgery.

Pedicled vascularized versus non-vascularized bone grafts in the treatment of scaphoid non-union: a meta-analysis of comparative studies.

Whether pedicled vascularized bone grafts (PVBGs) are beneficial over non-vascularized bone grafts (NVBGs) still remains controversial. The aim of this study was to compare the clinical results of PVBGs and NVBGs for the treatment of scaphoid non-union. We conducted a meta-analysis of the published studies comparing outcomes of these two different surgical techniques for scaphoid non-union. Outcomes of union rate, time to union, functional results and re-operation rate were analysed. Seven studies including four randomized controlled studies and three retrospective comparative studies with 413 participants were identified fitting inclusion criteria. Meta-analysis showed that (i) union rate in PVBG groups was 1.13 times of NVBG groups (P=0.002); (ii) the PVBG groups reached bone union significantly earlier by 1.73 weeks (P < 0.01); (iii) there was no significant difference in functional results, including active range of motion, grip strength, Mayo Wrist Score and excellent and good rate (P > 0.05); and (iv) re-operation rate was similar between the two groups (P=0.65). Although the PVBG technique attains higher union rate and earlier union, this radiological advantage does not bring any functional benefits. In addition, PVBGs are of greater technical difficulty and need more operation requirements. Hence, clinicians should be cautious in electing PVBGs for treating scaphoid non-union.

Scaphoid Nonunion Is a Disabling Problem in a Military Population.

Scaphoid nonunion can occur in up to 55% of displaced scaphoid fractures. Long-term functional outcomes of this injury are lacking. In addition, no study has published rate of return to active military service after this injury. Our goal was to educate providers and patients on expected functional outcomes and return to duty after treatment of scaphoid nonunion. We conducted a retrospective review of patients who underwent scaphoid nonunion repair at our institution from 2008 to 2017. The primary outcome measures were union rates, return to duty rates, and functional outcome scores obtained by telephone call. A total of 144 patients were included and 40 responded to our call for long-term follow-up. A total of 72% of patients achieved union after surgery, 18% required revision surgery, and 74% of patients were able to return to full duty after surgery. However, this number progressively decreased at 1, 2, and 5 years after surgery. At an average of 5.9 years after surgery, the mean Quick Disabilities of the Arm, Shoulder, and Hand (qDASH) score was 23.9. The mean qDASH for patients who achieved union (21.9) was significantly lower than those with persistent nonunion (29.2) (P = .0115). Scaphoid nonunion is a difficult problem in the military. We found a high rate of persistent nonunion often requiring revision to partial or full wrist arthrodesis. In addition, our long-term functional outcome scores demonstrate significant disability after this injury, even when union is achieved. This information can help us better counsel our patients and set expectations after treatment of this injury.

A vascularized bone graft harvested from the dorsal base of the third metacarpal bone for the treatment of scaphoid nonunion

The purpose of this retrospective study was to introduce the use of an alternative vascularized bone graft for treating scaphoid non-union. The vascularized bone graft was harvested from the dorsal base of the third metacarpal bone. From May 2014 to September 2017, 29 patients with scaphoid non-union were treated. Grip and pinch strengths were compared to the contralateral side. The patients rated wrist joint pain on a visual analogue scale. Wrist function was assessed on Mayo Wrist Score. p < 0.05 was considered statistically significant. 18 scaphoids healed at 6 weeks and the other 11 at 16 weeks. Follow-up ranged from 28 to 73 months, for a mean 48 months. At final follow-up, mean wrist flexion had improved from 65° (range, 51°–81°) preoperatively to 72° (range, 61–78°) (p > 0.05), for a contralateral value of 74° (range, 65°–86°). Mean extension had improved from 56° (range, 44°–72°) to 60° (range, 47°–76°) (p > 0.05) for a contralateral value of 66° (range, 52°–80°). Mean wrist pain improved from 4 (range, 3–8) to 2 (range, 0–4) (p < 0.05). Mean pinch strength improved from 6.4 kg (range, 5.2–7.3 kg) to 8.6 kg (6.1–9.9 kg) (p < 0.05). Mayo Wrist Score improved from 49 (range, 10–65) to 92 (range, 70–100) (p < 0.05). Transferring a vascularized bone graft harvested from the base of the third metacarpal bone was an effective alternative for the treatment of scaphoid non-union, achieving bone healing and normal wrist function without significant donor-site morbidity. Type of study/level of evidenceTherapeutic IV.

