Results of Scaphoid Nonunion Treatment with Vascularised Bone Grafting from the Distal Radius
Misdiagnosis or failed treatment of scaphoid fractures are frequently (25-45%) followed by disrupted healing and nonunion. This may reduce the wrist's capacity for occupational and daily use and, over time, lead to wrist arthrosis. Therefore, surgery is recommended even in asymptomatic nonunions of the scaphoid; the goal of this treatment is to achieve bone union and stability of the wrist.
The aim of the study was to evaluate the results of operative management of scaphoid nonunion by vascularized bone grafting from the distal radius.
Material and methods. Eleven patients, nine men and two women of a mean age of 29 (range 19-45 years) with scaphoid nonunion lasting a mean of 10 months (range 8-20) were recruited. The nonunion was localized in the waist of the scaphoid in seven patients and in proximal 1/3 in four patients. Operations were performed using cancellous bone grafts taken from the distal radius and supplied by the intercompartmental branch of the radial artery. Fracture fixation was accomplished with K-wires or headless canullated screws. The follow-up assessment at a mean of 10 months included measurements of wrist range of motion, grip strength and Mayo wrist score.
Results. All patients achieved bone union. The mean Mayo wrist score increased from 25 points preoperatively to 75 points at the final assessment, which suggested significant improvement of the hand functions. In a qualitative evaluation, two patients had an excellent result, four had a good result, four had a fair result and one had a poor result. Surgery resulted in significant pain relief and increase in hand strength, but failed to improve wrist range of motion. The modest clinical outcomes do not allow a definitive conclusion to be reached, but the fact that bone union was achieved in all patients with no complications justifies continued use of this technique for the management of scaphoid nonunion.
Markowicz A: Ocena odległych wyników operacyjnego leczenia stawów rzekomych kości łódeczkowatej metodą rekonstrukcji długości przeszczepem korowo-gąbczastym. Praca doktorska. Akademia Medyczna w Gdańsku 2005.
Chao-Yu Chen A, Chao EK et al.: Scaphoid nonunion treated with vescular bone grafts pedicled on the dorsal supra-retinacular artery of the distal radius. J Trauma 2006; 61: 1192-97.
Ramamurthy C, Butler L, Nuttall D et al.: The factors affecting outcome after non-vascular bone grafting and internal fixation for nonunion of the scaphoid. J Bone Joint Surg 2007; 89B: 627-32.
Waitayawinyu T, McCallister WV, Nemechek NM et al.: Scaphoid nonunion. J Am Acad Orthop Surg 2007; 15: 308-20.
Yin ZG, Hang JB, Kan SL et al.: Treatment of acute scaphoid fractures: Systemie review and metaanalysis. Clin Orthop Rel Res 2007; 460: 142-51.
Cooney WP: Nonunion of the carpus. W: Berger R. A, Weiss A. P. (red.). Hand Surgery. Lippincot, Wiliams and Wilkins, Philadelphia 2004; t. 1: 225-457.
Ruby LK, Stinson J, Belsky MR: The natural history of scaphoid nonunion: A review of fifty-five cases. J Bone Joint Surg 1985; 67: 428-32.
Schuind F, Haentjens P, van Innis F et al.: Prognostic factors in the treatment of carpal scaphoid nonunions. J Hand Surg 1999; 24A: 761-66.
Carpentier E, Sartorius C: Scaphoid nonunion: tratments by open reduction, bone graft and staple fixation. J Hand Surg 1995; 20A: 235-40.
Cooney WP, Linscheid RL, Dobyns JH et al.: Scaphoid nonunion: role of anterior interpositional bone graft. J Hand Surg 1988; 13A: 635-50.
Merrel GA, Wolfe SW, Slade JF: Treatment of scaphoid nonunions: Quantitative meta-analysis of the literature. J Hand Surg 2002; 27A: 685-95.
Munk B, Larsen CF: Bone grafting the scaphoid nonunion: A systematic review of 147 publications including 5246 cases of scaphoid nonunion. Acta Orthop Scand 2004; 75: 618-29.
Steimann SP, Adams JE: Scaphoid fractures and nonunions: diagnosis and treatment. J Orthop Sci 2006; 11: 424-31.
Malizos KN, Zachos V, Dailiana ZH et al.: Scaphoid nonunions: Management with vascularized bone grafts from the distal radius: A clinical and functional outcome study. Plast Reconstr Surg 2007; 119: 1513-25.
Shah J, Jones WA: Factors affecting the outcome in 50 cases of scaphoid nonunion treated with Herbert screw fixation. J Hand Surg 1998; 23B: 680-85.
Amadio PC, Berquist TH, Smith DK: Scaphoid malunion. J Hand Surg 1989; 14: 679-87.
Dias JJ: Definition of union after acute fracture and surgery forr fracture nonunion of the scaphoid. J Hand Surg2001; 26B: 321-25.
Stark A, Brostrom LA, Svartengren G: Scaphoid nonunion treated with the Matti-Russe technique. Long term results. Clin Orthop Rel Res 1987; 214: 175-80.
Sotereanos DG, Darli NA, Dailiana ZH et al.: A capsular based vascularized distal radius graft for proximal pole scaphoid pseudoarthrosis. J Hand Surg 2006; 31A: 580-87.
Steimann 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 2002; 27A: 391-401.
Boyer M, vos 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 1998; 23B: 686-93.
Straw RG, Davis TR, Dis 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 2002; 27B: 27-31.
Mathoulin C, Haerle M: Vascularized bone graft from the palmar carpal artery for treatment of scaphoid nonunion. J Hand Surg 1998; 23B: 318-23.
Dailiana ZH, Malizos KN, Zachos V et al.: Vascularized bone grafts from the palmar radius for the treatment of waist nonunions of the scaphoid. J Hand Surg 2006; 31A: 397-404.
Żyluk A, Walaszek I, Puchalski P: Zastosowanie płata z I tętnicy grzbietowej śródręcza do rekonstrukcji ubytków kciuka. Chir Narz Ruchu Ortop Pol 2005; 70: 17-20.
Yuceturk A, Isiklar ZU, Tuncay C et al.: Treatment of the scaphoid nonunions with a vascularized bone graft based on the first dorsal metacarpal artery. J Hand Surg 1997; 22B: 425-27.
Sawaizumi T, Nanno M, Nandu A et al.: Vascularized bone graft from the base of the secondo metacarpal for refractory nonunion of the scaphoid. J Bone Joint Surg 2004; 86B: 1007-12.
Bertelli JA, Tacca CP, Rost JR: Tumb metacarpal vascularized bone graft In long-standing scaphoid nonunion - a useful graft via dorsal or palmar approach: a kohort study of 24 patients. J Hand Surg 2004; 29A: 1089-97.
Doi K, Oda T, Soo-Heong T et al.: Free vascularized bone graft for nonunion of the scaphoid. J hand Surg 2000; 25A: 507-19.
Harpf C, Gabl M, Reinhard C et al.: Small free vascularized iliac crest bone grafts in reconstruction of the scaphoid bone: a retrospective study in 60 cases. Plast Reconstr Surg 2001; 108: 664-74.
Inoue G, Shionoya K, Kuwahata Y: Herbert screw fixation for scaphoid nonunions: an analysis of factors influencing outcome. Clin Orthop 1997; 343: 99-106.
Slade JF, Dodds SD: Minimally invasive management of scaphoid nonunions. Clin Orthop Rel Res 2006; 445: 108-19.