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Williams EA, Chao L, Chen E, Yoshida R, Kulber D. Distal Scaphoid Excision and Dermal Allograft Interposition in a Professional Athlete: Long-term Follow-up. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5898. [PMID: 39171246 PMCID: PMC11338259 DOI: 10.1097/gox.0000000000005898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 04/24/2024] [Indexed: 08/23/2024]
Abstract
Scaphoid nonunion occurs in 10%-15% of scaphoid fractures, potentially resulting in scaphoid nonunion advanced collapse. Distal scaphoid excision without allograft interposition is a known treatment, but can result in loss of carpal height and pain. This report describes the application of human acellular dermal matrix as an interposition graft after distal scaphoid excision for stage I scaphoid nonunion advanced collapse. Postoperatively, the patient initiated early range of motion and returned to full activity at 6 weeks. He demonstrated resolution of his pain 6 years later.
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Affiliation(s)
- Eva A. Williams
- From the Keck School of Medicine, Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, Calif
| | - Linda Chao
- Cedars-Sinai Medical Center, Division of Orthopaedic Hand Surgery, Los Angeles, Calif
| | - Eunise Chen
- McGovern Medical School, University of Texas Health Science Center, Houston, Tex
| | - Ryu Yoshida
- Cedars-Sinai Medical Center, Division of Orthopaedic Hand Surgery, Los Angeles, Calif
| | - David Kulber
- Cedars-Sinai Medical Center, Division of Orthopaedic Hand Surgery, Los Angeles, Calif
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Adaş M. Treatment of AVN-Induced Proximal Pole Scaphoid Nonunion Using a Fifth and Fourth Extensor Compartmental Artery as a Vascularized Pedicle Bone Graft: A Retrospective Case Series. Med Sci Monit 2024; 30:e944553. [PMID: 38762751 PMCID: PMC11113082 DOI: 10.12659/msm.944553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 05/01/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND Scaphoid nonunion (SN) is a challenging condition in wrist pathology, often resulting in severe consequences if left untreated. Surgical intervention, particularly using vascularized bone grafts (VBGs), is a promising but uncertain approach. The 4+5 extensor compartment artery (ECA) pedicled graft, less commonly used for SN, has potential benefits due to its vascular supply and accessibility to the scaphoid. This study aimed to evaluate the effectiveness of the 4+5 ECA pedicled graft combined with headless compression screw fixation in treating avascular necrosis (AVN)-induced proximal pole SN. Radiological results, functional outcomes, and complications related to this method were assessed. MATERIAL AND METHODS This was a retrospective analysis of 19 proximal pole SN cases with AVN treated using the 4+5 ECA-VBG technique from 2016 to 2022. Patients underwent preoperative evaluation and postoperative follow-up for at least 1 year. Data on surgery, demographics, radiological assessments, and functional outcomes were recorded and analyzed statistically. RESULTS All patients achieved radiographic union within 8.5 weeks postoperatively, with revascularization of proximal pole necrosis. Significant improvements in functional outcomes were observed, including pain reduction, increased wrist range of motion, improved grip and pinch strength, and enhanced wrist scores. No major complications were reported. CONCLUSIONS The 4+5 ECA-VBG technique, with headless compression screw fixation, showed high success rates in treating AVN-induced proximal pole SN. This method offers comprehensive restoration of wrist function and minimal complications, making it a viable option for SN management, especially in AVN cases. Further research is needed to confirm these results and establish standardized protocols for SN treatment.
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Chen N, Wang Y, Tang J. Free vascularized bone graft from the lateral epicondylar region of the humerus for treatment of scaphoid nonunion. Microsurgery 2024; 44:e31128. [PMID: 37877512 DOI: 10.1002/micr.31128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/17/2023] [Accepted: 10/06/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND Free vascularized bone grafting (FVBG) has become one of the essential methods for treating scaphoid nonunion complicated by avascular necrosis. However, commonly used bone graft, including the medial femoral condyle bone graft and iliac crest bone graft, still present challenges such as a high rate of donor site complications and variations of vascular pedicle. In this study, we have introduced a novel bone graft-the lateral humeral condyle bone graft with the posterior branch of the radial collateral artery (PBRCA) as the vascular pedicle-as an alternative option, with the aim of overcoming some of the limitations of previously described FVBG procedures. METHODS Nine patients who had a nonunion of the scaphoid that had been present for an average of 16.8 months (range 9-35 months) were managed with use of a free vascularized bone graft obtained from the lateral humeral epicondylar region. Avascularity of the scaphoid, as assessed on preoperative magnetic resonance imaging and intraoperative bone marrow puncture test. Postoperatively, regular X-ray and CT scans examinations were conducted to assess the progress of fracture healing. Active motion of the wrist, and grip strength recovery were measured periodically. Wrist pain was graded using the Visual Analogue Scale (VAS), while wrist joint functionality was evaluated using the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) questionnaire and the Patient-Rated Wrist Evaluation (PRWE) scale. The elbow functional outcome was evaluated by the Mayo Elbow Performance Score (MEPS). RESULTS All of nine lateral humeral epicondylar bone grafts were successfully harvested. The blood supply of the graft during surgery was excellent in six cases and good in three cases. The size of the bone grafts ranges from 1.0 cm × 0.5 cm × 0.5 cm to 2.0 cm × 1.0 cm × 0.5 cm. The average vascular pedicle length was 3.4 cm (range 2.0-6.0 cm). There were no early complications in either the donor or recipient areas after surgery. Union was successfully achieved in all nine patients, with an average time to union of 14.3 weeks (range 11-20 weeks) after surgery. The average follow-up period was 31.2 months (range 26-40 months). At the final follow-up, the average palmar flexion, dorsal extension, radial deviation, and ulnar deviation angles of the injured wrist joint were 56.1° (range 45°-70°), 56.1° (range 40°-80°), 10.6° (range 5°-20°), and 22.2° (range 15°-35°), respectively, which reached 79.0%, 82.1%, 59.4%, and 72.8% of the average activity of the contralateral normal side. The average grip strength of the injured side was 35.2 kg (range 22-51 kg), which was equivalent to 81.3% of the average grip strength of the contralateral side. The average VAS score for wrist joint pain was 1.0 point (range 0-2 points); the Quick-DASH score was 9.2 points (range 6-18 points); and the PRWE score was 13.1 points (range 9-16 points), the Mayo Elbow Performance Index was 100 points (range 100-100 points). One patient reported a feeling of friction during movement but no pain. One patient reported numbness in the donor site. One patient complained of pain when applying force to the scar in the donor area. During the follow-up period, these complications showed improvement without any treatment. CONCLUSION The FVBG technique has been considered an effective method for treating scaphoid nonunion with avascular necrosis. Compared to traditional FVBG, the lateral humeral epicondylar bone graft exhibits a higher union rate, fewer complications, and easier accessibility, making it a favorable choice.
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Affiliation(s)
- Nuo Chen
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yuling Wang
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Juyu Tang
- Department of Orthopedics, Hand and Microsurgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
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Kilic E, Unal KO, Ozdemir G, Bingol O, Keskin OH, Akinci M. Evaluation of free vascularized medial femoral condyle bone grafts in the treatment of avascular scaphoid waist nonunion. Jt Dis Relat Surg 2023; 34:661-668. [PMID: 37750271 PMCID: PMC10546847 DOI: 10.52312/jdrs.2023.1009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 07/20/2023] [Indexed: 09/27/2023] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the medial femoral condyle (MFC) bone graft procedure for scaphoid waist nonunion with avascular necrosis on magnetic resonance imaging or prior surgery failure. PATIENTS AND METHODS Between June 2015 and December 2018, a total of 17 patients (16 males, 1 female; mean age: 29±8.2 years; range, 16 to 40 years) with scaphoid waist nonunion who were treated with vascularized MFC bone grafting were retrospectively analyzed. Pre- and postoperative carpal indices, grip strengths for both hands, range of motion, Visual Analog Scale (VAS) pain score, Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) score, and Mayo Wrist Score (MWS) were evaluated. RESULTS After vascularized MFC bone graft surgery, 15 patients healed and returned to work without any limitations. Ten patients of left scaphoid nonunion and seven cases of right scaphoid nonunion were treated; for eight of these patients, the operation was on the dominant side. Eight of these patients were smokers. The mean follow-up was 22.4±5.8 months. The mean hand grip strength was increased from 74.5 to 84% on the contralateral side (p<0.05). The average revised carpal height ratio improved from 1.57 to 1.59 (p<0.05) and the scapholunate angle changed from 56.9° to 51.6° (p<0.05). CONCLUSION The MFC bone grafting is one of the best surgical procedures for small defects such as scaphoid waist nonunion with high union rates, good functional outcomes, and minimal donor site morbidity.
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Affiliation(s)
- Enver Kilic
- Ankara Bilkent Şehir Hastanesi Ortopedi ve Travmatoloji Kliniği, 06000 Çankaya, Ankara, Türkiye.
