treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapsea...

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2008;90:2616-2625. doi:10.2106/JBJS.G.01503 J Bone Joint Surg Am.David B. Jones, Jr., Heinz Bürger, Allen T. Bishop and Alexander Y. Shin

GraftsPole and Carpal Collapse. A Comparison of Two Vascularized Bone Treatment of Scaphoid Waist Nonunions with an Avascular Proximal

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Treatment of Scaphoid Waist Nonunions with anAvascular Proximal Pole and Carpal Collapse

A Comparison of Two Vascularized Bone Grafts

By David B. Jones Jr., MD, Heinz Burger, MD, Allen T. Bishop, MD, and Alexander Y. Shin, MD

Investigation performed at the Mayo Clinic, Rochester, Minnesota, and Landeskrankenhaus Klagenfurt, Klagenfurt, Austria

Background: Surgically, it is difficult to achieve union of a scaphoid nonunion that is associated with osteonecrosis of theproximal pole, and those with carpal collapse are especially difficult to treat. A variety of vascularized bone grafts can beused. The purpose of this study was to compare the effectiveness of two types of vascularized bone graft—a distal radialpedicle graft and a free vascularized medial femoral condyle graft—in the treatment of scaphoid waist nonunionsassociated with proximal pole osteonecrosis and carpal collapse.

Methods: A retrospective review was conducted at two institutions to identify all patients with a scaphoid waist nonunionassociated with an avascular proximal pole and carpal collapse. Between January 1994 and June 2006, twenty-two suchnonunions were identified in twenty-two patients. Ten were treated with a distal radial pedicle vascularized graft and twelve,with a free vascularized medial femoral condyle graft. Patient demographics were similar between the groups, and theduration of follow-up averaged twelve months. Unionwasdetermined withuse of plain radiographsand computed tomographyor trispiral tomograms. In addition, carpal angles, time to union, union rates, and complications were recorded.

Results: Four of the ten nonunions treated with the distal radial pedicle graft healed, at a median of nineteen weeks, andall twelve nonunions treated with the free medial femoral condyle graft healed, at a median of thirteen weeks. The rate ofunion was significantly higher (p = 0.005) and the median time to healing was significantly shorter (p < 0.001) for thenonunions treated with the medial femoral condyle graft.

Conclusions: A vascularized interposition graft from the medial femoral condyle is the recommended vascularized bonegraft for the surgical treatment of scaphoid waist nonunion with avascularity of the proximal pole and carpal collapse.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

An estimated 34,000 acute scaphoid fractures go on tononunion each year in the United States1, and 5%to 15% of all acute scaphoid fractures fail to unite2.

While many of the nonunions are initially asymptomatic3,they frequently become painful over time. Natural historystudies of symptomatic nonunions have demonstrated auniform progression of degenerative carpal arthritis, theseverity of which is proportional to the duration of thenonunion4-6. Risk factors for scaphoid nonunion includeabsent or delayed cast immobilization, fracture displace-ment, proximal location, osteonecrosis, and associated car-pal instability7-9.

Various surgical techniques have been proposed to im-prove union rates10. A recent meta-analysis demonstrated aunion rate of only 47% in the presence of avascularity of theproximal pole7. Use of vascularized bone grafts has been as-sociated with an 87% rate of union in similar circumstances7.Thus, vascularized bone grafts have been recommended for thetreatment of scaphoid nonunions associated with proximalpole osteonecrosis.

The use of a distal radial graft based on a 1,2 inter-compartmental supraretinacular artery pedicle in the treat-ment of scaphoid nonunions associated with osteonecrosis hasbeen reported to be successful in terms of achieving union and

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor amember of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercialentity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice,or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM/DVD (call oursubscription department, at 781-449-9780, to order the CD-ROM or DVD).

