Scaphoid nonunions: management with vascularized bone grafts from the distal radius: a clinical and functional outcome study.
BACKGROUND
Scaphoid nonunions remain controversial with regard to optimal management, especially for those located at the proximal third. In this study, the authors aim to assess the union rate, avascular proximal pole revascularization, and functional outcome of scaphoid nonunions managed with distal radius vascularized bone grafts.


METHODS
Thirty patients were treated with vascularized bone grafts between 1999 and 2003 and prospectively followed up. The average nonunion chronicity was 3.3 years. Nine patients (30 percent) had avascular necrosis of the proximal pole, five had unsuccessful previous surgical procedures, and four had radioscaphoid arthritis (Lichtman type III). Twenty proximal third nonunions were managed with dorsal radius bone graft, whereas 10 waist nonunions had palmar grafts. Union was assessed clinically and radiologically and, in 67 percent of the patients, by means of magnetic resonance imaging.


RESULTS
All cases were united by 12 weeks, and magnetic resonance imaging confirmed that all necrotic proximal poles were revascularized. On at least 24 months' follow-up, 90 percent of patients achieved complete pain relief. Wrist flexion-extension and radial-ulnar deviation arcs did not change. The postoperative grip strength was 82 percent of the contralateral side. The Mayo Modified Wrist Score increased significantly from 58 to 85 points and, overall, 77 percent of patients had an excellent or good outcome. No risk factors for compromised wrist function were identified. The scapholunate angle, the scaphoid length, and the Nattrass index improved significantly.


CONCLUSIONS
This series demonstrates the efficacy of distal radius vascularized bone grafts in union enhancement, proximal pole revascularization, pain relief, improved wrist function, and carpal alignment. Vascularized bone grafts are a reliable therapeutic alternative for scaphoid nonunions.
Malizos
Konstantinos N
KN
Larissa and Heraklion, Greece From the Department of Orthopedics, School of Health Sciences, University of Thessalia, and Department of Radiology, University of Crete.
Zachos
Vasileios
V
Dailiana
Zoe H
ZH
Zalavras
Charalampos
C
Varitimidis
Socratis
S
Hantes
Michael
M
Karantanas
Apostolos
A
D000293:Adolescent; D000328:Adult; D005260:Female; D005500:Follow-Up Studies; D005599:Fractures, Ununited / Q000601:surgery*; D006801:Humans; D008297:Male; D011446:Prospective Studies; D011884:Radius / Q000098:blood supply* / Q000637:transplantation*; D012307:Risk Factors; D021361:Scaphoid Bone / Q000293:injuries*; D016896:Treatment Outcome