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Schäfer RC, Nusche A, Einzmann A, Illg C, Daigeler A, Rachunek K. The corticocancellous press fit iliac crest bone dowel for recalcitrant scaphoid nonunion: analysis of union rate and clinical outcome. Arch Orthop Trauma Surg 2023; 143:6001-6010. [PMID: 37012506 PMCID: PMC10449721 DOI: 10.1007/s00402-023-04846-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/12/2023] [Indexed: 04/05/2023]
Abstract
INTRODUCTION Scaphoid nonunion after failed primary treatment remains challenging particularly when entailed by bone loss, avascular necrosis or deformity. We describe a scaphoid augmentation and fixation technique for cases of recalcitrant nonunion after screw placement by autologous press fit corticocancellous dowel. This study aims to provide reliable data on clinical and radiological outcomes and to contextualize in the face of other treatment options. MATERIAL AND METHODS The study included 16 patients with recalcitrant nonunion of the scaphoid. All patients received screw removal and scaphoid reconstruction by a dowel shaped non-vascularized corticocancellous bone graft from the iliac crest facilitating packing of the screw channel. Bone union, the scapholunate, radiolunate and intrascaphoidal angles were evaluated on X-ray and CT images, range of motion noted. Additionally grip strength, DASH and Green O'Brien scores were obtained from eight patients. RESULTS A union rate of 73% was noted after mean follow-up of 54 months. After revisional reconstruction of the scaphoid an extension-flexion rate of 84% of the healthy side was noted while pronation-supination reached 101%. DASH score averaged at 2.9, rest pain on a numeric rating scale was 0.43 with 99% peak grip force of the healthy side. CONCLUSION In complex cases of revisional scaphoid nonunion after screw placement, the corticocancellous iliac crest pressfit dowel is an option for augmentation and stabilization of the scaphoid by preserving the articular surface. LEVEL OF EVIDENCE IV, retrospective case series.
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Affiliation(s)
- Ruth Christine Schäfer
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tübingen, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany.
| | - Andreas Nusche
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tübingen, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany
| | - Anna Einzmann
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tübingen, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany
| | - Claudius Illg
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tübingen, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany
| | - Adrien Daigeler
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tübingen, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany
| | - Katarzyna Rachunek
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tübingen, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany
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Rodham PL, Giannoudis VP, Kanakaris NK, Giannoudis PV. Biological aspects to enhance fracture healing. EFORT Open Rev 2023; 8:264-282. [PMID: 37158338 PMCID: PMC10233810 DOI: 10.1530/eor-23-0047] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
The ability to enhance fracture healing is paramount in modern orthopaedic trauma, particularly in the management of challenging cases including peri-prosthetic fractures, non-union and acute bone loss. Materials utilised in enhancing fracture healing should ideally be osteogenic, osteoinductive, osteoconductive, and facilitate vascular in-growth. Autologous bone graft remains the gold standard, providing all of these qualities. Limitations to this technique include low graft volume and donor site morbidity, with alternative techniques including the use of allograft or xenograft. Artificial scaffolds can provide an osteoconductive construct, however fail to provide an osteoinductive stimulus, and frequently have poor mechanical properties. Recombinant bone morphogenetic proteins can provide an osteoinductive stimulus; however, their licencing is limited and larger studies are required to clarify their role. For recalcitricant non-unions or high-risk cases, the use of composite graft combining the above techniques provides the highest chances of successfully achieving bony union.
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Affiliation(s)
- Paul L Rodham
- Academic Department of Trauma & Orthopaedics, Leeds General Infirmary, Leeds, United Kingdom of Great Britain and Northern Ireland
| | - Vasileios P Giannoudis
- Academic Department of Trauma & Orthopaedics, Leeds General Infirmary, Leeds, United Kingdom of Great Britain and Northern Ireland
| | - Nikolaos K Kanakaris
- Academic Department of Trauma & Orthopaedics, Leeds General Infirmary, Leeds, United Kingdom of Great Britain and Northern Ireland
- Department of Trauma & Orthopaedics, University of Leeds, Leeds, United Kingdom of Great Britain and Northern Ireland
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedics, Leeds General Infirmary, Leeds, United Kingdom of Great Britain and Northern Ireland
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Altaş O, Bayram S, Aydin AS, Ayik Ö, Durmaz H. Management of Scaphoid Pseudoarthrosis Surgery With Wide-Awake Local Anesthesia No Tourniquet (WALANT) Versus Axillary Block Anesthesia: Comparison of Patient Satisfaction. Plast Surg (Oakv) 2023. [DOI: 10.1177/22925503231157092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
Objectives: We aimed to compare clinical and functional results of treatment of scaphoid pseudoarthrosis between patients undergoing wide-awake local anesthesia no tourniquet (WALANT) versus axillary block anesthesia. Methods: The patients diagnosed with scaphoid non-union who underwent pseudoarthoris surgery were divided into WALANT group ( n = 12) and axial block group ( n = 11). Visual analog scores (VAS) were measured by calling the patients via phone on postoperative days 1, 2, 3, and 7. The VASs were also measured on the 14th day during patient check-ups. At the end of 12 months, Michigan Hand Questionnaire was used to assess clinical recovery. Bone union rate and surgery time were also investigated. Radiological and clinical examinations were compared between the groups. Results: Eleven patients (91.7%) in the WALANT group and 10 patients (90.9%) in the axillary block group achieved bone union ( P = .94). Although there was no significant difference in preoperative VAS score between the groups, the WALANT group had significantly lower VAS score of the first 3 days postoperatively. However, there was no significant difference in VAS score between the groups on the seventh and 14th day postoperatively. There was no significant difference between the groups regarding Michigan score, time to surgery, time to union and operation time. Conclusion: The scaphoid pseudoarthrosis surgery can be done safely with WALANT technique which has significant lower VAS score on the first 3 days postoperatively.
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Affiliation(s)
- Okyar Altaş
- Department of Hand and Microsurgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Serkan Bayram
- Department of Orthopaedics and Traumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ahmet Serhat Aydin
- Department of Orthopaedics and Traumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ömer Ayik
- Department of Hand Surgery, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Hayati Durmaz
- Department of Orthopaedics and Traumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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De Bie A, Louis P, Cognet JM. Correction of residual humpback deformity after arthroscopic treatment of scaphoid non-union. Orthop Traumatol Surg Res 2022; 108:103294. [PMID: 35487429 DOI: 10.1016/j.otsr.2022.103294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/15/2021] [Accepted: 12/07/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The aim of this study was to assess residual humpback deformity after arthroscopic treatment of scaphoid non-union. MATERIAL AND METHOD We reviewed the medical records of 47 patients with scaphoid non-union who underwent arthroscopic treatment between 2012 and 2018. Patients who did not receive an intraoperative bone graft were excluded (10 patients), as were those who did not achieve bone union (three patients). The radiographic assessment consisted of pre- and postoperative radiographs and CT-scans. RESULTS The radiolunate angle, scapholunate angle and Youm index were measured. At the final follow-up, the scapholunate angle was 54±8̊ (36-80̊) and the radiolunate angle was 11±7̊ (2-45̊). The scapholunate angle was significantly different between the preoperative measurement and the last follow-up; however, the radiolunate angle and Youm index did not change significantly. CONCLUSION Our study found that arthroscopic treatment of scaphoid non-union with a cancellous bone graft taken from the distal radius results corrects the humpback deformity. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Anaïs De Bie
- SOS Mains Champagne Ardenne, Clinique Courlancy, 38b, rue de Courlancy, 51100 Reims, France
| | - Pascal Louis
- SOS Mains Champagne Ardenne, Clinique Courlancy, 38b, rue de Courlancy, 51100 Reims, France
| | - Jean Michel Cognet
- SOS Mains Champagne Ardenne, Clinique Courlancy, 38b, rue de Courlancy, 51100 Reims, France.