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COPYRIGHT � 2008 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

J Bone Joint Surg Am. 2008;90:2616-25 d doi:10.2106/JBJS.G.01503

alleviating symptoms11-16. While several studies have demon-strated high rates of union11-16, we recently reported an overallunion rate of 71% for scaphoid nonunions and a rate of 50%in the setting of osteonecrosis17. Nine of the fourteen failureshad evidence of dorsal intercalated segment instability and/or ahumpback deformity. The high rate of failure in patients withcarpal collapse was the result of a failure to restore normalscaphoid geometry, suggesting the need to modify the tech-nique or use an alternative method17. In nearly all other reportson pedicled vascularized bone grafts, the grafts were used onlyfor nondisplaced or minimally displaced scaphoid nonunionsor for nonunions with minimal structural collapse18,19.

The use of a free vascularized medial femoral condylebone graft was first described by Doi et al., who reported suc-cessful union in all of ten patients at an average of twelve weeksafter the surgery20. The technique that Doi et al. describedinvolved use of the medial femoral condyle as a cortico-periosteal inlay graft with the descending genicular vesselsanastomosed to the radial artery and venae comitantes. Amodification of this technique that allows harvest of a corti-cocancellous structural graft in addition to maintaining thevascular supply for use in the treatment of scaphoid nonunionshas been described21,22.

The treatment of scaphoid waist nonunions combinedwith an avascular proximal pole and carpal collapse has notbeen thoroughly addressed in the literature. Typically, thissubset of scaphoid nonunions has been included with othertypes of scaphoid nonunions, and it is therefore difficult todetermine the results of their treatment from the literature21.The purpose of the present study was to evaluate the outcomesin a series of scaphoid waist nonunions with an avascularproximal pole and carpal collapse to determine whethertreatment with a distal radial graft based on a 1,2 inter-compartmental supraretinacular artery pedicle or treatmentwith a free vascularized medial femoral condyle graft is moreeffective.

Materials and Methods

Following institutional review board approval, a retrospec-tive review was conducted of the medical records of pa-

tients at two institutions (Mayo Clinic, Rochester, Minnesota,and Landeskrankenhaus Klagenfurt, Klagenfurt, Austria). Adiagnosis of scaphoid waist nonunion with proximal pole os-teonecrosis and carpal collapse (Figs. 1-A through 1-D) treatedwith either a distal radial bone graft based on a 1,2 inter-compartmental supraretinacular artery pedicle16,23 or a freevascularized medial femoral condyle graft21,22 was necessary forinclusion in this study. The diagnosis of osteonecrosis wasdetermined on the basis of preoperative radiographic findings,including loss of trabecular structure, collapse of subchon-dral bone, formation of bone cysts, and decreased uptake ongadolinium-enhanced magnetic resonance imaging. The diag-nosis was ultimately confirmed at the time of surgery by a findingof white, sclerotic bone with absent punctate bleeding on tour-niquet release24-26. Carpal collapse, as evidenced by a scaphoidhumpback deformity or dorsal intercalated segment instabil-

ity deformity secondary to the nonunion, was defined as arevised carpal height ratio of £1.52 (normal, 1.57 ± 0.05)27, alateral intrascaphoid angle of ‡45� (normal, £35�)28, or a ra-diolunate angle of ‡15� (normal, £10�)29. Scaphoids withoutevidence of both osteonecrosis and carpal collapse or thosetreated with a different procedure were excluded. BetweenJanuary 1994 and June 2006, twenty-two patients who metthese criteria were identified. Medical records and radiographswere reviewed. Patient demographics, including age, sex,smoking status, and prior treatment, were recorded. Preop-erative and postoperative radiographic measurements of carpalangles (lateral intrascaphoid28, radiolunate29, and scapholunateangles29) and revised carpal height ratios were obtained27.Operative details, including the type of graft, type of fixation,time to union, complications, and subsequent surgery, werealso recorded.