Scaphoid Nonunion Volar Plating with Pure Nonvascularized Cancellous Autograft.

Surgical treatment of scaphoid nonunion has evolved over the years to include a variety of procedures and techniques involving a number of vascularized and nonvascularized bone grafting options and fixation strategies. Volar plating of scaphoid nonunions with use of pure cancellous nonvascularized autograft is a safe and effective treatment method with good functional outcomes and union rates1. Volar plating of the scaphoid nonunion is performed via a volar approach, with debridement and reduction of the nonunion site. A nonvascularized pure cancellous bone autograft is then harvested and impacted from the distal aspect of the ipsilateral radius or the olecranon. Finally, a low-profile volar locking plate is applied for fixation2. There is no consensus regarding the optimal treatment of scaphoid nonunion. Headless compression screws are currently popular, and advances have been made over time to include various nonvascularized and vascularized corticocancellous grafts. The advent of plate fixation of the scaphoid has enabled the surgical treatment of nonunion to better replicate scaphoid morphology, allowing for improved biomechanical stability and optimizing the biologic milieu for healing. Headless compression screws, although a reasonable option for most acute scaphoid fractures, may not be the most appropriate application for nonunions. Compression, in itself, is not required for the surgical treatment of scaphoid nonunion, and can even prove detrimental by forcing the reduction into a malunion. The stability of headless compression screws must rely on a structural graft to resist the compression and create friction. The more structural the graft, however, the less biologically active it tends to be. Further, the simple placement of a metallic screw within the fracture site is counter to orthopaedic principles because it dramatically lowers the surface area available for union. Volar locking plates address the shortcoming of headless compression screws by (1) directly buttressing the deforming forces superior to headless screws3-6; (2) utilizing the most accessible, biologically active nonvascularized bone graft, which is pure cancellous graft; (3) allowing for maximal surface area contact for union; and (4) preserving the intraosseous vascular network within the scaphoid and its vascular supply at its dorsal ridge. Volar scaphoid plating with cancellous bone grafting is a reliable technique with excellent union rates and favorable functional outcomes. A review of 34 patients with scaphoid nonunions with segmental defects treated with volar plates and pure cancellous autograft demonstrated 100% union as verified by computed tomography scans postoperatively1. Average Disabilities of the Arm, Shoulder and Hand scores and grip strengths improved by final follow-up. Another series of 13 scaphoid nonunions with osteonecrosis treated with volar plating and pure cancellous autograft showed 100% union and good patient-reported and functional outcomes, despite smokers, proximal poles, and previous failed surgical procedures in the cohort2. These favorable results are consistent with earlier reports of the modern plating systems; however, concerns for hardware-related complications have been elucidated over the years, including symptomatic hardware impingement7. This risk can be mitigated by proper surgical technique and plate placement. Clear visualization of the entire volar surface of the scaphoid is crucial. Take care not to reflect too much capsule, so as to cause ulnar translation of the carpus.Thorough debridement of nonviable bone is paramount. Using a 2.0 or 3.0-mm low-speed burr with continuous irrigation can be helpful. We have had successful unions even in cases in which the remaining proximal pole was just a cortical shell and essentially a hollow vessel for graft.Err on the side of verticalization of the scaphoid, overextending and supinating the distal pole. Overstuffing the nonunion site with cancellous autograft aids in reduction and maximizes the osteoinductive and osteoconductive properties of the graft.Impaction of the graft is crucial, and the surgeon should harvest more autograft than one might initially anticipate.Secure the plate to the proximal portion of the scaphoid first. There is less room for error on the proximal portion where plate positioning is more critical.Do not cross the scaphoid "line in the sand"; to do so will result in plate impingement on the radius. Proper placement of the plate is just distal to the point at which the convex surface of the proximal pole transitions to become the concave surface of the scaphoid waist, as viewed from a volar approach.Plate modification for proximal pole fractures and nonunions: removal of the most proximal hole in the plate allows for improved fixation despite the plate itself remaining behind the scaphoid "line in the sand." In these cases, the locking screws must be directed so that they buttress the subchondral bone of each pole, especially the proximal pole.

