Bone grafting for scaphoid nonunion with dry arthroscopy.

Outcome After Vascularized Bone Grafting of Scaphoid Nonunions With Avascular Necrosis

Outcomes of Scaphoid Nonunion with Segmental Defect Treated with Plate Fixation and Autogenous Cancellous Graft: First Clinical Report

Zaidemberg reported on a new vascularized bone graft for scaphoid non-union in 1989. This is a pedicled vascularized bone graft from the dorsum of the distal radius combined with the innominate artery and is approached dorsally. We used this technique in 4 cases of non-union of the scaphoid. All 4 cases exhibited radiographic union, 3 within 6 weeks, and 1 at 9 weeks postoperatively. Wrist pain was diminished remarkably in all patients. Although the dorsal approach to the scaphoid has some disadvantages for hand surgeons, this treatment offered a higher union rate in comparison with conventional bone grafts. We believe that this procedure should be recommended as a new vascularized bone graft for scaphoid non-union. Additionally, it may also have the potential for use as a procedure for avascular necrosis of lunate.

Objectives This study aims to assess the blood flow and the vascularity pattern across the newly bridged vascularized bone grafts for scaphoid nonunions using three-dimensional (3D) high frequency power Doppler ultrasonography and its role in the union. Materials and Methods A total of 26 patients with scaphoid nonunions were operated with 1,2-intercompartmental supraretinacular artery (ICSRA) graft. CT scan and 3D high frequency power Doppler ultrasonography were performed in all patients between 12 and 18 weeks, and its results were analyzed. Results Doppler ultrasonography confirmed the pulsatile flow and vascularity across the pedicle and vascularized bone graft incorporation into the scaphoid nonunion site. Conclusions 3D high frequency power Doppler ultrasonography is a simple, noninvasive, nonradiation, reproducible, and well-reliable diagnostic modality in assessing the blood flow and vascularity of the bone grafts used for scaphoid nonunions. Level of Evidence This is a Level IV study.

Background Scaphoid nonunion with humpback deformity and avascular necrosis (AVN) is a challenging problem. Correction of dorsal intercalated segment instability (DISI) requires grafting of a large and hard vascularized bone segment onto the volar side of the scaphoid. Purposes We have been treating the patients with one-incision vascularized bone grafting technique for scaphoid nonunion to improve blood supply and correct humpback deformity. We evaluated these cases retrospectively to the surgical efficacy of our procedure. Methods We harvested vascularized bone from the dorsal side of the radius using the method by Zaidemberg et al and inserted the cortical aspect into the scaphoid volar side using a direct lateral approach. Totally, 11 patients (nine males andtwo females) with a mean age of 40 years were recruited for this study. The mean time from fracture to treatment was 6 years and 3 months. The mean preoperative radiolunate angle was 25 degrees. All the patients showed AVN of the proximal scaphoid on T1-weighted images. An averaged follow-up period was 2 years and 3 months. Results Postoperative computed tomography revealed bony union in 10 patients (91% of union rate) with a mean modified Mayo'swrist score of 88 points (range, 75–100 points) and a mean disabilities of arm, shoulder, and hand (DASH) score of 4 points (range, 0–20 points). The mean radiolunate angle was corrected from 25 to 5 degrees. No adverse events were observed, except temporary mild paresthesia of the radial nerve territory in two patients. Conclusion This technique effectively corrected DISI in patients with scaphoid nonunion accompanied by humpback deformity and AVN.

Background Vascularized bone grafting (VBG) has the potential to yield reliable results in scaphoid nonunion; however, results across studies have been highly variable. This study critically evaluates surgical techniques, fracture location, and patient selection in relation to radiographic, clinical, and patient-centered outcomes after VBG for scaphoid nonunion. Methods We conducted a systematic review of the literature for the use of VBG in scaphoid nonunion. Physical examination, radiographic, and patient-centered outcomes were assessed. Four substratifications were performed: the location of scaphoid nonunion, pedicled versus free technique, Kirschner wire (K-wire) versus screw fixation, and VBG done as a primary versus revision procedure. Results A total of 41 publications were included in final analysis. VBG had an 84.7% union rate at 13 weeks after surgery. On an average, 89% of patients returned to preinjury activity levels by 18 weeks after surgery and 91% of patients reported satisfaction with the procedure. Proximal pole nonunions demonstrated similar union rates but lower functionality scores compared with nonunions across all regions of the scaphoid. Pedicled techniques demonstrated slightly improved range of motion compared with free technique. K-wire versus screw fixation demonstrated significantly higher union rates and faster union times. There were no differences in outcomes for VBG done as a primary versus revision procedure. Conclusion VBG serves as a viable option for the treatment of scaphoid nonunion, with consistent union rates in addition to significantly improved postoperative patient functionality. The fixation of these vascularized bone grafts with K-wires versus screw fixation may result in superior radiologic outcomes. Level of Evidence Therapeutic, Level III, systematic review.