DemographicsThree women and nineteen men with a total of twenty-twoscaphoid waist nonunions associated with an avascular prox-imal pole and carpal collapse were followed until union ortreatment failure. The minimum duration of follow-up wastwelve months, and the maximum was fifty months. The av-erage age of the patients was twenty-seven years (range, eigh-teen to sixty-six years). Treatment failure was defined asevidence of nonunion on computed tomography scans ac-companied by persistent symptoms. Nine of the twenty-twopatients reported smoking tobacco. Ten of the fractures oc-curred in the dominant hand. Ten of the patients had had priorsurgical treatment, and eight of them still had a screw in placein the scaphoid when they presented for evaluation. The priorsurgical treatment was open reduction with internal screwfixation in three patients, use of a nonvascularized iliac-crestwedge graft and screw fixation in four, use of a dorsal non-vascularized radial bone graft with screw fixation in one andwith Kirschner wire fixation in one, and cancellous bone-grafting with Kirschner wire fixation in one. The duration ofnonunion was known for twenty patients, for whom the me-dian time to surgery was twenty-four months (range, six tosixty-six months).

Preoperative AssessmentPatients generally presented with a limited range of motion,pain at the extremes of motion or with exertion, and tendernessat the anatomic snuffbox. Preoperative evaluation includedimaging (Figs. 1-A through 1-D) with plain radiographs as wellas trispiral tomograms or computed tomography and/or mag-netic resonance imaging with gadolinium (see Appendix). Therange of motion and grip strength were measured preoperativelyand postoperatively.

Surgical ProceduresTen scaphoid nonunions were treated with a vascularized distalradial bone graft based on a 1,2 intercompartmental supra-retinacular artery pedicle as described by two of us (A.T.B. andA.Y.S.) and colleagues30,31 (Figs. 2-A and 2-B). Four of these

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TH E J O U R N A L O F B O N E & JO I N T SU R G E RY d J B J S . O R G

VO LU M E 90-A d NU M B E R 12 d D E C E M B E R 2008TR E AT M E N T O F SC A P H O I D WA I S T NO N U N I O N S W I T H A N

AVA S C U L A R PR OX I M A L PO L E A N D CA R PA L CO L L A P S E

Fig. 1-C Fig. 1-D

Lateral (Fig. 1-C) and coronal (Fig. 1-D) computed tomography scans.

Fig. 1-A Fig. 1-B

Figs. 1-A through 1-D Images of a scaphoid waist nonunion with carpal collapse and osteonecrosis of the proximal pole. Figs. 1-A

and 1-B Lateral (Fig. 1-A) and posteroanterior (Fig. 1-B) radiographs.

2618




patients had a radial styloidectomy in addition to the bone-grafting to treat early degenerative changes (i.e., beaking of theradial styloid process)32. The other six patients had no evidenceof degenerative changes at the time of surgery.

Twelve scaphoid nonunions were treated with a freevascularized medial femoral condyle bone graft to achieveosseous union and simultaneously correct scaphoid length andvascularity as described by one of us (A.Y.S.)21 and by Larsonet al.22 (Figs. 3-A, 3-B, and 3-C). The pedicle for this flap,

which has been described, included the descending genicularartery or the superomedial genicular artery when the descendinggenicular artery was not present20,21. The descending genicularartery and vein were used in ten patients, and the superomedialgenicular artery was used in two.

A volar approach to the scaphoid was used for themedial femoral condyle graft procedures, and a dorsoradialexposure was used for the distal radial pedicle graft proce-dures. The scaphoid was inspected, and the nonunion was

Fig. 2-A

Fig. 2-B

Technique for use of a vascularized bone graft from the dorsal, distal part of the radius based on a

1,2 intercompartmental supraretinacular artery pedicle. The graft can be used as either an inlay graft

(Fig. 2-A) or an opening wedge graft placed from the dorsal, radial aspect of the wrist (Fig. 2-B). (By

permission of the Mayo Foundation.)