Clinical and radiological evaluation of nonvascularized cancellous iliac bone graft for the treatment of nonunited scaphoid fracture

Purpose We evaluated the clinical and radiological outcome of pure cancellous iliac bone graft for the treatment of scaphoid nonunion. Patients and methods The subjects of this study were 30 patients who had a nonunited scaphoid fracture treated with pure cancellous iliac bone graft and casting between March 2015 and April 2019. The average follow-up period was 9 months. We performed open reduction through the volar approach with impaction of the fracture site with pure nonvascularized cancellous iliac bone graft and scaphoid cast for a period ranging from 1 1/2 to 3 months. Results Bony union was achieved in 29 of 30 patients. Nonunion occurred in only one patient.

Vascularized pisiform graft for the treatment of scaphoid nonunion: An anatomical study

Scaphoid fracture can evolve into scaphoid nonunion leading to wrist arthritis. Vascularized bone flaps used to treat scaphoid nonunion are supplied by delicate, small, or short arteries that are not always reliable. The pisiform bone has never been considered as a possible treatment of scaphoid nonunion since the traditionally harvested pedicle is too short. This study aimed to characterize the vascularization of the pisiform with the goal of developing a method of harvesting it with a longer pedicle that can be used as a graft to treat scaphoid nonunion. A cadaver study on 30 upper limbs was done in two parts: firstly, we dissected 20 cadaver specimens and documented the pisiform's vascularization (size, length, and articular surface) as well as anatomical characteristics of the dorsal ulnar artery; secondly, we used 10 cadaver specimens to study an experimental surgical procedure in which a vascularized pisiform graft is used to treat an artificially created nonunion and confirm its feasibility. The pisiform artery originated from the dorsal ulnar artery in all 20 dissections. Its average length of 4.036cm could be increased by 11% by ligating the upstream collateral branches from the dorsal ulnar artery. The pedicled vascularized pisiform flap was grafted to the scaphoid in 10 experimental procedures performed on fresh cadavers. The vascularized pisiform graft consists of a reliable vascular pedicle and well vascularized multi-cortical bone with a cartilaginous surface. However, more studies are needed to confirm the feasibility of this flap as an alternative for treating unstable scaphoid nonunion.

Volar Plating versus Headless Compression Screw Fixation of Scaphoid Nonunions: A Meta-analysis of Outcomes.

Background Headless compression screw fixation with bone grafting has been the mainstay of treatment for scaphoid nonunion for the past several decades. Recently, locked volar plate fixation has gained popularity as a technique for scaphoid fixation, especially for recalcitrant or secondary nonunions. Purpose The purpose of this meta-analysis was to compare union rates and clinical outcomes between locked volar plate fixation and headless compression screw fixation for the treatment of scaphoid nonunions. Methods A literature search was performed for studies documenting treatment outcomes for scaphoid nonunions from 2000 to 2020. Inclusion criteria consisted of (1) average age > 18 years, (2) primary study using screw fixation, plate fixation, or both, with discrete data reported for each procedure, and (3) average follow-up of at least 3 months. Exclusion criteria consisted of studies with incomplete or missing data on union rates. Data from each study was weighted, combined within treatment groups, and compared across treatment groups using a generalized linear model or binomial distribution. Results Following title and full-text review, 23 articles were included for analysis. Preoperatively, patients treated with plate fixation had significantly longer time from injury to surgery and were more likely to have failed prior surgical intervention. There was no significant difference between union rates at 92 and 94% for screw and plate fixation, respectively. However, plate fixation resulted in longer time to union and lower modified Mayo wrist scores. Conclusion Patients treated with locked volar plate fixation were more likely to be used for recalcitrant or secondary nonunions. There was no statistically significant difference in union rates between screw and plate fixation. The results from this meta-analysis support the select use of locked volar plate fixation for scaphoid nonunion, especially recalcitrant nonunions and those that have failed prior surgical repair.