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Mulica M, Horch RE, Arkudas A, Cai A, Müller-Seubert W, Hauck T, Ludolph I. Does indocyanine green fluorescence angiography impact the intraoperative choice of procedure in free vascularized medial femoral condyle grafting for scaphoid nonunions? Front Surg 2022; 9:962450. [PMID: 36117816 PMCID: PMC9478374 DOI: 10.3389/fsurg.2022.962450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/04/2022] [Indexed: 11/23/2022] Open
Abstract
Background Free vascularized medial femoral condyle (MFC) bone grafts can lead to increased vascularity of the proximal pole and restore scaphoid architecture in scaphoid nonunions. The intraoperative perfusion assessment of the bone graft is challenging because the conventional clinical examination is difficult. Indocyanine green (ICG) angiography has previously been shown to provide a real-time intraoperative evaluation of soft tissue perfusion in reconstructive surgery. The present study investigated the utility of ICG angiography in patients treated with a free medial femoral condyle graft for scaphoid nonunions. Methods We performed a retrospective analysis of patients with scaphoid nonunions, in which ICG angiography was used intraoperatively for perfusion assessment. The medical records, radiographs, intraoperative imaging, and operative reports of all patients were reviewed. Intraoperative ICG dye was administered intravenously, and laser angiography was performed to assess bone perfusion. The scaphoid union was examined using postoperative CT scans. Results Two patients had documented osteonecrosis of the proximal pole at the time of surgery. Four patients received a nonvascularized prior bone graft procedure, and a prior spongiosa graft procedure was performed in one patient. The mean time from injury to the MFC bone graft surgery was 52.7 months, and the mean time from prior failed surgery was 10.4 months. Perfusion of the vascular pedicle of the MFC and the periosteum could be detected in all patients. In two patients, even perfusion of the cancellous bone could be demonstrated by ICG angiography. Following transplantation of the bone graft, patency of the vascular anastomosis and perfusion of the periost were confirmed by ICG angiography in the assessed cases. No additional surgery regarding a salvage procedure for a scaphoid nonunion advanced collapse was necessary for the further course. Conclusion ICG-angiography has shown to be a promising tool in the treatment of scaphoid nonunion with medial femoral condyle bone grafts. It enables intraoperative decision making by assessment of the microvascular blood supply of the periosteum and the vascular pedicle of the MFC bone graft. Further studies need to evaluate the impact on union rates in a long-term follow-up.
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Testa G, Lucenti L, D’Amato S, Sorrentino M, Cosentino P, Vescio A, Pavone V. Comparison between Vascular and Non-Vascular Bone Grafting in Scaphoid Nonunion: A Systematic Review. J Clin Med 2022; 11:jcm11123402. [PMID: 35743472 PMCID: PMC9225170 DOI: 10.3390/jcm11123402] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 06/09/2022] [Accepted: 06/13/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Scaphoid fractures correspond to 60% of all carpal fractures, with a risk of 10% to progress towards non-union. Furthermore, ~3% present avascular necrosis (AVN) of the proximal pole, which is one of the main complications related to the peculiar vascularization of the bone. Scaphoid non-union can be treated with vascularized and non-vascularized bone grafting. The aim of the study is to evaluate the rates of consolidation of scaphoid non-union treated using two types of grafts. Methods: A systematic review of two electronic medical databases was carried out by two independent authors, using the following inclusion criteria: non-union of the proximal pole of the scaphoid bone, treated with vascular bone grafting (VBG) or non-vascular bone grafting (NVBG), with or without the use of internal fixation, patients aged ≥ 10 years old, and a minimum of 12 months follow-up. Research of any level of evidence that reports clinical results and regarding non-union scaphoid, either using vascularized or non-vascularized bone grafting, has been included. Results: A total of 271 articles were identified. At the end of the first screening, 104 eligible articles were selected for the whole reading of the text. Finally, after reading the text and the control of the reference list, we selected 26 articles following the criteria described above. Conclusions: The choice of the VBG depends mainly on the defect of the scaphoid and on the surgeon’s knowledge of the different techniques. Free vascular graft with medial femoral condyle (MFC) seems to be a promising alternative to local vascularized bone grafts in difficult cases.
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Larkins CG, Tannan SC, Burkett AE, Mithani SK, Srinivasan RC, Pederson WC. Autologous Osteoligamentous Reconstruction of Scaphoid Proximal Pole With Metatarsal Head and Collateral Ligament: Cadaver Anatomic Description of Novel Surgical Technique. Hand (N Y) 2021; 16:843-846. [PMID: 31965865 PMCID: PMC8647322 DOI: 10.1177/1558944719895616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Historically, scaphoid nonunion has been surgically treated with vascularized bone graft taken from multiple different anatomic sites. However, none of these grafts fully recapitulate the unique osteoligamentous anatomy of the proximal pole of the scaphoid and the attachment of the scapholunate ligament (SLIL). We studied the anatomy of the vascularized second metatarsal head with its lateral collateral ligament as a potential novel treatment of proximal pole scaphoid nonunion with collapse. Methods: Scaphoids and second metatarsal heads were harvested from bilateral upper and lower extremities of 18 fresh frozen cadavers (10 male, 8 female) for a total of 36 scaphoids and 36 second metatarsal heads. The ipsilateral second metatarsal head was harvested with its lateral collateral ligament and its blood supply from the second dorsal metatarsal artery (SDMA). Measurements of the scaphoid, the SLIL, the second metatarsal head, and lateral collateral ligaments were compared to matched limbs from the same cadaver. Results: The anatomic dimensions of the second metatarsal head with its lateral collateral ligament are similar to the scaphoid proximal pole and the SLIL in matched cadaveric specimen. Conclusions: This anatomic cadaver study reveals that the second metatarsal head with its associated lateral collateral ligament is a well-matched donor to reconstruct the proximal pole of the scaphoid and SLIL. This anatomic similarity may be well suited to treat nonunion of the scaphoid proximal pole with or without avascular necrosis with simultaneous reconstruction of the SLIL. The authors describe a technique of vascularized reconstruction of the osteoligamentous proximal pole of the scaphoid with its attached SLIL utilizing autologous second metatarsal head with its attached lateral collateral ligament. Based on this cadaver study, this technique merits consideration.
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Affiliation(s)
| | | | | | | | - Ramesh C. Srinivasan
- The Hand Center of San Antonio, TX, USA,Ramesh C. Srinivasan, The Hand Center of San Antonio, 21 Spurs Lane, Suite 310, San Antonio, TX 78240, USA.
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Reconstruction of proximal pole scaphoid non-union with avascular necrosis using proximal hamate: A four-case series. HAND SURGERY & REHABILITATION 2021; 40:744-748. [PMID: 34274497 DOI: 10.1016/j.hansur.2021.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 07/06/2021] [Accepted: 07/10/2021] [Indexed: 11/23/2022]
Abstract
Union of proximal pole scaphoid fracture is challenging because the vascular supply is limited. The avascular necrosis accompanying non-union and progressive fragmentation make surgical reconstruction difficult. The present study aimed to report short-term results of reconstruction with proximal hamate in proximal pole scaphoid non-union with avascular necrosis. Four patients (3 male, 1 female) were assessed for non-union following proximal pole scaphoid fracture. Mean age was 25.7 years (range, 22-35 years). Mean interval between injury and reconstruction was 7.5 years (range, 5-9 years). In 3 patients, no treatment was given following the fracture and in the other internal fixation was performed following cast immobilization. The non-united avascular proximal scaphoid was resected and reconstructed with proximal hamate autograft. Mean follow-up was 14.0 months (range, 9-22 months) after reconstruction. At the last control, cases were evaluated in terms of clinical and functional status, and radiologic union was determined on CT scan. Three patients reported subjective decrease in pain. Mean grip strength proportionally to the unaffected side was 24% (range, 8-51%), mean flexion-extension was 55.3% (range, 21-60%), and radial-ulnar deviation was 63.6% (range, 25-100%). Mean QuickDASH score was 32.3 (range, 13.6-52.2). Union was observed in all patients. Proximal hamate reconstruction provided union and pain relief, but only moderate objective functional results. It can be used as an alternative technique in proximal pole scaphoid non-union with avascular necrosis.
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Zhang H, Gu J, Liu H, Yuan C. Pedicled vascularized versus non-vascularized bone grafts in the treatment of scaphoid non-union: a meta-analysis of comparative studies. ANZ J Surg 2021; 91:E682-E689. [PMID: 33890706 DOI: 10.1111/ans.16894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 03/21/2021] [Accepted: 03/30/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Whether pedicled vascularized bone grafts (PVBGs) are beneficial over non-vascularized bone grafts (NVBGs) still remains controversial. The aim of this study was to compare the clinical results of PVBGs and NVBGs for the treatment of scaphoid non-union. METHODS We conducted a meta-analysis of the published studies comparing outcomes of these two different surgical techniques for scaphoid non-union. Outcomes of union rate, time to union, functional results and re-operation rate were analysed. RESULTS Seven studies including four randomized controlled studies and three retrospective comparative studies with 413 participants were identified fitting inclusion criteria. Meta-analysis showed that (i) union rate in PVBG groups was 1.13 times of NVBG groups (P = 0.002); (ii) the PVBG groups reached bone union significantly earlier by 1.73 weeks (P < 0.01); (iii) there was no significant difference in functional results, including active range of motion, grip strength, Mayo Wrist Score and excellent and good rate (P > 0.05); and (iv) re-operation rate was similar between the two groups (P = 0.65). CONCLUSIONS Although the PVBG technique attains higher union rate and earlier union, this radiological advantage does not bring any functional benefits. In addition, PVBGs are of greater technical difficulty and need more operation requirements. Hence, clinicians should be cautious in electing PVBGs for treating scaphoid non-union.
