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J Wrist Surg 2017; 06(03): 251-257
DOI: 10.1055/s-0036-1597575
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Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

A Critical Appraisal of Vascularized Bone Grafting for Scaphoid Nonunion

Ram K. Alluri
1   Department of Orthopaedic Surgery, Keck Medical Center of the University of Southern California, Los Angeles, California
,
Christine Yin
2   Department of Plastic Surgery, Keck Medical Center of the University of Southern California, Los Angeles, California
,
Matthew L. Iorio
3   Division of Hand and Upper Extremity Surgery, Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Carl J. Shapiro Clinical Center, Boston, Massachusetts
,
Hyuma Leland
2   Department of Plastic Surgery, Keck Medical Center of the University of Southern California, Los Angeles, California
,
Wendy J. Mack
4   Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
,
Ketan Patel
2   Department of Plastic Surgery, Keck Medical Center of the University of Southern California, Los Angeles, California
› Author Affiliations
Further Information

Publication History

19 September 2016

03 November 2016

Publication Date:
08 December 2016 (online)

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Abstract

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.

Keywords

bone graft - microvascular - nonunion - scaphoid - vascular

Supplementary Material

 

  • References

  • 1 Simonian PT, Trumble TE. Scaphoid nonunion. J Am Acad Orthop Surg 1994; 2 (04) 185-191
    CrossrefPubMedGoogle Scholar
  • 2 Dias JJ, Brenkel IJ, Finlay DB. Patterns of union in fractures of the waist of the scaphoid. J Bone Joint Surg Br 1989; 71 (02) 307-310
    CrossrefPubMedGoogle Scholar
  • 3 Kuschner SH, Lane CS, Brien WW, Gellman H. Scaphoid fractures and scaphoid nonunion. Diagnosis and treatment. Orthop Rev 1994; 23 (11) 861-871
    PubMedGoogle Scholar
  • 4 Inoue G, Shionoya K, Kuwahata Y. Herbert screw fixation for scaphoid nonunions. An analysis of factors influencing outcome. Clin Orthop Relat Res 1997; (343) 99-106
    PubMedGoogle Scholar
  • 5 Bunker TD, McNamee PB, Scott TD. The Herbert screw for scaphoid fractures. A multicentre study. J Bone Joint Surg Br 1987; 69 (04) 631-634
    CrossrefPubMedGoogle Scholar
  • 6 Cooney III WP, Dobyns JH, Linscheid RL. Nonunion of the scaphoid: analysis of the results from bone grafting. J Hand Surg Am 1980; 5 (04) 343-354
    CrossrefPubMedGoogle Scholar
  • 7 Green DP. The effect of avascular necrosis on Russe bone grafting for scaphoid nonunion. J Hand Surg Am 1985; 10 (05) 597-605
    CrossrefPubMedGoogle Scholar
  • 8 Barton NJ. Experience with scaphoid grafting. J Hand Surg [Br] 1997; 22 (02) 153-160
    CrossrefPubMedGoogle Scholar
  • 9 Krimmer H. Management of acute fractures and nonunions of the proximal pole of the scaphoid. J Hand Surg [Br] 2002; 27 (03) 245-248
    CrossrefPubMedGoogle Scholar
  • 10 Merrell GA, Wolfe SW, Slade III JF. Treatment of scaphoid nonunions: quantitative meta-analysis of the literature. J Hand Surg Am 2002; 27 (04) 685-691
    CrossrefPubMedGoogle Scholar
  • 11 Jones Jr DB, Rhee PC, Shin AY. Vascularized bone grafts for scaphoid nonunions. J Hand Surg Am 2012; 37 (05) 1090-1094
    CrossrefPubMedGoogle Scholar
  • 12 Roy-Camille R. Fractures et pseudoarthroses du scaphoide carpien: Utilisation d'un greffon pedicule. Actual Chir Ortho R Poincare 1965; 4: 197-214
    PubMedGoogle Scholar
  • 13 Tambe AD, Cutler L, Stilwell J, Murali SR, Trail IA, Stanley JK. Scaphoid non-union: the role of vascularized grafting in recalcitrant non-unions of the scaphoid. J Hand Surg Br 2006; 31 (02) 185-190
    CrossrefPubMedGoogle Scholar
  • 14 Kirkeby L, Baek Hansen T. Vascularised bone graft for the treatment of non-union of the scaphoid. Scand J Plast Reconstr Surg Hand Surg 2006; 40 (04) 240-243
    CrossrefPubMedGoogle Scholar
  • 15 Straw RG, Davis TR, Dias JJ. Scaphoid nonunion: treatment with a pedicled vascularized bone graft based on the 1,2 intercompartmental supraretinacular branch of the radial artery. J Hand Surg Br 2002; 27 (05) 413
    CrossrefPubMedGoogle Scholar
  • 16 Boyer MI, von Schroeder HP, Axelrod TS. Scaphoid nonunion with avascular necrosis of the proximal pole. Treatment with a vascularized bone graft from the dorsum of the distal radius. J Hand Surg Br 1998; 23 (05) 686-690
    CrossrefPubMedGoogle Scholar
  • 17 Zaidemberg C, Siebert JW, Angrigiani C. A new vascularized bone graft for scaphoid nonunion. J Hand Surg Am 1991; 16 (03) 474-478
    CrossrefPubMedGoogle Scholar
  • 18 Steinmann SP, Bishop AT, Berger RA. Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg Am 2002; 27 (03) 391-401
    CrossrefPubMedGoogle Scholar
  • 19 Munk B, Larsen CF. Bone grafting the scaphoid nonunion: a systematic review of 147 publications including 5,246 cases of scaphoid nonunion. Acta Orthop Scand 2004; 75 (05) 618-629
    CrossrefPubMedGoogle Scholar
  • 20 Pinder RM, Brkljac M, Rix L, Muir L, Brewster M. Treatment of scaphoid nonunion: a systematic review of the existing evidence. J Hand Surg Am 2015; 40 (09) 1797-1805.e3
    CrossrefPubMedGoogle Scholar
  • 21 Al-Jabri T, Mannan A, Giannoudis P. The use of the free vascularised bone graft for nonunion of the scaphoid: a systematic review. J Orthop Surg 2014; 9 (01) 21-29
    CrossrefPubMedGoogle Scholar
  • 22 Jones Jr DB, Bürger H, Bishop AT, Shin AY. Treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapse. A comparison of two vascularized bone grafts. J Bone Joint Surg Am 2008; 90 (12) 2616-2625
    CrossrefPubMedGoogle Scholar
  • 23 Panchal A, Kubiak EN, Keshner M, Fulkerson E, Paksima N. Comparison of fixation methods for scaphoid nonunions: a biomechanical model. Bull NYU Hosp Jt Dis 2007; 65 (04) 271-275
    PubMedGoogle Scholar
  • 24 Chang MA, Bishop AT, Moran SL, Shin AY. The outcomes and complications of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone grafting of scaphoid nonunions. J Hand Surg Am 2006; 31 (03) 387-396
    CrossrefPubMedGoogle Scholar
  • 25 Smith BS, Cooney WP. Revision of failed bone grafting for nonunion of the scaphoid. Treatment options and results. Clin Orthop Relat Res 1996; (327) 98-109
    PubMedGoogle Scholar
  • 26 Reigstad O, Thorkildsen R, Grimsgaard C, Reigstad A, Røkkum M. Is revision bone grafting worthwhile after failed surgery for scaphoid nonunion? Minimum 8.  year follow-up of 18 patients. J Hand Surg Eur Vol 2009; 34 (06) 772-777
    CrossrefPubMedGoogle Scholar