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identified and debrided. Carpal alignment was temporarilyrestored by flexion of the wrist and placement of a radio-lunate Kirschner wire when the lunate was collinear with theradius on a lateral fluoroscopic image. The wrist was thenextended, which resulted in separation of the scaphoidnonunion gap. The proximal and distal edges of the nonunionwere prepared with a sagittal saw or curets, and the dimensionsof the defect were measured. The proximal pole was evaluated,and its vascularity was determined. White and sclerotic bonewith the absence of punctate bleeding when the tourniquet wasreleased was considered the final and ultimate evidenceof osteonecrosis25. The bone grafts were placed to span the

nonunion site. The distal radial graft was placed dorsally asan inlay or wedge graft spanning the nonunion site, and themedial femoral condyle graft was placed volarly as a wedgegraft.

Type of FixationSeven nonunions treated with the medial femoral condylegraft were stabilized with a cannulated scaphoid screw; four,with Kirschner wires; and one, with both a screw andKirschner wires. Seven fractures treated with the distal radialpedicle graft were stabilized with Kirschner wires and three,with both a screw and Kirschner wires. Although the choice of

Fig. 3-A

Figs. 3-A, 3-B, and 3-C Technique for use of a free vascularized medial femoral

condyle structural bone graft. (By permission of the Mayo Foundation.) Fig. 3-A After

the size of the defect in the scaphoid is determined, the medial femoral condyle

bone graft is harvested based on the descending genicular artery (arrow) or the

superomedial genicular artery (asterisk).

Fig. 3-B

Intraoperative photograph of the medial femoral condyle exposure and the harvest of

the structural vascularized bone graft.

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fixation was based on fragment size and stability at the time ofthe surgery, an attempt was made to achieve screw fixation ineach case.

Radiographic EvaluationAll preoperative and postoperative radiographs, includingcomputed tomography scans, trispiral tomograms, and mag-netic resonance imaging scans, were reviewed. Union wasdefined as bridging trabeculae consolidating the majority ofboth the proximal and the distal interface as seen on plainradiographs and a computed tomography scan or trispiraltomogram accompanied by the absence of adverse featuressuch as a gap at the graft interface or a shift of the graft33,34.Radiographic determination of union was performed bymusculoskeletal radiologists blinded to the study, and long-term clinical and radiographic follow-up confirmed their de-termination. The time to union was estimated, as patients wereevaluated at three to six-week intervals rather than on a weeklybasis. Preoperative and postoperative revised carpal heightratios27 and lateral intrascaphoid28, scapholunate29, and radio-lunate29 angles were measured. Patients who had a screw inplace from a prior operation were excluded from the analysis of

the change in carpal parameters, as the screw artificially heldthe nonunion in a partially corrected position.

Statistical MethodsThe primary analysis outcome was the rate of successfulfracture union among the twenty-two patients in the study.Because not all patients had union and the durations of follow-up differed, this end point was analyzed as a time-to-eventoutcome. Specifically, the cumulative probability of scaphoidunion was estimated with use of the method of Kaplan andMeier, and fractures that remained ununited at the time of datacollection were censored at the time of their most recentfollow-up. As a secondary analysis, the subset of patients whohad scaphoid union was analyzed with two-sample t tests to eval-uate the strength of the association of prior surgery or screwfixation with the time to union. Preoperative and postoper-ative radiographic measures were analyzed with use of pairedt tests. Since there were so few postoperative complications,these were summarized only descriptively; no formal com-parisons were performed. All statistical tests were two-sided,and p £ 0.05 was considered significant.