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Affiliation(s)
- Hanyu Zhang
- Department of Emergency Medicine, Subei People's Hospital, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Jiaxiang Gu
- Department of Hand and Foot Surgery, Subei People's Hospital, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Hongjun Liu
- Department of Hand and Foot Surgery, Subei People's Hospital, Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Chaoqun Yuan
- Department of Hand and Foot Surgery, Subei People's Hospital, Clinical Medical College, Yangzhou University, Yangzhou, China.,Shanghai Tenth People's Hospital, Clinical Medical College of Nanjing Medical University, Shanghai, China
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Elgayar L, Elmajee M, Aljawadi A, Abdelaal A, Khan S, Pillai A. A systematic review of mechanical stabilization by screw fixation without bone grafting in the management of stable scaphoid non-union. J Clin Orthop Trauma 2021; 17:112-117. [PMID: 33816106 PMCID: PMC7995648 DOI: 10.1016/j.jcot.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 01/12/2021] [Accepted: 03/03/2021] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Sixty percent of all carpal fractures affect the scaphoid bone, with an annual incidence of 4.3/10,000. Displacement and instability are the main risk factors for non-union, but missed diagnosis, location of fracture and poor blood supply are also risk factors. Non-union is defined as non-healed fracture on radiographs 6 months after the injury and this can lead to degenerative wrist arthritis. Treatment options vary from internal fixation with bone grafting to salvage procedures including arthrodesis of carpals. We aimed to determine the effectiveness of screw fixation without bone grafting for the treatment of stable well-aligned scaphoid non-union. METHODS In this systematic review, MEDLINE, Science Direct, Web of Science and CINHAL were searched from inception to May 2019. All clinical studies that examined the functional and radiological outcomes of screw fixation without bone grafting to treat stable scaphoid non-union were included. RESULTS 838 articles were retained of which 6 case series, describing 95 patients who had undergone scaphoid non-union fixation without bone grafting, were included. Favourable functional outcomes were reported by the 6 included studies using validated functional outcome measures ROM improved to weighted mean of 67.5° (±13°) and 62.12° (±13°) for flexion and extension respectively. The fracture had united in 91 out of 95 participants with a union rate of 95.7% (95%, CI 89.5 to 98.8) and the weighted mean time to union was 3.8 (±1.5) months. CONCLUSION Rigid screw fixation without bone grafting can be suggested for the treatment of selected well aligned scaphoid nonunions to achieve healing and good functional outcomes. However, adequately powered clinical studies with good methodology are essential to draw an accurate conclusion.
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Affiliation(s)
| | - Mohammed Elmajee
- ST4 Spine Department, Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, B31 2AP, UK
| | - Ahmed Aljawadi
- Trauma and Orthopaedics, Wythenshawe Hospital, Manchester, M23 9LT, UK,Corresponding author.
| | - Ahmed Abdelaal
- Trauma and Orthopaedics Registrar, Royal Gwent Hospital, Cardiff, NP20 2UB, UK
| | - Shoaib Khan
- ST4 Trauma and Orthopaedics, Warrington Hospital, Warrington, WA5 1QG, UK
| | - Anand Pillai
- Consultant Trauma and Orthopedics, Manchester Foundation Trust, Southmoor Rd, Wythenshawe, Manchester, M23 9LT, UK
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Kalb K, Pillukat T, Jonke B, Schmidt A, van Schoonhoven J, Prommersberger KJ. [Scaphoid non-union: Experience from more than 280 reconstructions using a medial femur condyle bone graft]. HANDCHIR MIKROCHIR P 2020; 52:425-434. [PMID: 32992393 DOI: 10.1055/a-1250-8026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Since 2008 we have been using many free vascularized medial femoral condyle grafts for reconstruction of difficult scaphoid non-unions. This article aims to report our results and experiences. PATIENTS AND METHODS Until the end of 2019 a total of 287 patients had a microvascular scaphoid reconstruction, 158 with use of a corticocancellous, and 129 using an osseocartilaginous graft. Complete analysis of all of these patients was impossible. This manuscript is based on a retrospective analysis of 28 out of 42 patients with corticocancellous grafts operated on between 2008 and 2010 with a mean follow-up time of 6.1 years as well as another 44 out of 76 patients with an osseocartilaginous graft operated on between 2011 and 2016 with a mean follow-up time of 44 months. Follow-up included clinical parameters, conventional x-rays, a DASH-Score and a modified Mayo wrist score. Additionally, the authors report their personal experiences - necessarily without quantification. In view of this incomplete data-pool statistical analysis was not reasonable. RESULTS In the group with corticocancellous reconstructions bony healing was achieved in 69 %, salvage operations were required in 9,5 %. The 28 patients had a mean DASH-Score of 11, a mean modified Mayo wrist score of 83 points, a mean ROM of 86° and a mean grip strength of 89 % of the contralateral side. In the group with osseocartilaginous reconstructions complete bony healing was seen in 80 %, partial healing in 5 %, and salvage procedures were required in 11 %. The remaining 39 patients had a mean DASH-Score of 15, a mean modified Mayo wrist score of 80 points, a mean ROM of 90° and a grip strength of 81 % of the contralateral hand. A specific complication was an ossification of the pedicle, but the main problem was a satisfying reconstruction of the shape of the scaphoid and reestablishment of carpal stability in far advanced cases. We could not identify factors reliable for the persisting non-unions. CONCLUSIONS These operations combine great chances for healing with considerable risks for serious complications. So future patients have to be fully informed, so that their decision for such a procedure is based on realistic expectations.
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Kastenberger T, Kaiser P, Bode S, Horling L, Schmidle G, Arora R. [Treatment of scaphoid non-union: vascularised iliac crest graft or medial femur condyle graft?]. HANDCHIR MIKROCHIR P 2020; 52:419-424. [PMID: 32992398 DOI: 10.1055/a-1258-5357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Treatment of scaphoid non-unions is still challenging for responsible hand surgeons, especially in cases of avascular proximal pole non-unions or failed prior surgeries. Several surgical procedures treating scaphoid non-unions have been established. These aim to restore correct anatomy to provide stability and adequate blood flow. Treatment options range from avascular to free, vascularized bone grafts. The two most used free vascularized bone grafts derive from the iliac crest and the medial femoral condyle. The vascular anatomy of the medial femoral condyle graft is more constant, the donor site morbidity lower and the healing rate higher in comparison to the iliac crest graft. It is easier to harvest the femoral condyle graft and additionally, it can be harvested as a cortico-cancellous or osteochondral graft. Looking at all advantage, we come to the conclusion that the free vascularized medial femoral condyle graft is our method of choice for the treatment of a avascular proximal pole non-union of the scaphoid.
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Affiliation(s)
| | | | | | | | | | - Rohit Arora
- Universitätsklinik für Unfallchirurgie und Sportraumatologie, Medizinische Universität Innsbruck
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BMP9 exhibits dual and coupled roles in inducing osteogenic and angiogenic differentiation of mesenchymal stem cells. Biosci Rep 2020; 40:225099. [PMID: 32478395 PMCID: PMC7295632 DOI: 10.1042/bsr20201262] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/25/2020] [Accepted: 05/26/2020] [Indexed: 12/27/2022] Open
Abstract
Bone morphogenetic protein (BMP) 9 (BMP9) is one of most potent BMPs in inducing osteogenic differentiation of mesenchymal stem cells (MSCs). Recently, evidence has shown that osteogenesis and angiogenesis are coupled, however, it is unclear whether BMP9 induces MSC differentiation into endothelial-like cells and further promotes blood vessel formation. In the present study, we explored the potential of BMP9-induced angiogenic differentiation of MSCs, and the relationship between BMP9-induced osteogenic and angiogenic differentiation of MSCs. Osteogenic activities and angiogenic differentiation markers were analyzed at mRNA and protein levels. In vivo osteogenic and angiogenic differentiation of MSCs were tested by the ectopic bone formation model. We identified that adenoviral vectors effectively transduced in immortalized mouse embryonic fibroblasts (iMEFs) and expressed BMP9 with high efficiency. We found that BMP9 induces early and late osteogenic differentiation, and it up-regulated osteogenic marker expression in MSCs. Meanwhile, BMP9 induces angiogenic differentiation of MSCs via the expression of vascular endothelial growth factor a (VEGFa) and CD31 at both mRNA and protein levels. CD31-positive cells were also increased with the stimulation of BMP9. The ectopic bone formation tests found that BMP9-induced trabecular bone formation was coupled with the expression of blood vessel formation markers and sinusoid capillary formation. These findings suggest that BMP9 exhibits dual and coupled roles in inducing osteogenic and angiogenic differentiation of MSCs.