The results of pedicled vascularized bone grafts in the treatment of scaphoid nonunion

Objectives: Scaphoid nonunion still creates a big challenge for hand surgeons due to high failure rates after surgery, particularly in proximal pole fractures. The pedicled vascularized bone graft (VBG) is a valuable option to achieve union and good outcomes. This study aimed to analyze the clinical and radiological results of patients who underwent scaphoid fixation with pedicled VBG due to non-union of a scaphoid fracture. Methods: The patients who were operated due to scaphoid non-union and underwent fixation with pedicled VBG between 2017 and 2018 were reviewed retrospectively. The patients were evaluated both preoperatively and postoperatively. The clinical assessments included; the range of motion, grip strength, Mayo wrist score, and visual analogue scale (VAS) pain score. The presence of bony union was evaluated with direct radiographs. Results: Eight patients were included in the final analysis. Four patients who had waist non-union were reconstructed with volar pedicled VBG, while the other four patients with proximal non-union were reconstructed with dorsal 1,2 ICSRA pedicled VBG. The average age was 28.7 and the average follow-up was 12.3 months. The bony union was achieved in 7 patients at average 3.1 months with gain of both range of motion and grip strength. The average VAS pain score was improved from 6.8 to 2. The average Mayo wrist score was improved from 52.2 to 80.4. Conclusion: The application of pedicled VBGs harvested from the distal radius provides good clinical and radiological outcomes in the treatment of scaphoid non-unions.

Treatment of scaphoid nonunion with nonvascularized distal radius bone graft and headless cannulated compression screw

Treatment of scaphoid nonunion with nonvascularized distal radius bone graft and headless cannulated compression screw

Mid-term outcome of volar plate fixation for scaphoid nonunion.

Fixation of scaphoid nonunion with a volar locking plate and cancellous bone grafting has been shown to be a successful technique in small series. Few mid- or long-term follow-up studies have been reported. The aim of this study was to report the mid-term radiological and functional outcome of plate fixation for scaphoid nonunion. Patients with a scaphoid nonunion were prospectively enrolled and treated with open reduction using a volar approach, debridement of the nonunion, and fixation using a locking plate and cancellous bone grafting, from the ipsilateral iliac crest. Follow-up included examination, functional assessment using the patient-rated wrist/hand evaluation (PRWHE), and multiplanar reformation CT scans at three-month intervals until union was confirmed. A total of 49 patients with a mean age of 31 years (16 to 74) and a mean duration of nonunion of 3.6 years (0.4 to 16) were included. Postoperatively, the nonunion healed in 47 patients (96%) as shown on CT scans. The mean time to union was 4.2 months (3 to 12). Due to impingement of the plate on the volar rim of the radius and functional limitation, the hardware was removed in 18 patients. At a median follow-up of 38 months in 34 patients, the mean active range of motion (ROM) improved significantly from 89° to 124° (SD 44°; p = 0.003). The mean grip strength improved significantly from 52% to 79% (SD 28%; p < 0.001) of the contralateral side. The mean PRWHE score improved significantly from 66 to 17 points (SD 25; p < 0.001). Locking plate fixation supplemented with autologous cancellous bone grafting is a successful form of treatment for scaphoid nonunion. Functional outcomes improve with the passage of time, and mid-term results are excellent with a significant improvement in ROM, grip strength, and functional outcome as measured by the PRWHE. Cite this article: Bone Joint J 2020;102-B(12):1697-1702.

Arthroscopic-assisted reduction, bone grafting and screw fixation across the scapholunate joint for proximal pole scaphoid nonunion

BackgroundThere are some difficulties in treating proximal scaphoid nonunion, mainly including poor vascularity of the proximal scaphoid fragment and limited space for a stable fixation in the proximal scaphoid fragment. This study reports the outcomes of treating proximal scaphoid nonunion with arthroscopic assist for reduction, bone grafting and screw fixation across the scapholunate (SL) joint.MethodsBetween 2008 and 2017, 21 patients were enrolled. Fracture healing and change in the lateral SL angle and SL gap were evaluated. Functional outcomes were evaluated using the Disabilities of the Arm, Shoulder, and Hand (DASH) score, wrist range of motion, grip strength, and the Visual Analog Scale (VAS) for pain.ResultsNineteen patients achieved fracture healing and their mean follow-up duration was 31.3 months (24–120 months). The average fracture healing time was 16.3 weeks (10 to 28 weeks). From the preoperative to the postoperative final evaluation, there was some significant improvement in wrist function, including wrist flexion from 54.5o to 67.4o, wrist extension from 62.3o to 71.7o, DASH scores from 52.4 to 21.4, VAS during activity from 4.6 to 2.1, and grip strength from 9.6 kg to 24.7 kg. The lateral SL angle also improved significantly, from 82o to 66o. Seventeen patients requested screw removal after fracture healing because of their cultural belief in not leaving hardware in the body. No significant SL gap widening was noted after screw removal in the sequential follow-ups.ConclusionsUsing arthroscopic-assisted reduction, bone grafting and screw fixation across the SL joint in proximal scaphoid nonunion treatment, satisfactory functional and radiographic outcomes can be achieved.

