Invited Article

Hand Surgery 2015;20(2):222-227 • DOI: 10.1142/S0218810415400043

Bone Grafts for Scaphoid Nonunion: An Overview Steven E.R. Hovius, Tim de Jong

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Departmentt of Plastic and Reconstructive and Hand Surgery, ErasmusMC University Medical Center, Rotterdam, The Netherlands

The scaphoid is the most common fractured bone in the wrist. Despite adequate non-surgical treatment, around 10% to 15% of these fractures will not heal. Untreated scaphoid non-union can cause a scaphoid non-union advance collapse (SNAC), this is a progressive deformity and can cause degenerative changes in the wrist. Surgery is focused on achieving consolidation, pain reduction and a good position of the scaphoid while preventing osteoarthritis in the long-term. Surgery consists of reduction and fixation of the scaphoid with a non-vascularized or vascularized bone graft. An overview of the most used vascularized and non-vascularized bone grafts and their indications are presented. Keywords: Scaphoid bone, Scaphoid, Pseudarthrosis, Bone transplantation, Bone grafting, Vascularized bone graft, Pedicled bone graft

INTRODUCTION The scaphoid is the most common fractured bone in the wrist. Despite adequate non-surgical treatment around 10% to 15% of these fractures will not heal.1,2) For clinical purpose it is important to distinguish between non-displaced, displaced and proximal scaphoid fractures because the latter two types are at risk for nonunion.3-6) Amirfeyz et al. showed that all fractures with signs of consolidation on the CT-scan 4 weeks following trauma will heal with conservative treatment. However, only half of the fractures with >3 mm displacement will heal.6) This allows us to distinguish between an almost certain union and a high risk for non-union at an early stage. Therefore, Davis suggests that all fractures with >3 mm displacement should be operated early to prevent the development of non-union.7) This makes it important to differentiate early between displaced and nonReceived: Mar. 9, 2015; Revised: Apr. 2, 2015; Accepted: Apr. 6, 2015 Correspondence to: Steven E.R. Hovius Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, NL-3000 CA Rotterdam, The Netherlands Tel: +31-107033407, Fax: +31-107033731 E-mail: [email protected]

displaced fractures. Plain radiographs have only a 33% sensitivity for the diagnosis of displacement, even when scaphoid series are performed. Therefore, MRI or CTscans are indicated in most scaphoid fractures.8) When a scaphoid non-union has developed because of late diagnosis or failed treatment it can cause a scaphoid non-union advance collapse (SNAC), this is a progressive deformity and can cause degenerative changes ranging from arthritis at the radial styloid to pancarpal arthritis. The risk of osteoarthritis increases with time from injury to surgery.5,9) If there is already evidence of osteoarthritis on preoperative imaging, scaphoid surgery is not advised and other therapy is indicated instead. The short-term goal of scaphoid surgery is achieving consolidation, pain reduction and a good position of the scaphoid while prevention of osteoarthritis is the longterm goal. Surgery consists of reduction and fixation of the scaphoid with a non-vascularized or vascularized bone graft. While there is little evidence in the current literature what type of graft is best, in a systematic review Munk et al. found a slightly higher union rate in pedicled vascularized grafts compared to non-vascularized bone grafts with internal fixation, 90% versus 84%, respectively.10) Furthermore, they did take into account the severity or type of non-union. However, postoperative wrist function is probably similar in both groups.11)

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There is a wide spectrum that can be treated with bone grafts ranging from very early non-union to pseudoarthrosis with cysts and bone loss that has been operated several times before (Fig. 1). Most experts agree that a vascularized bone graft is preferred in cases of avascular necrosis and proximal pole nonunion, where vascularity is compromised and augmentation of the local biology is needed.12) Furthermore, vascularized (pedicled) grafts are advocated in long standing pseudarthrosis or failed prior surgery. Besides pedicled bone grafts, a free vascularized bone graft can be used for scaphoid non-union. This was first reported by Pechlaner et al. in 1987, taking a cortico-cancellous graft from the iliac crest based on vascular branches from the deep iliac circumflex artery.13) More recently the free medial femoral condyle has been described which has the advantage of a lower donor site morbidity.14-16) Although free vascularized bone grafts are increasingly used and may have an even better union rate compared to pedicled bone grafts,17) it is major surgery and should be reserved for therapy resistant cases or the cases where a small proximal pole needs to be reconstructed.