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Vakalopoulos KA, Balagué N, Vostrel P, Boudabbous S, Beaulieu JY. Carpal Collapse After Scaphoid Nonunion: A Novel Combined Approach to the 1,2 Intercompartmental Supraretinacular Artery Radial Flap. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2020; 2:143-149. [PMID: 35415492 PMCID: PMC8991731 DOI: 10.1016/j.jhsg.2020.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 02/10/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose Scaphoid nonunion remains a major problem in hand surgery. The 1,2 intercompartmental supraretinacular artery flap (1,2 ICSRA), as first described by Zaidemberg et al, is widely used with reported union rates of approximately 80%. However, its use is limited in the case of associated carpal collapse as in dorsal intercalated segmental instability (DISI) and humpback deformity. In this study, we present a novel approach to this flap enabling the correction of associated carpal collapse. Methods Between 2006 and 2015, 9 patients with scaphoid nonunion or delayed union with carpal collapse were treated with a vascularized bone flap based on the 1,2 ICSRA using a combined volar and dorsal approach. Immobilization in a short-arm cast was applied for 8 weeks. Union rates, correction of DISI and humpback deformity, as well as clinical end points were noted. In addition, scapholunate (SL) angles were measured using 2 accepted radiological techniques, employing either the scaphoid midline axis or its proximal radiological landmarks as a reference. Results All cases united and a median time to bone consolidation of 4 months (range, 2–5 months) was observed. Preoperative DISI deformities (n = 4) were corrected in all patients. Humpback deformities (n = 5) were also corrected. Two patients had repeat surgery: one for K-wire removal after bony consolidation and the other for neuropathic pain. Conclusions The 1,2 ICSRA bone flap is a reliable treatment for scaphoid nonunion associated with carpal collapse. This combined volar and dorsal approach permits the correction of DISI and humpback deformity without compromising the scaphoid vascular supply, which eliminates the need to use free bone flaps from other sites. In this series, we observed a 100% union rate. Two patients required reoperation for symptomatic hardware and dorsal wrist pain linked to superficial neuritis. Type of study/level of evidence Therapeutic IV.
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Tsumura T, Matsumoto T, Matsushita M, Doi H, Shiode H, Kakinoki R. Correction of Humpback Deformities in Patients With Scaphoid Nonunion Using 1,2-Intercompartmental Supraretinacular Artery Pedicled Vascularized Bone Grafting With a Dorsoradial Approach. J Hand Surg Am 2020; 45:160.e1-160.e8. [PMID: 31350100 DOI: 10.1016/j.jhsa.2019.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 03/20/2019] [Accepted: 06/05/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE Although 1,2-intercompartmental supraretinacular artery (1,2-ICSRA)-based vascularized bone grafting (VBG) has gained popularity in the treatment of scaphoid nonunion, correcting humpback deformities with this technique remains challenging. The purpose of this retrospective study was to determine the possibility of correcting humpback deformities using a 1,2-ICSRA VBG with a dorsoradial approach. METHODS We treated 25 patients with scaphoid nonunion using a 1,2-ICSRA VBG between January 2007 and December 2017. For those with a humpback deformity, we performed vascularized wedge grafting from the dorsoradial side, instead of inlay bone grafting from the dorsal or volar side of the scaphoid. After excluding patients with scaphoid nonunion without a humpback deformity and those followed up for less than 6 months, we reviewed the imaging results and union rate in the remaining 19 patients (18 men and 1 woman). The nonunion sites and patient distribution were as follows: proximal one-third, 2; waist, 16; and distal one-third, 1. RESULTS The union rate at the last follow-up performed a minimum of 6 months after the intervention was 94.7%. The correction was adequate in 17 patients and inadequate in 2 patients. The lateral intrascaphoid, radiolunate, and scapholunate angles were improved. CONCLUSIONS Humpback and dorsal intercalated segmental instability deformities can be corrected adequately using a 1,2-ICSRA VBG with a dorsoradial approach. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Takuya Tsumura
- Department of Orthopedic Surgery, Kurashiki Central Hospital, Okayama, Japan.
| | - Taiichi Matsumoto
- Department of Orthopedic Surgery, Kurashiki Central Hospital, Okayama, Japan
| | - Mutsumi Matsushita
- Department of Orthopedic Surgery, Kurashiki Central Hospital, Okayama, Japan
| | - Hiroyuki Doi
- Department of Orthopedic Surgery, Kurashiki Central Hospital, Okayama, Japan
| | - Hayao Shiode
- Department of Orthopedic Surgery, Kurashiki Central Hospital, Okayama, Japan
| | - Ryousuke Kakinoki
- Department of Orthopedic Surgery, Kindai University Hospital, Osaka, Japan
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20
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Yang K, Boehm L, Rivedal D, Yan JG, Matloub H. Vascularized Olecranon Bone Graft: An Anatomical Study and Novel Technique. J Hand Surg Am 2020; 45:157.e1-157.e6. [PMID: 31303364 DOI: 10.1016/j.jhsa.2019.05.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/27/2019] [Accepted: 05/10/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE Autologous bone grafting is commonly used in reconstructive hand surgery. Various sources of nonvascularized autologous bone grafts have been described in the literature. However, in some situations, a vascularized bone graft may be needed. Popular vascularized bone grafts are taken from the distal radius, iliac crest, and medial femoral condyle. The purpose of this study was to examine the feasibility of harvesting a free vascularized bone flap from the proximal ulna. METHODS Latex was injected via the brachial artery to facilitate visualization of perforators in 10 cadaveric specimens. Dissections were performed of the olecranon; all periosteal perforators were noted, and their lengths and diameters recorded. Corticocancellous bone flaps with their supplying pedicles were harvested. Three additional fresh specimens were injected with india ink via the pedicles to demonstrate perfusion of the harvested bone flap. RESULTS Consistent vascular anatomy supplied the olecranon. A perforator from the posterior ulnar recurrent artery supplied the proximal ulna and olecranon, from which a vascularized bone flap can be harvested. Branches to the flexor carpi ulnaris muscle may allow chimeric flaps to be harvested. Average pedicle length was 5.8 cm and average pedicle diameter was 2.4 mm. India ink injection of the pedicles showed perfusion of the periosteum as well as intraosseous cancellous bone. CONCLUSIONS A vascularized olecranon free flap can be harvested based on the posterior ulnar recurrent artery. Vascular anatomy is consistent and flap harvest is simple and straightforward in all cadaveric specimens. CLINICAL RELEVANCE A vascularized olecranon free flap represents a potential new surgical option when vascular bone flap reconstruction is considered.
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Affiliation(s)
- Kai Yang
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Lucas Boehm
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - David Rivedal
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Ji-Geng Yan
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Hani Matloub
- Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI.
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Abstract
Surgical strategies for scaphoid nonunions become more complex based on time from injury to treatment. The decision-making process, however, can follow a logical sequence. Scaphoid nonunions less than 1 year after trauma and no carpal malalignment can be treated with percutaneous screw fixation under fluoroscopic and/or arthroscopic guidance. Reinterventions or patients with avascular proximal poles that do not need substantial grafts are reliably treated with pedicle vascularized bone grafts. Resection of the distal pole of the scaphoid is a good option in old nonunions or after a failed scaphoid procedures. When there are radioscaphoid degenerative changes, salvage procedures such as proximal row carpectomy (PRC) should be considered.
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Guzzini M, Lanzetti RM, Proietti L, Lupariello D, Iorio R, Ferretti A. The role of vascularized flaps in the treatment of proximal pole avascular necrosis in scaphoid non-unions. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:64-68. [PMID: 31821286 PMCID: PMC7233702 DOI: 10.23750/abm.v90i12-s.8367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 07/12/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The purpose of this study is to evaluate the clinical and radiological outcomes of scaphoid non unions surgically treated with bone graft versus medial condyle corticoperiosteal free flaps. MATERIALS AND METHODS 32 patients were divided in 2 groups. Group A (17 patients 12male, 5 females, mean age 35 years old) treated with bone grafts; Group B (15patients 11 male, 4 females, mean age 33 years old) treated with medial condyle cortico periosteal free flap. A radiological follow up was performed about every 30 days after surgery until the complete healing and at 12-month follow-up. The clinical follow up was performed at 6 and 12 months from surgery. Functional assessment was provided by Mayo wrist score and Visual Analogic Scale (VAS). RESULTS The average length of follow up was 12.52 months ± 1.36. In group A 60% of patients healed in 4.4 ± 1months with a reduction of 28.4% of healing times in group B (p<0.05).In Group B all nonunion sites healed primarily at an average time period of 3.2 ± 1 months. Statistical analysis showed a significant difference (p<0.001) about the preoperative and the postoperative VAS and Mayo Wrist Score evaluation in both groups at 6 and 12-month follow-up, moreover we recorded a statistical difference between groups at the 6-month and 12-month follow-up (p<0.05). CONCLUSION The present study showed that the free flaps showed better clinical and radiographic results for the surgical treatment of scaphoid nonunions. In fact, despite the good results of the bone graft, the flaps seems to be preferable in the treatment of these nonunions.