The purpose of this case series is to identify and illustrate the phenomenon of scaphoid remodeling in skeletally mature subjects following bone grafting for scaphoid nonunion. Nine patients with scaphoid nonunions were treated with interpositional bone grafting (with iliac crest bone graft) and K-wire fixation. The mean length of follow-up was 28.6 ± 9months. Radiographs and CT scans were reviewed and assessed for degree of union and a qualitative assessment of scaphoid architecture. Following surgery, there was marked distortion of the scaphoid. Once healed, the contour of the scaphoid was still significantly distorted in all nine patients. Remodeling then became evident along the articular surfaces between 8 and 12months. By 3years, the scaphoid was completely recontoured and the normal architecture was completely restored in all nine patients. We conclude that the articular surface of the scaphoid remodels over time in skeletally mature subjects.

The treatment of scaphoid nonunions remains a challenge, with multiple surgical techniques described. The purpose of this retrospective study was to evaluate the union rates in patients undergoing treatment of scaphoid nonunion with a single headless compression screw and the risk factors associated with failure to achieve union.Using the CPT code for the repair of a scaphoid nonunion (25440), 167 patients were identified as having operative repair of a scaphoid fracture nonunion using headless compression screw fixation performed at a single institution between the years of 2002 and 2024. All patients were followed clinically and with serial radiographic analysis postoperatively to determine if union was achieved. The primary outcome of fracture union was analyzed for each patient. Demographics of individual patients, fracture characteristics, and different autograft types were collected as a secondary analysis to evaluate for risk factors for scaphoid nonunion repair failure.The overall union rate was 75.5% (126/167). Female patients trended toward a higher rate of union following repair compared with male patients, although statistical significance was not fully met (p = 0.07). Age, time from injury to surgery, fracture location, bone graft source, bone graft type, avascular necrosis, tobacco use, and workers' compensation did not demonstrate a significant impact on union rates. No difference was found in the union rate of scaphoid nonunion repairs based on the graft harvest location or graft type.Fixation with headless compression screws and autologous bone graft is a reliable, effective method for treating scaphoid nonunions, with union rates similar to those previously reported. Female patients trended toward having a higher rate of union following repair, although statistical significance was not reached.Therapeutic Level IV.

The June 2013 Wrist & Hand Roundup360 looks at: whether size is a limitation; cancellous bone grafting in scaphoid nonunion; the Kienböck’s dichotomy; late displacement of the distal radius; flexor slide for finger contracture; aesthetic syndactyly; flexor tendon repair; and fixation of trapeziometacarpal cups.

Over the past years, different fixation techniques focused on rotational stability in order to increase stability and stimulate union rates. Additionally, extracorporeal shockwave therapy (ESWT) has gained importance in the treatment of delayed and nonunions. Purpose of this study was to compare the radiological and clinical outcome of two headless compression screws (HCS) and plate fixation in scaphoid nonunions, in combination with intraoperative high energy ESWT. Thirty-eight patients with scaphoid nonunions were treated by using a nonvascularized bone graft from the iliac crest and stabilization with either two HCS or a volar angular stable scaphoid plate. All patients received one ESWT session with 3000 impulses and energy flux per pulse of 0.41mJ/mm2 intraoperatively. 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. To confirm union, a CT scan of the wrist was performed. Thirty-two patients returned for clinical and radiological examination. Out of these, 29 (91%) showed bony union. All patients treated with two HCS compared to 16 out of 19 (84%) patients treated by plate showed bony union on the CT scans. The difference was not statistically significant.However, at a mean follow-up interval of 34months, no significant differences could be found in ROM, pain, grip strength and patient-reported outcome measurements between the two HCS and plate group. Height-to-length ratio and capitolunate angle improved significantly in both groups compared to preoperative. Scaphoid nonunion stabilization by using two HCS or angular stable volar plate fixation and intraoperative ESWT results in comparable high union rates and good functional outcome. Due to the higher rate for a secondary intervention (plate removal), HCS might be preferable as first choice, whereas the scaphoid plate fixation should be reserved for recalcitrant (substantial bone loss, humpback deformity or failed prior surgical intervention) scaphoid nonunions.

The Efficacy of Vascularized Bone Grafts in the Treatment of Scaphoid Nonunions and Kienbock Disease: A Systematic Review in 917 Patients

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

Erratum to: Local distal radius bone graft versus iliac crest bone graft for scaphoid nonunion: a comparative study

29 The Volar Carpal Artery Vascularized Bone Graft for Scaphoid Nonunion

Adverse Effects of Smoking on Outcomes of Orthopaedic Surgery: 吸煙對骨科手術結果的不良影響