ResultsDistal Radial Pedicle Grafts

Ten nonunions in three women and seven men with anaverage age of thirty-one years (range, eighteen to sixty-six

years) were treated with a distal radial graft on a 1,2 inter-compartmental supraretinacular artery pedicle. Four of thepatients were smokers at the time of surgery. The time fromthe injury to the surgery was known for eight of the patientsand averaged twenty-six months (range, six to forty-eightmonths). Four of the patients had undergone prior surgery,and four still had a screw in place at the time of presentation.Of the ten nonunions that were treated, four united at a me-dian of nineteen weeks (range, eleven to thirty weeks). Three ofthe seven grafts secured with Kirschner wire alone united, andone of three grafts secured with both a screw and Kirschnerwire united. There were six failures. In one case, a deeppostoperative infection developed and required incision anddrainage and intravenous antibiotics. The screw backed out inanother, requiring removal of the screw with simultaneousanterior and posterior interosseus neurectomy for pain con-trol. The remaining four failures had no clear cause. Two ofthose failures were treated with subsequent salvage surgery,including a proximal row carpectomy in one and scaphoidexcision combined with a four-corner arthrodesis in the other.The postoperative range of motion of the wrists in which thescaphoid failed to unite was 36� of flexion and 26� of exten-sion. The grip strength of the affected hand of the patients whohad a failure averaged 61% of that of the unaffected hand.

Comparison of preoperative and postoperative radio-graphs demonstrated no significant change in the revisedcarpal height ratio or the carpal angles (see Appendix). Thepostoperative range of motion of the wrists in which thescaphoid united averaged 38� of flexion and 47� of extension.The grip strength of the affected hand of the patients who had

Fig. 3-C

The bone graft is inserted volarly and is placed as a wedge graft in the

scaphoid nonunion site. Screw fixation is preferred, but occasionally

Kirschner wires are used if the bone fragments are too small. An end-

to-side anastomosis of the genicular artery to the radial artery and an

end-to-end anastomosis of the vein to one of the venae comitantes

are performed.

2621




union averaged 68% of that of the unaffected hand (40 and59 kg, respectively).

Free Vascularized Medial Femoral Condyle GraftTwelve men with an average age of twenty-three years (range,eighteen to thirty-two years) were treated with a medial fem-oral condyle graft (Figs. 4-A and 4-B). Five of the patients weresmokers at the time of surgery. The time from the injury to thesurgery was known for all of the patients, and it averagedthirty-one months (range, nine to sixty-six months). Six of thepatients had undergone previous surgery, and four still had ascrew in place at the time of presentation. All twelve nonun-ions united, at a median of thirteen weeks after the surgery(Figs. 5-A and 5-B). Seven grafts were secured with screwfixation alone; four, with Kirschner wire alone; and one, withboth a screw and Kirschner wire.

Comparison of preoperative and postoperative radiographsdemonstrated marked improvement, with an average decrease inthe lateral intrascaphoid angle of 25� (from 57� preoperatively to32� postoperatively; p < 0.001), an average decrease in the sca-pholunate angle of 13� (from 70� to 57�; p = 0.05), and anaverage decrease in the radiolunate angle of 5� (from 15� to 10�;p = 0.03). The average revised carpal height ratio increased from1.49 preoperatively to 1.51 postoperatively; however, this changewas not significant (p = 0.24). The postoperative range of mo-tion averaged 42� of flexion and 40� of extension. The gripstrength of the affected hand averaged 86% of that of the unaf-fected hand (44 and 51 kg, respectively).

All patients reported knee pain at the site of the medialfemoral condyle. This resolved by an average of six weeks

(range, four to seven weeks) postoperatively. There were noother donor-site-related complications.

Comparative AnalysisKaplan-Meier analysis demonstrated that the median time tounion after treatment with the medial femoral condyle graft(thirteen weeks) was significantly shorter than that after treat-ment with the distal radial pedicle graft (nineteen weeks) (p <0.001). Analysis of the postoperative radiographic parametersdemonstrated a significantly smaller average lateral intra-scaphoid angle in the group treated with the medial femoralcondyle graft compared with the group treated with the distalradial pedicle graft (32� and 48�, respectively; p = 0.003). Dif-ferences in postoperative revised carpal height indices, scapho-lunate angles, and radiolunate angles between the groups didnot reach significance. A post hoc power analysis demonstratedan 80% power to detect differences in means between thegroups of at least 0.07 for the carpal height ratio, 19.1� for thescapholunate angle, and 12.3� for the radiolunate angle. Ananalysis of potential risk factors for failure did not demonstrate asignificant difference between nonunions treated with a screwand those treated with Kirschner wire (p = 0.62). However, onlytwo of thirteen nonunions treated with a screw failed, whereasfour of eleven treated with a Kirschner wire alone failed. Therewas also no significant difference in the risk of failure betweenpatients with and those without previous surgery (p = 0.65). Apost hoc power analysis demonstrated an 80% power to detect ahazard ratio of at least 3.76 for the comparison of screw andKirschner wire fixation and 3.75 for the comparison of priorsurgical treatment and no prior surgery.