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Kalb KH, Langer M, Windolf J, van Schoonhoven J, Pillukat T. [Scaphoid pseudarthrosis : Complex reconstruction using vascularized bone grafts]. Unfallchirurg 2019; 122:200-210. [PMID: 30725118 DOI: 10.1007/s00113-019-0609-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The most important goals of scaphoid reconstruction in pseudarthrosis are correction of the humpback deformity, the realignment of the proximal carpal row and the bony union of the scaphoid. Therefore, in most cases bone grafting is required. To increase the healing rate and to improve vascularization, several kinds of vascularized bone grafts have been developed. Pedicled grafts are preferably harvested from the dorsal or palmar side of the distal radius with fusion rates between 27% and 100%. Free microvascular grafts can be obtained from the iliac crest and the medial or lateral femoral condyle with fusion rates between 60% and 100%. For their application microsurgical equipment and skills are required. Up to now osteochondral grafts from the femoral condyle offer the only chance for joint surface replacement by transferring part of the surface of the femoropatellar joint. The use of vascularized grafts is still a matter of controversy, since their superiority is still unproven compared to nonvascularized grafts, which also achieved 100% fusion rates in several series. They are indicated in secondary procedures after failed reconstruction and nonunion with small avascular proximal pole fragments. Since no evidence-based guidelines exist, this article provides an experience-based treatment algorithm for scaphoid nonunion with special consideration to vascularized bone grafts.
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Affiliation(s)
- K H Kalb
- Klinik für Handchirurgie, Salzburger Leite 1, 97616, Bad Neustadt an der Saale, Deutschland
| | - M Langer
- Klinik und Poliklinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Westfälische Wilhelms-Universität, Münster, Deutschland
| | - J Windolf
- Klinik für Unfall- und Handchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - J van Schoonhoven
- Klinik für Handchirurgie, Salzburger Leite 1, 97616, Bad Neustadt an der Saale, Deutschland
| | - T Pillukat
- Klinik für Handchirurgie, Salzburger Leite 1, 97616, Bad Neustadt an der Saale, Deutschland.
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Abstract
Many hand surgeons argue that vascularized bone grafting is indicated in proximal pole avascular necrosis, prior failed surgery, or long-standing scaphoid nonunion. However, the available evidence does not support improved treatment outcomes for vascularized bone grafting rather than traditional nonvascularized techniques. This article addresses the available evidence and examines the role of vascularized bone grafting in scaphoid nonunion treatment. It also identifies important factors that influence healing, clarifies the decision-making algorithm, and proposes areas for further research.
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Affiliation(s)
- Schneider K Rancy
- College of Medicine, SUNY Downstate Medical Center, 1160 Ocean Avenue, Apt 5F, Brooklyn, NY 11230, USA
| | - Gernot Schmidle
- Department of Trauma Surgery, Medical University Innsbruck, Anichstraße 35, Innsbruck 6020, Austria
| | - Scott W Wolfe
- Hand and Upper Extremity Service, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY 10021, USA.
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Versatility of the Medial Femoral Condyle Flap for Extremity Reconstruction and Identification of Risk Factors for Nonunion, Delayed Time to Union, and Complications. Ann Plast Surg 2018; 80:364-372. [DOI: 10.1097/sap.0000000000001332] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Dicalcium Phosphate Coated with Graphene Synergistically Increases Osteogenic Differentiation In Vitro. COATINGS 2017. [DOI: 10.3390/coatings8010013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Severo AL, Lemos MB, Lech OLC, Barreto Filho D, Strack DP, Candido LK. Bone graft in the treatment of nonunion of the scaphoid with necrosis of the proximal pole: a literature review. REVISTA BRASILEIRA DE ORTOPEDIA (ENGLISH EDITION) 2017; 52:638-643. [PMID: 29234645 PMCID: PMC5720849 DOI: 10.1016/j.rboe.2016.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 11/10/2016] [Indexed: 11/22/2022]
Abstract
Scaphoid fractures are the most common fractures of the carpal bones, corresponding to 60%. Of these, 10% progress to nonunion; moreover, 3% can present necrosis of the proximal pole. There are various methods of treatment using vascularized and non-vascularized bone grafts. To evaluate and compare the rate of scaphoid consolidation with necrosis of the proximal pole using different surgical techniques. The authors conducted a review of the literature using the following databases: PubMed and BIREME/LILACS, where 13 case series were selected (ten with use of vascularized bone grafts and three of non-vascularized bone grafts), according to inclusion and exclusion criteria. In most cases VBGs were used, especially those based on the 1,2 intercompartmental supraretinacular artery, due to greater reproducibility in performing the surgical technique.
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Severo AL, Lemos MB, Lech OLC, Barreto Filho D, Strack DP, Candido LK. Enxerto ósseo no tratamento da não consolidação do escafoide com necrose do polo proximal: revisão da literatura. Rev Bras Ortop 2017. [DOI: 10.1016/j.rbo.2016.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Kazmers NH, Rozell JC, Rumball KM, Kozin SH, Zlotolow DA, Levin LS. Medial Femoral Condyle Microvascular Bone Transfer as a Treatment for Capitate Avascular Necrosis: Surgical Technique and Case Report. J Hand Surg Am 2017; 42:841.e1-841.e6. [PMID: 28495027 DOI: 10.1016/j.jhsa.2017.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 04/06/2017] [Accepted: 04/13/2017] [Indexed: 02/02/2023]
Abstract
UNLABELLED Avascular necrosis (AVN) of the capitate is a rare clinical entity for which a variety of treatment options have been described, ranging from immobilization to microvascular bone transfer. Outcomes following medial femoral condyle corticocancellous free flap reconstruction have not been reported for this specific pathology. We present the case of a 16-year-old girl with posttraumatic capitate AVN who was treated with curettage and medial femoral condyle corticocancellous vascularized bone grafting. At 18 months after surgery, the patient remains pain-free and had resumed all activities including lifeguarding by 6 months after surgery. This microsurgical technique, described previously for AVN of the scaphoid and lunate, may be applied in a similar fashion for the capitate with promising clinical results. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
| | - Joshua C Rozell
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
| | | | - Scott H Kozin
- Shriners Hospital for Children-Philadelphia, Philadelphia, PA
| | - Dan A Zlotolow
- Shriners Hospital for Children-Philadelphia, Philadelphia, PA
| | - L Scott Levin
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
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Alluri RK, Yin C, Iorio ML, Leland H, Mack WJ, Patel K. A Critical Appraisal of Vascularized Bone Grafting for Scaphoid Nonunion. J Wrist Surg 2017; 6:251-257. [PMID: 28725510 PMCID: PMC5515614 DOI: 10.1055/s-0036-1597575] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 11/03/2016] [Indexed: 10/20/2022]
Abstract
Background Vascularized bone grafting (VBG) has the potential to yield reliable results in scaphoid nonunion; however, results across studies have been highly variable. This study critically evaluates surgical techniques, fracture location, and patient selection in relation to radiographic, clinical, and patient-centered outcomes after VBG for scaphoid nonunion. Methods We conducted a systematic review of the literature for the use of VBG in scaphoid nonunion. Physical examination, radiographic, and patient-centered outcomes were assessed. Four substratifications were performed: the location of scaphoid nonunion, pedicled versus free technique, Kirschner wire (K-wire) versus screw fixation, and VBG done as a primary versus revision procedure. Results A total of 41 publications were included in final analysis. VBG had an 84.7% union rate at 13 weeks after surgery. On an average, 89% of patients returned to preinjury activity levels by 18 weeks after surgery and 91% of patients reported satisfaction with the procedure. Proximal pole nonunions demonstrated similar union rates but lower functionality scores compared with nonunions across all regions of the scaphoid. Pedicled techniques demonstrated slightly improved range of motion compared with free technique. K-wire versus screw fixation demonstrated significantly higher union rates and faster union times. There were no differences in outcomes for VBG done as a primary versus revision procedure. Conclusion VBG serves as a viable option for the treatment of scaphoid nonunion, with consistent union rates in addition to significantly improved postoperative patient functionality. The fixation of these vascularized bone grafts with K-wires versus screw fixation may result in superior radiologic outcomes. Level of Evidence Therapeutic, Level III, systematic review.