NON-VASCULARIZED BONE GRAFTS A non-vascularized bone graft is less technical demanding than the vascularized bone graft and is mostly used as standard treatment for simple, non-dislocated, non-unions.18) The bone graft can be taken from several places but most used are the crista and distal radius. The Matti-Russe procedure is the most used technique and originally used the crista but similar union rates can be obtained with grafts from the distal radius.19) The advantage of the distal radius over the crista is less donor site morbidity. The Matti-Russe technique uses

A

a palmar approach between the m. flexor carpi radialis tendon and the radial artery. After exposure of the fracture, an osteotomy is done to remove the fracture edges and all the avascular cancellous bone. After reduction of the fracture the resulting defect is filled with a corticocancellous bone graft. The fracture is usually stabilized with a compression screw or one or more Kirschner wires. Although there is little evidence on the efficacy of internal fixation, slightly higher union rates were found reviewing the literature, 80% vs 84% respectively (Table 1).10) A drawback of the Matti-Russe technique is the difficulty to correct a humpback deformity. If a humpback deformity is present, a wedge bone graft can be used instead to correct this deformity. This wedge results in a good union rate and correction of the displacement, but only when performed early (6-12 months).20) In most cases a cortico-cancellous bone wedge is used as a strut. However, similar results can be obtained with a cancellous graft when the proximal and distal poles are large enough to support fixation, so that a screw can be placed as internal strut.21)

PEDICLED BONE GRAFTS Pedicled bone grafts are increasingly used for the

Table 1. Non-vascularized Bone Grafts

Non-vascularized bone graft Without internal fixation10) Non-vascularized bone graft With internal fixation10)

Number of articles

Number of patients

Union rate (95% CI)

60

2246

80 (78-82)

76

2669

84 (82-85)

B

Fig. 1. (A) Scaphoid non-union of the proximal pole. (B) Long standing scap­ hoid non-union with several cysts.

224 Steven E.R. Hovius and Tim de Jong. Bone Grafts for Scaphoid Nonunion: An Overview

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treatment of scaphoid nonunion (Table 2). These grafts can be taken from several places but most often come from the distal radius. Examples are: The volar vascularized pedicled graft (Fig. 2) The graft can be based on the volar carpal artery as first described by Kullman in 1989 and has later been popularized by Mathoulin.22,23) The artery originates 1 cm proximal of the styloid of the radius from the radial artery and crosses the volar aspect of the radius just distal to the pronator quadratus to join the ulnar artery on the other side.23) After the bone graft is outlined on the distal radius the pedicle is dissected to its origin; to protect the pedicle a 5 mm strip of periosteum and fascia surrounding it can be taken.24) Consequently, the bone graft is taken and rotated in the defect of the scaphoid after which it is fixed with Kirschner wires or a compression screw. The pronator quadratus muscle can also be used to pedicle a bone graft.25) The graft is taken at the distal insertion, caution should be taken to prevent separation of the muscle from the graft. A strip of 2 cm pronator quadratus is dissected to its origin on the ulna. If the pedicle is too short for transfer to the scaphoid, the origin can be dissected subperiosteally.

The dorsoradial pedicled graft (Fig. 3) One of the most used pedicled bone graft is described by Zaidemberg et al. based on the 1,2-intercompartmental supraretinacular artery (1,2-ICSRA).26) The 1,2-ICSRA runs superficial to the extensor retinaculum between the first and second extensor compartments. During dissection of the pedicle it should not be lifted more than 1.5 cm proximal to the wrist joint as this is the area where the nutrient vessels penetrate the bone. The downside of this, is the relative short pedicle. After outlining the bone graft on the distal radius the pedicle is dissected to its origin in the radial artery at the level of the first compartment. A cortico-cancellous bone graft is taken from

Table 2. Vascularized Bone Grafts Number of Number of articles patients 1,2-ICSRA Zaidemberg, 199126) Steinmann, 200231) Boyer, 199832) Straw, 200233) Chang, 200634) Henry, 200735) Waitayawinyu, 200936) Lim, 201337) Liang, 201338) Hirche, 201439) Volar carpal artery Kuhlmann, 198722) Mathoulin, 201040) Mathoulin, 199823) Dailiana, 200624) Medial femoral condyle Doi, 200941) Jones, 200817) Larson, 201115) Elgammal, 201414)

10

4

4

210 11 14 10 22 48 15 30 21 11 28 141 3 112 17 9 64 11 12 11 30

Union rate (95% CI) 78% (72-84%) 100% 100% 60% 27% 71% 100% 93% 86% 100% 75% 97% (93-99%) 100% 96% 100% 100% 93% (83-98%) 100% 100% 100% 80%

Fig. 2. Volar vascularized pedicled graft (Mathoulin).