Fig. 4-A Fig. 4-B

Figs. 4-A and 4-B Biplanar intraoperative fluoroscopic images of the case illustrated in Figure 1, demonstrating the placement of the vascularized medial

femoral condyle bone graft with screw fixation.

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Discussion

In a meta-analysis of the literature, vascularized bone-grafting of scaphoid nonunions with osteonecrosis was

found to be associated with a union rate of 88% comparedwith 47% in association with conventional (nonvascularized)grafting7. However, vascularized grafts do not uniformly yieldthe desired outcome. In 1998, Boyer et al.35 reported union insix of ten patients treated with a distal radial graft based on a1,2 intercompartmental supraretinacular artery pedicle. Inthat series, the four persistent nonunions had all been pre-viously treated with a nonvascularized graft, which had failed.It was suggested that previous surgery may be a predictor of apoor outcome. In 2002, Straw et al.36 reported a union rate of27% after the use of vascularized distal radial grafts based ona 1,2 intercompartmental supraretinacular artery pedicle. Inthat series, sixteen of the twenty-two nonunions were asso-ciated with avascularity of the proximal pole and only twoof those went on to union. Neither group of authors com-mented on the presence or absence of scaphoid deformity orcarpal collapse.

Henry reported that use of a graft based on a 1,2 inter-compartmental supraretinacular artery pedicle was successfulin the treatment of scaphoid collapse and osteonecrosis37. Inthat series, the graft was placed volarly as a wedge graft and allfifteen scaphoids united. We recently reported an overall unionrate of 71% after treatment of scaphoid nonunions with a graft

based on a 1,2 intercompartmental supraretinacular arterypedicle17. A detailed analysis of the failures demonstrated thepresence of dorsal intercalated segmental instability (orhumpback) deformity in nine of fourteen cases with nonun-ion. It was hypothesized that the failure of the graft to correcthumpback deformity may have contributed to the failure.

Several other pedicled vascularized grafts have been de-scribed for the treatment of persistent scaphoid nonunion. Use ofa vascularized graft from the volar and ulnar aspect of the distalpart of the radius supplied by the palmar carpal artery has beenreported to result in excellent rates of union19,38. This graft wasinitially described as an inlay graft for the treatment of nonun-ions without carpal collapse; its use for scaphoid waist nonun-ions with an avascular proximal pole and carpal collapse has notbeen reported, to our knowledge. Dailiana et al. modified thisgraft, shaping it into a trapezoidal wedge to provide structuralsupport39. However, carpal collapse was not present in associa-tion with any of the nine nonunions in this series, and only onenonunion was associated with osteonecrosis of the proximalpole. Bertelli et al. described a graft from the thumb that waspedicled on the first dorsal metacarpal artery18. While they didnot comment on the presence or absence of osteonecrosis in thatseries, six of the ten scaphoids had dorsal intercalated segmentinstability deformity and nine went on to union.

Other vascularized grafts that provide structural supportin addition to a vascular supply to the scaphoid have been

Fig. 5-A Fig. 5-B

Figs. 5-A and 5-B Twelve-week postoperative radiographs of the case illustrated in Figures 1 and 4, demonstrating complete

healing.