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Affiliation(s)
- Ram K. Alluri
- Department of Orthopaedic Surgery, Keck Medical Center of the University of Southern California, Los Angeles, California
| | - Christine Yin
- Department of Plastic Surgery, Keck Medical Center of the University of Southern California, Los Angeles, California
| | - Matthew L. Iorio
- Division of Hand and Upper Extremity Surgery, Carl J. Shapiro Department of Orthopaedics, Beth Israel Deaconess Medical Center, Carl J. Shapiro Clinical Center, Boston, Massachusetts
| | - Hyuma Leland
- Department of Plastic Surgery, Keck Medical Center of the University of Southern California, Los Angeles, California
| | - Wendy J. Mack
- Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Ketan Patel
- Department of Plastic Surgery, Keck Medical Center of the University of Southern California, Los Angeles, California
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Contrast-Enhanced Microtomographic Characterisation of Vessels in Native Bone and Engineered Vascularised Grafts Using Ink-Gelatin Perfusion and Phosphotungstic Acid. CONTRAST MEDIA & MOLECULAR IMAGING 2017; 2017:4035160. [PMID: 29097920 PMCID: PMC5612680 DOI: 10.1155/2017/4035160] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 03/18/2017] [Accepted: 04/02/2017] [Indexed: 11/17/2022]
Abstract
Objectives Bone ischemia and necrosis are challenging to treat, requiring investigation of native and engineered bone revascularisation processes through advanced imaging techniques. This study demonstrates an experimental two-step method for precise bone and vessel analysis in native bones or vascularised bone grafts using X-ray microtomography (μCT), without interfering with further histological processing. Methods Distally ligated epigastric arteries or veins of 6 nude rats were inserted in central channels of porous hydroxyapatite cylinders and these pedicled grafts were implanted subcutaneously. One week later, the rats were perfused with ink-gelatin and euthanised and the femurs, tibias, and grafts were explanted. Samples were scanned using μCT, decalcified, incubated with phosphotungstic acid (PTA) for contrast enhancement, rescanned, and processed histologically. Results Contrast-enhanced μCT displayed the course and branching of native bone vessels. Histologically, both central (-17%) and epiphyseal vessels (-58%) appeared smaller than in μCT scans. Hydroxyapatite cylinders were thoroughly vascularised but did not display bone formation. Grafts with a central artery had more (+58%) and smaller (-52%) vessel branches compared to grafts with a vein. Conclusions We present a relatively inexpensive and easy-to-perform two-step method to analyse bone and vessels by μCT, suitable to assess a variety of bone-regenerative strategies.
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Chaudhry T, Uppal L, Power D, Craigen M, Tan S. Scaphoid Nonunion With Poor Prognostic Factors: The Role of the Free Medial Femoral Condyle Vascularized Bone Graft. Hand (N Y) 2017; 12:135-139. [PMID: 28344523 PMCID: PMC5349415 DOI: 10.1177/1558944716661994] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background: To report on the results of free medial femoral condyle (MFC) vascularized bone graft for scaphoid nonunions with 1 or more poor prognostic factors. Methods: We have used the free MFC vascularized bone graft for scaphoid nonunions that have 1 or more factors associated with a poor prognosis. These were, a delay in presentation of over 5 years, a proximal pole nonunion, the presence of avascular necrosis (AVN), or previous nonunion surgery. We used this technique on 20 patients over a 4.5-year period. Results: Our overall union rate was 88.5% (17 of 19 patients), with 1 patient failing to attend for follow-up. Our mean union time was 7 months (2-18). All patients had at least 1 poor prognostic factor and over half had 2 or more. Of those with AVN with or without other factors, the union rate was 85% (11 of 13). There were 2 donor site complications that required a further procedure and 2 patients with residual wrist pain that required a scapho-trapezio-trapezoid joint fusion and a radial styloidectomy, respectively. Both nonunions were offered further surgery, and 1 elected to undergo successful revision surgery. Conclusions: Overall, this technique showed good results, in a subgroup of patients that typically have poorer outcomes, with a low incidence of donor site morbidity. Our union rate compares favorably with other techniques for this difficult subset of patients with 1 or more poor prognostic factors, although results are clearly not as good as those of studies using the MFC graft for all scaphoid nonunions. We continue to reserve this technique for nonunions with 1 or more poor prognostic factors, and we believe that this technique should at least be considered in these patients.
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Affiliation(s)
- Tahseen Chaudhry
- University Hospital Birmingham, UK,Tahseen Chaudhry, University Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK.
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Henry M. Vascularized Medial Femoral Condyle Bone Graft for Resistant Nonunion of the Distal Radius. J Hand Surg Asian Pac Vol 2017; 22:23-28. [DOI: 10.1142/s0218810417500046] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Nonunion involving the metaphyseal region of the distal radius is exceedingly rare, usually involving co-morbidity. Patients that have failed multiple prior conventional surgical interventions represent an even more difficult subset to treat; this investigation examined the utility of a specially designed free vascularized medial femoral condyle flap consisting of a central structural block graft with an extended corticoperiosteal sleeve to wrap around the junctions. Methods: Six patients (5 males, 1 female) with a mean age of 52 years had failed to achieve union involving the distal radius metaphysis after a mean of 3.7 prior surgeries occurring over a mean period of 24 months. Comorbidities included smoking, alcoholism, chronic nutritional deficiency, and prior osteomyelitis. The unique descending genicular artery medial femoral condyle flap designed to address these patients consisted of a central structural block graft in continuity with an extended corticoperiosteal sleeve. The structural block filled the bone defect, and the corticoperiosteal sleeve wrapped around the bone junctions and the neighboring bone margins. The mean flap size was 5.3 (+/- 1.3) cm long by 4.5 (+/- 0.9) cm wide. Pre-operative to post-operative DASH scores were compared using the paired student’ s t-test, with p < 0.05. Results: All flaps achieved union at a mean of 6.8 (+/- 2.1) weeks following surgery, using the criteria of bridging trabeculae on all 3 radiographs: coronal, sagittal, and oblique. The mean pre-operative DASH score of 63 (+/- 10) was statistically significantly different compared to the mean post-operative DASH score of 18 (+/- 8). Conclusions: With few alternative solutions able to address this unique and difficult problem, the structural block of vascularized bone with the extended corticoperiosteal sleeve proved able to achieve a union that had failed multiple previous attempts and able to resist reactivation of infection, in a challenging group of patients with comorbidities.
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Affiliation(s)
- Mark Henry
- Hand and Wrist Center of Houston, Houston, USA
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Cognet JM, Louis P, Martinache X, Schernberg F. Arthroscopic grafting of scaphoid nonunion – surgical technique and preliminary findings from 23 cases. HAND SURGERY & REHABILITATION 2017; 36:17-23. [DOI: 10.1016/j.hansur.2016.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 11/16/2016] [Accepted: 11/18/2016] [Indexed: 10/20/2022]
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Murphy AD, Atkins SE, Thomas DJ, McCombe D, Coombs CJ. The use of vascularised bone capping to prevent and treat amputation stump spiking in the paediatric population. Microsurgery 2017; 37:589-595. [PMID: 28121366 DOI: 10.1002/micr.30160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 01/02/2017] [Accepted: 01/05/2017] [Indexed: 11/06/2022]
Abstract
BACKGROUND Overgrowth of the stump skeleton is a major complication seen in children after an amputation. In advanced cases, perforation of the bone spike through the skin can occur. Many surgical treatments have been employed to treat and prevent this, with best results seen when non-vascularised osteo-chondral bone grafts are placed to try to mimic a trans-articular amputation. We reviewed our outcomes using vascularized bone flaps to prevent and treat spiking. PATIENTS AND METHODS Between 2000 and 2016 we carried out six vascularised osteo-cartilaginous bone capping procedures. Five patients underwent the procedure as an adjunct to primary amputation and in a single patient it was used to treat established bone spiking. Trauma accounted for three cases, with the other three being tumour, vascular malformation and ischemia. Three patients had pedicled bone flaps placed on the amputation stump and three underwent free tissue transfer (free calcaneus, free scapular angle, and free proximal tibia). Five cases involved lower limb amputations, with one in the upper limb. RESULTS One patient had an early post-operative complication in the form of partial skin flap necrosis that required debridement and skin grafting. All bone flaps survived. Mean follow-up was 6.5 years. All patients had bony union with no development of stump spiking. Two patients required further procedures unrelated to the bone flaps. CONCLUSION Vascularised bone flaps to cap amputation stumps may be a safe and effective method of preventing and treating long-bone stump spiking following amputation in children.