1,2 Intercompartmental Supraretinacular Artery-Based Vascularized Graft for Scaphoid Nonunion With Avascular Necrosis.

BackgroundThe treatment for scaphoid nonunion with avascular necrosis is vascularized and non-vascularized bone grafts. A vascularized bone graft promotes biological healing and revascularizes ischemic bone. The purpose of this retrospective study is to analyze the outcome of 1,2 intercompartmental supraretinacular artery (1,2-ICSRA)-based vascularized graft in scaphoid nonunion with avascular necrosis.Materials and methodsWe treated 11 patients with scaphoid nonunion with avascular necrosis using a (1,2-ICSRA)-based vascular graft and Herbert screw fixation between 2013 and 2017. Plain radiographs, computed tomography (CT) scan, magnetic resonance imaging (MRI) confirmed the avascular necrosis in all patients. We noted the age, delay in treatment, time for bone union, preoperative range of movements, grip strength, scapholunate, intrascaphoid angle, and radiolunate angles. We confirmed the bone union by CT scan and measured the functional outcome with pain score, modified Mayo wrist score, grip strength, range of movement, and Disabilities of the Arm, Shoulder, and Hand (DASH) score.ResultsThe mean age of the patients was 29 years (range 20-42 years). The mean follow-up was 31 months (range, 26-36 months). All patients achieved good radiological union and revascularization of the proximal pole necrosis at an average of 14 weeks (range, 12-18 weeks). There was a significant postoperative improvement in grip strength, visual analog scale VAS score, intrascaphoid angle, scapholunate angle, and radiolunate angle (p<.05). The mean range of wrist flexion was 88%, extension 70%, radial deviation 80%, and ulnar deviation 85% of the opposite side.ConclusionsScaphoid nonunion with avascular necrosis can be treated with a 1,2-ICSRA-based vascularized bone graft. Vascularized bone grafts promote biological healing and revascularization of the ischemic bone.

Arthroscopic realignment and osteosynthesis of unstable scaphoid nonunion with cancellous bone graft from the ipsilateral radius.

The treatment of delayed union and established nonunion of the scaphoid using a volar approach with impaction of bone graft, either a cancellous or cortico-cancellous wedge graft, for osteosynthesis and maintenance of reduction. With the advancement of instruments and techniques of wrist arthroscopy, wider indications for wrist problems can be solved by this minimally invasive technique. We report our results of arthroscopic reduction, cancellous bone grafting to the regional distal radius, and headless screw fixation for the treatment of scaphoid nonunion, even with humpback deformity. Between August 2014 and February 2018, 41 patients (42 wrists) with unstable scaphoid nonunion received arthroscopic surgery. The mean follow-up was 38.1months (range 24-70months). We evaluated the results with a function questionnaire and clinical outcomes based on the visual analog scale (VAS) pain score, range of motion and grip strength, and radiologic measurements. The union rate was 92.6% (38/41 patients) and union time was 4.6months. Patients regained almost a full range of motion compared with the contralateral wrist. The post-op Quick DASH, Mayo wrist score, and VAS pain score all had significant improvement, with p < 0.05. The scapholunate angle showed significant correction from pre-op 68.0° to post-op 58.3°. The average VAS satisfaction score at final follow-up was 8.7. Arthroscopic realignment and osteosynthesis for the treatment of unstable scaphoid nonunion with ipsilateral radius bone graft, even with humpback deformity, can achieve a high union rate, good radiological correction, and good functional recovery.

Pedicled vascularized bone grafts compared with xenografts in the treatment of scaphoid nonunion.

