Arch Hand Microsurg.  2021 Jun;26(2):109-117. 10.12790/ahm.20.0077.

Free Vascularized Medial Femoral Condyle Bone Graft for Scaphoid Nonunion with Poor Prognosis Factors

• Park SG
• Shim BJ
• Seok HG

• KMID: 2516155
• DOI: http://doi.org/10.12790/ahm.20.0077

Abstract

Purpose
Authors attempt to evaluate the clinical and radiographic results of the treatment of scaphoid nonunion with poor prognostic factors with the free vascularized medial femoral condyle bone graft.
Methods
We operated on eight patients with avascular necrosis or prolonged nonunion of the scaphoid between January 2016 and July 2019. Wrist motion in terms of flexion, extension, and ulnar and radial deviation, a visual analogue scale (VAS), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the modified Mayo wrist score, scapholunate angle, and carpal height index were collected in the clinic setting preoperatively and at the latest follow-up in all patients
Results
Eight patients with union achieved correction and maintenance of both scapholunate angle and carpal height index. The VAS pain scores significantly improved from 5.1 preoperatively to 3.3 postoperatively. There was a statistically significant improvement in the average DASH score at the final follow-up. Scapholunate relationships in the reconstructed wrists remained almost unchanged, with average scapholunate angles of 49.7° before surgery and 47.0° at the latest postoperative follow-up. There was no statistical significance between the number of poor prognosis factors and the time to union, but there was a positive correlation.
Conclusion
It could help surgeons manage the scaphoid nonunion associated with poor prognostic factors such as avascular necrosis, carpal collapse (posttraumatic arthritis), prolonged nonunion, and failed prior scaphoid nonunion surgery.

Keyword

Avascular necrosis; Scaphoid nonunion; Free vascularized medial femoral condyle bone graft

Figure

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  Fig. 1. (A) Anterior (Russe) scaphoid exposure shows the nonunion site. When the nonunion site was exposed, an oval cortical window was made using a 3-mm diameter high-speed burr on the volar aspect of the proximal and distal pole of the scaphoid. (B) Intraoperative photos of debridement of the nonunion site at the scaphoid and preparation to accept the vascularized medial femoral condyle graft. (C) The graft was further shaped to fit the nonunion site. The periosteal surface attached to the pedicle should lie volar. (D) Vascular repairs were end-to-side to the radial artery and end-to-end to a vena comitans.

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  Fig. 2. (A) Lateral aspect of the scaphoid. (B) The surgeon excavated as much necrotic bone as possible if encountered while leaving the dorsal cortex intact. (C) The graft is inset obliquely into the scaphoid defect with the cortex facing palmarly. (D) Push the distal part of the graft with the impactor. (E) To fit graft properly without rotation or extrusion of graft and vessels, the surgeon holds the distal part of the graft with the index finger during temporary fixation with guide wire. (F) A 3.0-mm partially threaded headless compression screw was inserted along the guide wire and the guide wire was removed.

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  Fig. 3. (A) Preparation and harvesting of the medial femoral condyle graft. The vastus medialis fascia was incised sharply at its posterior aspect, and the muscle retracted properly exposing the medial genicular artery system. (B) A rectangular shape of sufficient size to fill the gap in the scaphoid is marked out, the periosteum sharply incised, and the bone cut with a micro sagittal saw and osteotomes. (C) The corticocancellous graft was harvested with its vascular pedicle.

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  Fig. 4. (A) Scaphoid view of the wrist of a 51-year-old man, showing an scaphoid fracture. (B) Anteroposterior and (C) scaphoid view of wrist at 10 month after 1st operation in other hospital, showing an established scaphoid nonunion, sclerotic change around the fracture site. (D) Postoperative computed tomography at 10 month after 1st operation in other medical center, showing sclerotic change. (E) Anteroposterior and (F) scaphoid view of wrist 1-year after the last operation, showing achievement of union, correction, and maintenance of carpal height index.

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