Fig. 3. Dorsoradial pedicled graft (Zaidemberg).

225 Hand Surgery • Vol. 20, No. 2, 2015 • www.jhs-ap.org

A

B

C

D

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Fig. 4. (A) Pedicled bone graft based on the 1,2-ICSRA. (B) Defect of the scaphoid after osteotomy of the fracture edges and all avascular cancellous bone is removed. (C) After inset of the bone graft. (D) Radiograph 6 months after inset of bone graft.

the distal radius, taking care not to damage the vascular pedicle. The pedicled graft is subsequently rotated into the defect of the scaphoid. The first author has used the Zaidemberg technique in the last 13 years for mostly longstanding non-unions. They were often defect pseudarthrosis with cysts and bone loss, including proximal pole fractures (Fig. 4). Other options described in the literature but less known are the 2,3-ICSRA, 4,5-intercompartmental retinacular artery, proximal part of the first metacarpal based on the first dorsal metacarpal artery and the distal ulnar aspect of the ulnar head based on the ulnar artery.27-29) Free vascularized bone grafts In cases where a vascularized pedicled graft has fa­ iled, in cases with avascular necrosis or if there is an indication for a large wedge to correct a humpback deformity, a free vascularized bone graft could be a good option. The two most used free vascularized bone grafts are taken from the iliac crest and the medial femoral condyle. Reviewing the current literature Al-Jabri et al. found union in 88% of the iliac crest cases compared to 100% of the medial femoral condyle cases, this difference was significant.16) More recently Elgammal et al. reported on 30 cases with a union rate of 80%, showing that the medial femor condyle has its failures as well.14) The free vascularized bone graft obtained from the iliac crest is based on the deep circumflex iliac artery and vein. The vascular bundle is identified through an incision parallel to the inguinal ligament. After the small vessels that penetrate the bone are identified a tricorticalcancellous bone graft is taken. When a humpback deformity is present the graft can be given a wedge shape to correct the deformity. After debridement of the scaphoid the bone graft is placed between the two parts of the scaphoid and fixed with a Kirschner wire. Subsequently an end-to-side anastomosis is made to the radial artery and an end-to-end anastomosis to the venae comitantes.30)

Fig. 5. Free medial femoral condyle bone graft.

The medial femoral condyle is based on the descending genicular artery and vein or the superomedial genicular vessels (Fig. 5). The vessels are preoperatively located by Doppler. An incision is made just anterior to where the vessels were preoperatively identified. The vessels can be identified by retracting the medial vastus muscle. When the descending genicular artery and vein are too small for anastomosis, the superiomedial genicular vessels can be used instead. When this is not the case, the superiomedial genicular vessels are ligated. The bone graft is taken from the medial femoral condyle where the vessels enter the cortex. Care should be taken not to damage the medial collateral ligament and joint capsule. After debridement of the scaphoid, the bone graft is shaped and placed in the defect. Subsequently, an anastomosis is made to the radial artery and its comitant vein. We have performed five of these cases at our unit of which one had a re-intervention for non-union.

226 Steven E.R. Hovius and Tim de Jong. Bone Grafts for Scaphoid Nonunion: An Overview

CONCLUSION There are several options for bone grafting scaphoid non-unions. In the absence of high level evidence most experts advocate non-vascularized bone grafts as standard treatment for simple, non-dislocated non-unions and vascularized bone grafts for cases of avascular necrosis, proximal pole nonunion, long standing pseudarthrosis or failed prior surgery.

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CONFLICT OF INTEREST This study was not supported by any external sources or funds. The authors have no financial interest in any medical device, product or procedure mentioned in this article.

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Bone Grafts for Scaphoid Nonunion: An Overview.

The scaphoid is the most common fractured bone in the wrist. Despite adequate non-surgical treatment, around 10% to 15% of these fractures will not he...
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