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Affiliation(s)
- Adrian D Murphy
- Department of Plastic & Maxillofacial Surgery, Royal Children's Hospital, Victoria, 3052, Melbourne, Australia
| | - Sara E Atkins
- Department of Plastic & Reconstructive Surgery, John Radcliffe Hospital, Oxford, United Kingdom
| | - Damon J Thomas
- Department of Plastic & Maxillofacial Surgery, Royal Children's Hospital, Victoria, 3052, Melbourne, Australia
| | - David McCombe
- Department of Plastic & Maxillofacial Surgery, Royal Children's Hospital, Victoria, 3052, Melbourne, Australia
| | - Chris J Coombs
- Department of Plastic & Maxillofacial Surgery, Royal Children's Hospital, Victoria, 3052, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
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Kazmers NH, Thibaudeau S, Steinberger Z, Scott Levin L. Upper and lower extremity reconstructive applications utilizing free flaps from the medial genicular arterial system: A systematic review. Microsurgery 2016; 38:328-343. [DOI: 10.1002/micr.30138] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 11/10/2016] [Accepted: 12/02/2016] [Indexed: 11/07/2022]
Affiliation(s)
| | - Stephanie Thibaudeau
- Division of Plastic and Reconstructive Surgery; McGill University; Montreal Quebec H3A 14A Canada
| | - Zvi Steinberger
- Department of Orthopaedic Surgery; Penn Medicine University City; Philadelphia Pennsylvania
| | - L. Scott Levin
- Department of Orthopaedic Surgery; Penn Medicine University City; Philadelphia Pennsylvania
- Division of Plastic Surgery; Perelman Center for Advanced Medicine; Philadelphia Pennsylvania
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Namazi H, Kayedi T. Investigating the Effect of Intra-articular Platelet-Rich Plasma Injection on Union: Pain and Function Improvement in Patients with Scaphoid Fracture. J Hand Microsurg 2016; 8:140-144. [PMID: 27999456 DOI: 10.1055/s-0036-1597088] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/25/2016] [Indexed: 02/07/2023] Open
Abstract
Introduction Fracture of the scaphoid bone is the most common fracture of the carpus. However, the fracture union occurs late or may not heal. Sometimes, fracture healing requires prolong immobilization. Because of potential for joint stiffness, muscle atrophy, or the inability to use the hand during and after prolonged immobilization, there is great incentive to develop therapies that will accelerate bone healing and allow a quick return to work. To date, the effect of platelet-rich plasma (PRP) on scaphoid fracture has not been studied. We aimed to assess the effect of intra-articular PRP injection on union: pain, range of motion, and function in patients with scaphoid fracture. Hypothesis Union: pain reduction and functional improvement can be noticed after PRP use in scaphoid fracture. Materials and Methods A randomized controlled trial was designed with 14 patients with scaphoid fractures (Herbert type B2). Casting was done for them. Seven patients received intra-articular autologous PRP. Patients were followed up 2 weeks after casting using radiography and then at 2 months using radiography and computed tomography (CT) scan to check bone healing. Then patients were followed up for 3 and 6 months and after evaluation of healing by CT scan, the patient-rated wrist evaluation questionnaire was completed and the range of motion of the wrist was measured. Results Analysis revealed significant improvement in pain at rest, as well as during specific and usual activities following PRP injection in the case group. However, no statistically significant difference in wrist motion including radial and ulnar deviation, flexion, and extension was found in 6 months follow-up except some improvement in ulnar deviation after 3 months. However, this study showed that scaphoid union occurred earlier in the case group, but it was not statistically significant. Conclusion PRP may have a significant effect on pain reduction at rest and amount of difficulty in functions including specific and usual activities in patients with scaphoid fractures. Level of Evidence This is a level III, therapeutic trial.
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Affiliation(s)
- Hamid Namazi
- Bone and Joint Disease Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Toomaj Kayedi
- Bone and Joint Disease Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Schuind F, Moungondo F, El Kazzi W. Prognostic factors in the treatment of carpal scaphoid non-unions. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 27:3-9. [DOI: 10.1007/s00590-016-1886-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 10/24/2016] [Indexed: 01/22/2023]
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Asmus A, Lautenbach M, Schacher B, Kim S, Eisenschenk A. [Scaphoid pseudarthrosis : Indications for avascular iliac crest or radius bone grafts]. DER ORTHOPADE 2016; 45:951-965. [PMID: 27637546 DOI: 10.1007/s00132-016-3337-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Operative treatment of the scaphoid nonunion includes avascular corticocancellous and cancellous bone grafts and increasingly the use of vascular pedicled and free vascular corticocancellous grafts. Especially the latter require a fair amount of operative expertise and experience in microsurgical techniques. OBJECTIVE Which criteria lead to the decision for or against an avascular graft used for reconstruction of scaphoid nonunion? Is our current classification system of a scaphoid pseudarthrosis able to illustrate our diagnostic potential in a way that makes us refer to operative procedures? METHODS Evaluation of current literature and expert opinions RESULTS: Avascular bone grafts show a high union rate as long as a sufficient vascularisation of the remaining fragments is present. In general, patients benefit from a very good functional outcome. Even revisions of failed scaphoid union may be successfully treated with an avascular bone graft. Failures of union are repeatedly experienced in treating proximal pole fractures with critical vascularisation or extensive bone loss, especially including avascular necrosis of the proximal pole (AVN). Current classification systems do not allow description and correlation of morphologic findings so as to compare results profoundly and to recommend specific procedures. CONCLUSIONS As long as sufficient vascularisation of remaining fragments is seen, the avascular bone graft is eligible for reconstructing scaphoid nonunion. Classification systems do not seem to reflect the status quo of diagnostic possibilities and make it difficult to provide guidelines for state-of-the-art operative procedures.
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Affiliation(s)
- A Asmus
- Abt. Hand-, Replantations- und Mikrochirurgie, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Deutschland.
| | - M Lautenbach
- Handchirurgie, obere Extremität und Fußchirurgie, Zentrum für Orthopädie und Unfallchirurgie, Krankenhaus Waldfriede e.V., Argentinische Allee 40, 14163, Berlin, Deutschland
| | - B Schacher
- Abt. Hand-, Replantations- und Mikrochirurgie, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Deutschland
| | - S Kim
- Abt. Hand- und funktionelle Mikrochirurgie, Universitätsmedizin Greifswald, Ferdinand-Sauerbruchstr, 17475, Greifswald, Deutschland
| | - A Eisenschenk
- Abt. Hand-, Replantations- und Mikrochirurgie, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Deutschland.,Abt. Hand- und funktionelle Mikrochirurgie, Universitätsmedizin Greifswald, Ferdinand-Sauerbruchstr, 17475, Greifswald, Deutschland
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Kalb K. Freies gefäßgestieltes Femurknochentransplantat bei Skaphoidpseudarthrose. DER ORTHOPADE 2016; 45:966-973. [DOI: 10.1007/s00132-016-3334-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kazmers NH, Thibaudeau S, Levin LS. A Scapholunate Ligament-Sparing Technique Utilizing the Medial Femoral Condyle Corticocancellous Free Flap to Reconstruct Scaphoid Nonunions With Proximal Pole Avascular Necrosis. J Hand Surg Am 2016; 41:e309-15. [PMID: 27436566 DOI: 10.1016/j.jhsa.2016.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 06/18/2016] [Indexed: 02/02/2023]
Abstract
This article demonstrates a technique for the treatment of scaphoid fracture waist and proximal pole nonunions with avascular necrosis using a free vascularized medial femoral condyle flap. We present our surgical technique and representative case examples in which the scapholunate ligament, a key structure required to preserve carpal kinematics, is spared.
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Affiliation(s)
- Nikolas H Kazmers
- Department of Orthopaedic Surgery, Penn Medicine University City, Philadelphia, PA.
| | - Stephanie Thibaudeau
- Department of Orthopaedic Surgery, Penn Medicine University City, Philadelphia, PA
| | - L Scott Levin
- Department of Orthopaedic Surgery, Penn Medicine University City, Philadelphia, PA
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Abstract
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.
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Affiliation(s)
- Steven E R Hovius
- 1 Department of Plastic and Reconstructive and Hand Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Tim de Jong
- 1 Department of Plastic and Reconstructive and Hand Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Henry M. Free Vascularized Medial Femoral Condyle Structural Flaps for Septic Terminal Digital Bone Loss. J Hand Microsurg 2015; 7:306-13. [PMID: 26578834 DOI: 10.1007/s12593-015-0207-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 10/20/2015] [Indexed: 10/22/2022] Open
Abstract
A unique clinical problem exists when the majority of distal bone stock in a digit is destroyed by osteomyelitis, leaving a residual soft tissue envelope with tenuous, random perfusion surrounding a nidus of scar tissue. Pulp pinch is lost in the absence of bony support, and limited options exist. Apart from toe transfer or revision amputation with shortening, non-vascularized bone grafting inside the residual soft tissue envelope risks graft resorption and reactivation of infection. The purpose of this investigation was to evaluate the clinical outcomes of free vascularized medial femoral condyle structural bone flaps to restore lost pulp pinch in such cases. Nine patients (8 males, 1 female) with a mean age of 43 years sustained extensive terminal bone loss near digital tips following osteomyelitis. The mean length of bone defect was 28 mm (± 8.4). The patients were reconstructed at a mean of 12 weeks from initial trauma/infection, having undergone a mean of two prior surgeries. A structural block of vascularized bone from the medial femoral condyle replaced the missing bone at the digital tip defect, temporarily fixed with K-wires. The bone flap was encased by the residual soft tissue envelope after removing scar tissue from the prior trauma and infection. All bone flaps incorporated fully, restoring pulp pinch function to the respective digits with a mean time to union of 8.6 (± 2.1) weeks; range 6-11 weeks. With few alternative solutions able to address this unique and difficult problem, the structural block of vascularized bone proved able to resist resorption, nonunion, and reactivation of infection; the problems normally encountered under this scenario.
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Affiliation(s)
- Mark Henry
- Hand and Wrist Center of Houston, 1200 Binz Street, 13th Floor, Houston, TX 77004 USA
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