Fractures of the scaphoid account for 60-70% of all wrist bone fractures. The results of treatment in terms of bone healing vary depending on the type and location of the fracture, the time elapsed since the injury, the type of surgical treatment. Nonunion occurs in 5-15% of the cases on average. The purpose of this paper is to compare the surgical techniques and results of treating scaphoid nonunion (SNU) with osteoplastic xenografts of bovine origin or a vascularized autograft of the distal part of the dorsal radius. We compare two groups of patients with symptomatic SNU, treated surgically with either a vascularized graft (n = 15) or a xenograft of bovine origin (n = 15). In the presurgical stage, the demographic characteristics of the patients, the time elapsed between injury and surgery, and classification of the injury (Schonberg, Herbert-Fisher, and Geissler-Slade) were recorded. One year following surgery, bone healing, total duration of the treatment, complications, the Mayo wrist score, and answers to the DASH questionnaire were analyzed. No statistically significant differences between the two groups of patients were observed for bone healing (86.7% vs 80%) or functional results. A highly significant difference was observed with respect to duration of the surgical intervention in favor of xenografts. The xenograft method is simple and relatively acceptable, providing good results in terms of healing and functionality.

Treatment of scaphoid non-union: vascularised iliac crest graft or medial femur condyle graft?

Treatment of scaphoid non-unions is still challenging for responsible hand surgeons, especially in cases of avascular proximal pole non-unions or failed prior surgeries. Several surgical procedures treating scaphoid non-unions have been established. These aim to restore correct anatomy to provide stability and adequate blood flow. Treatment options range from avascular to free, vascularized bone grafts. The two most used free vascularized bone grafts derive from the iliac crest and the medial femoral condyle. The vascular anatomy of the medial femoral condyle graft is more constant, the donor site morbidity lower and the healing rate higher in comparison to the iliac crest graft. It is easier to harvest the femoral condyle graft and additionally, it can be harvested as a cortico-cancellous or osteochondral graft. Looking at all advantage, we come to the conclusion that the free vascularized medial femoral condyle graft is our method of choice for the treatment of a avascular proximal pole non-union of the scaphoid.

Arthroscopic treatment for nonunion of the scaphoid.

Scaphoid nonunion has traditionally been treated by open surgery where the pseudarthrosis has been cleaned while either a structural wedged bone graft, or chips of cancellous bone has been used to fill the defect. K-wires or a screw has been used to stabilize the bone. Using the arthroscopic technique for treatment of nonunion of the scaphoid gives us small exposure to the joint, however with an excellent view of the bones, the articular surfaces and the intraarticular ligaments. The results from arthroscopic treatment for scaphoid nonunion with bone grafting using chips of cancellous bone are as good as from the open technique. The arthroscopic treatment, though, helps us to diagnose and treat concomitant lesions. There is less damage of blood supply, nerves and capsule, which might lead to a faster recovery and rehabilitation. The technique will be described and discussed.

How Long Should We Immobilize the Wrist after Vascularized Bone Grafting for the Treatment of Scaphoid Nonunion?

Background: Although vascularized bone grafting can effectively treat scaphoid nonunion, the optimal duration of the immobilization period after bone grafting is unclear. Therefore, we aimed to examine the difference in the union rate and range of motion between short and long immobilization periods and infer the optimal post-immobilization period after pedicled vascularized bone grafting for scaphoid nonunion treatment. Methods: A total of 23 wrists (21 men and 1 woman) with scaphoid nonunion treated using an intercompartmental supraretinacular artery pedicled vascularized bone graft were analyzed. We examined the difference in the union rate and range of motion between patients immobilized for less than 49 days (short immobilization group) and those immobilized for more than 49 days (long immobilization group). The range of motion of the wrist joint was measured before and after surgery. Patient outcomes were also assessed. Results: The overall union rate was 95.6%. A significant difference was found in postoperative extension and flexion between the two groups, but not in terms of the functional outcome. If the intraoperative fixation is solid, intraoperative proximal pole bleeding is confirmed, and the follow-up radiograph shows a normal healing process, we propose immobilization of the wrist for ≤ 7 weeks. Conclusions: The immobilization duration should depend on the solidity of intraoperative fixation and a satisfactory appearance on follow-up radiography: absence of a gap at the graft interface, surrounding lucency, or movement of the implant and displacement of the graft. If there are no signs of graft failure and fixation is solid, immobilization of the wrist for 7 weeks or less is recommended.