2623




described. In a canine study, Hori et al.40 initially described theangiogenesis of autogenous bone when a bundle consisting ofan artery, venae comitantes, and perivascular tissue was im-planted into it. Fernandez and Eggli reported that ten of elevennonunions associated with osteonecrosis of the proximal poleunited at an average of ten weeks after treatment with an inlaycorticocancellous wedge graft from the iliac crest accompaniedby implantation of the second dorsal intermetacarpal arterio-venous pedicle41. Eight of the nonunions were in the proximalone-third of the scaphoid, and three were at the waist. Onlyone of the wrists had dorsal intercalated segment instabilitydeformity. The remaining wrists had normal carpal angles.Additionally, only three patients were treated with a structuraliliac crest graft and screw fixation while the remainder weretreated with an inlay graft and Kirschner wire.

Free vascularized iliac-crest wedge grafts have also beendescribed21. In 2001, Harpf et al. reported on sixty scaphoidnonunions (twenty-six with an avascular proximal pole)treated with this technique42. The authors found an overallunion rate of 91.7%. The union rate for the nonunions asso-ciated with an avascular proximal pole was 90%; however, itshould be noted that none of these wrists had carpal collapse orhumpback deformity and all grafts were used as an inlay graft.Donor site morbidity was high, with a 55% prevalence ofhyperostosis of the iliac crest, an 8.3% prevalence of deformityof the iliac crest, and a 31.7% prevalence of nerve hypoesthesia.

In 2000, Doi et al.20 described the treatment of tenscaphoid nonunions with a free vascularized medial femoralcondyle inlay graft. All ten united, at an average of twelve weeksafter the surgery, and the scapholunate angle improved by anaverage of 6� (from 58� preoperatively to 52� postoperatively).The duration of follow-up averaged 3.5 years, and no patienthad long-term morbidity at the donor site. In the present study,all twelve scaphoids treated with a free vascularized medialfemoral condyle graft united, at a median of thirteen weeksafter the surgery. The average correction of the scapholunateangle was 13� (from 70� preoperatively to 57� postoperatively).Donor site morbidity was minimal, with an average durationof knee discomfort of six weeks without loss of motion.

This study has several limitations; it was retrospective,and there were multiple surgeons and relatively small numbers

of patients in each treatment group. The relative rarity of thecombination of scaphoid waist nonunion with an avascularproximal pole and carpal collapse (humpback deformity)makes a comparison of multiple techniques challenging. Theselimitations notwithstanding, we demonstrated that the rate ofunion of scaphoid waist nonunions associated with osteone-crosis and carpal collapse is higher with the use of a medialfemoral condyle graft, which provides both a vascular supplyand correction of the scaphoid deformity, than it is with adistal radial graft based on a 1,2 intercompartmental supra-retinacular artery pedicle. The vascularized pedicled distalradial bone graft was not sufficient to maintain carpal align-ment and was associated with an unacceptably high failure ratewhen used to treat nonunions with both osteonecrosis andcarpal collapse. The optimal vascularized bone graft is one thathas structural integrity as well as a robust blood supply and canbe harvested with minimal donor site morbidity. The vascu-larized medial femoral condyle bone graft has become thevascularized bone graft of choice for our patients with scaphoidwaist nonunion associated with carpal collapse (humpbackdeformity) and osteonecrosis of the proximal pole.

AppendixTables showing demographics and detailed results for allpatients are available with the electronic versions of this

article, on our web site at jbjs.org (go to the article citation andclick on ‘‘Supplementary Material’’) and on our quarterly CD/DVD (call our subscription department, at 781-449-9780, toorder the CD or DVD). n

David B. Jones Jr., MDAllen T. Bishop, MDAlexander Y. Shin, MDDivision of Hand Surgery, Department of Orthopaedic Surgery, MayoClinic, 200 First Street S.W., E14A, Rochester, MN 55905. E-mail addressfor A.Y. Shin: [email protected]

Heinz Burger, MDFacharzt fur Unfallchirurgie, Radetzkystrasse 50,9020 Klagenfurt, Austria

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treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapsea...

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