Free vascularized bone graft for nonunion of the scaphoid

doi:10.1053/jhsu.2000.5993

The Journal of Hand Surgery

Volume 25, Issue 3, May 2000, Pages 507-519

https://doi.org/10.1053/jhsu.2000.5993 Get rights and content

Abstract

We used a free vascularized small periosteal bone graft to treat scaphoid nonunion. The graft consisted of periosteum, full-thickness cortex, and the underlying cancellous bone and was harvested from the supracondylar region of the femur. The graft was nourished by the articular branch of the descending geniculate artery and vein. Unlike the currently used vascularized bone grafts, this graft can be easily harvested and shaped to accommodate the bone defect of the scaphoid without disturbing its vascularity and can then be transferred with microvascular anastomosis of the nutrient vessels to the radial artery and its venae commitantes. Ten patients with longstanding nonunion of the scaphoid secondary to avascular necrosis, confirmed by radiologic and intraoperative findings, were treated with this vascularized bone graft. Union was achieved in all 10 patients at an average of 12 weeks after surgery. The average follow-up period for all fractures was 3.5 years. The scores for overall outcome, according to the Mayo wrist scoring system, were excellent in 4 patients, good in 4, and fair in 2. Two unsatisfied patients had preoperative signs of early periscaphoid osteoarthrosis. This free vascularized small bone graft from the supracondylar region of the femur is an attractive alternative to the conventional vascularized bone grafting procedures. (J Hand Surg 2000;25A:507–519. Copyright © 2000 by the American Society for Surgery of the Hand.)

Section snippets

Materials and methods

Between 1986 and 1995, 10 cases of established scaphoid nonunion secondary to AVN were treated with vascularized periosteal bone. Informed consent was obtained from each patient and the study protocol was reviewed and approved by the institutional review committee. There were 9 males and 1 female; the average age was 33 years (range, 15–60 years) (Table 1).

. Patients Demographics

Empty Cell	Empty Cell	Empty Cell	Empty Cell	Empty Cell	Empty Cell	Empty Cell	Empty Cell	Preoperative MRI Findings, T1-Weighted Image		Intraoperative Findings of Marrow Changes²		Empty Cell	Empty Cell	Empty Cell	Empty Cell	Empty Cell
Case No	Occupation	Gender	Age (yr)	Empty Cell

Early results

All 10 scaphoids were graded as total necrosis of the proximal fragments. The vascularity of the distal fragments were classified as total necrosis in 4, poor in 4, and fair in 2. All 5 cases without a skin paddle underwent secondary closure of the wrist incision to avoid compression of the vascular pedicle following primary covering with a wet dressing.

All 5 monitoring skin flaps used to assess the circulation of the bone grafts survived without any postoperative vascular compromise. In 3

Discussion

The vascular periosteal bone graft that was used in our study has several advantages compared with conventional vascularized bone grafts. This graft from the supracondylar region of the femur is nourished by the periosteal blood supply from the descending genicular artery and vein. In addition, as long as the overlying periosteal artery and vein are included, the underlying cortical and cancellous bone is well vascularized even after the bone graft has been shaped to accommodate into the

References (23)

WP Cooney et al.
Nonunion of the scaphoid: analysis of the results from bone grafting
J Hand Surg
(1980)
DP Green
The effect of avascular necrosis on Russe bone grafting for scaphoid nonunion
J Hand Surg
(1985)
WP Cooney et al.
Scaphoid nonunion: role of anterior interpositional bone grafts
J Hand Surg
(1988)
C Zaidemberg et al.
A new vascularized bone graft for scaphoid nonunion
J Hand Surg
(1991)
KK Sheetz et al.
The arterial blood supply of the distal radius and ulna and its potential use in vascularized pedicled bone grafts
J Hand Surg
(1995)
JN Kuhlmann et al.
Vascularized bone graft pedicled on the volar carpal artery for non-union of the scaphoid
J Hand Surg
(1987)
Y Hori et al.
Blood vessel transplantation to bone
J Hand Surg
(1979)
T Imaeda et al.
Magnetic resonance imaging in scaphoid fractures
J Hand Surg
(1992)
PC Perlik et al.
Magnetic resonance imaging to assess vascularity of scaphoid nonunions
J Hand Surg
(1991)
DP Green et al.
Open reduction of carpal dislocations: indications and operative techniques
J Hand Surg
(1978)

DL Fernandez

A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability

J Hand Surg

(1984)

Cited by (178)

Total Nasal Reconstruction: Advances in Free Tissue Transfer for Internal Lining and Structural Support
2024, Facial Plastic Surgery Clinics of North America
Fracture risk assessment of vascularized medial femoral condylar bone graft: A finite element analysis
2024, Journal of Plastic, Reconstructive and Aesthetic Surgery
Vascularized medial femoral condyle (MFC) bone graft is useful for pseudarthrosis and osteonecrosis, but has the risk of fracture as a complication. This study aimed to create multiple three-dimensional (3D) finite element (FE) femur models to biomechanically evaluate the fracture risk in the donor site of a vascularized MFC bone graft.
Computer tomography scans of the femurs of nine patients (four males and five females) with no left femur disease were enrolled in the study. A 3D FE model of the left femur was generated based on the CT images taken from the patients. The descending genicular artery (DGA), the main nutrient vessel in vascularized MFC bone grafts, divides into the proximal transversal branch (TB) and the distal longitudinal branch (LB) before entering the periosteum. Thirty-six different bone defect models with different sizes and locations of the harvested bone were created.
The highest stress was observed in the proximal medial and metaphyseal portions under axial and external rotation, respectively. In the bone defect model, the stress was most elevated in the extracted region’s anterior or posterior superior part. Stress increased depending on proximal location and harvested bone size.
Increasing the size of the bone graft proximally raises the stress at the site of bone extraction. For bone grafting to non-load-bearing areas, bone grafting distally using LB can reduce fracture risk. If TB necessitates a larger proximal bone extraction, it is advisable to avoid postoperative rotational loads.
Vascularized Medial Femoral Condyle Flap Reconstruction for Osseous Defects of the Hand and Wrist
2024, Hand Clinics
Clinical outcomes in patients with scaphoid non-union treated with the vascularized medial femoral condyle technique a case series
2023, Injury
Non-union is a prevalent complication of scaphoid fractures. Late diagnosis is common and has a clinical impact due to functional limitations for the patient. Multiple treatments have been proposed to manage this complication, ranging from conservative (i.e., orthopedic) to surgical treatment. The vascularized medial femoral condyle technique has shown satisfactory clinical and paraclinical results, mainly in presence of avascular necrosis of the proximal pole but data regarding functional outcomes and patient satisfaction is scarce.
This case series aims to describe the clinical and patient-reported outcomes in a consecutive series of patients with non-union of the proximal third of the scaphoid treated with vascularized medial femoral condyle technique.
Case series reporting results for a consecutive – initial cohort of patients who presented with a non united fracture of the proximal pole of the scaphoid, avascular necrosis of the proximal pole was documented by CT od MRI imaging preoperatively in all patients. Measurement instruments include the q-DASH and PRWE questionnaires, radiographic images, goniometry, and assessment of grip strength.
Twelve consecutive patients are included and they represent the initial cases for all surgeons involved; bone union was obtained in 10 patients (83%) after a mean follow-up time of 31 months (6–72), successful improvement in the range of motion and grip strength was documented. A high rate of satisfaction expressed by the patient was obtained, with an average score in Q-DASH of 17.3 and 20.1 in PRWE.
The vascularized medial condyle technique in cases of nonunion of scaphoid fracture is a reproducible treatment in clinical terms, both in imaging and functional terms, and in patient satisfaction. The learning curve is flat for a dedicated multi surgeon team.
Successful treatment of total avascular necrosis in a pediatric scaphoid nonunion with vascularized medial femoral condyle bone graft: Case report
2023, Journal of Orthopaedic Science
Vascularised versus non-vascularised bone graft for scaphoid nonunion: Meta-analysis of randomised controlled trials and comparative studies
2023, JPRAS Open
Numerous studies have investigated surgical techniques for vascularised bone graft (VBG) for scaphoid nonunion; however, their efficacies remain unclear. Thus, to estimate the union rate of VBG for scaphoid nonunion, we performed a meta-analysis of randomised controlled trials (RCTs) and comparative studies.
A systematic search was conducted using PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials. The search formula was as follows: ((scaphoid nonunion) OR (scaphoid pseudarthrosis)) AND (bone graft). Only RCTs were used in the primary analysis, and comparative studies, including RCTs, in the secondary analysis. The primary outcome was nonunion rate. We compared the outcome between VBG and non-vascularised bone graft (NVBG), pedicled VBG and NVBG, and free VBG and NVBG.
This study included a total of 4 RCTs (263 patients) and 12 observational studies (1411 patients). In the meta-analyses of both RCTs only and RCTs and other comparative studies, no significant difference in nonunion rate was found between VBG and NVBG (summary odds ratio [OR], 0.54; 95% confidence interval [CI], 0.19–1.52 and summary OR, 0.71; 95% CI, 0.45–1.12), respectively. The nonunion rates of pedicled VBG, free VBG, and NVBG were 15.0%, 10.2%, and 17.8%, respectively, and no significant difference was found.
Our results indicated that the postoperative union rate in NVBG is similar to that in VBG; thus, NVBG could be the first choice of treatment for scaphoid nonunion.

View all citing articles on Scopus

^*: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

^**: Reprint requests: Kazuteru Doi, MD, Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Shimogo 862–3, Ogori, Yamaguchi-ken, 754-0002, Japan.

^*: J Hand Surg 2000;25A:507–519

^**: 0363-5023/00/25A03-0001$3.00/0

View full text

Original CommunicationsFree vascularized bone graft for nonunion of the scaphoid*,**,*,**

Abstract

Section snippets

Materials and methods

Early results

Discussion

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

Original Communications
Free vascularized bone graft for nonunion of the scaphoid*,**,*,**