Reconstruction of the Irreparable Proximal Scaphoid with Costo-Osteochondral Graft (Rib Graft)

Abstract

Background Irreparable proximal pole fractures of the scaphoid remain a real challenge for the treating handsurgeon. Standard salvage options include 4-corner fusion or proximal row carpectomy. These procedures limit the range of motion and have a high rate of conversion to total wrist fusion. The two current biological reconstructive options are the rib graft or the vascularized femoral trochlea osteocartilaginous free flap. In addition, there is the prosthetic semi-replacement arthroplasty using the pyrocarbon adaptive proximal scaphoid implant (APSI). Aims To present our series of patients with non-reconstructable proximal scaphoid nonunion/fracture (not suitable for conventional bone graft reconstruction) who were treated by the rib graft technique. Methods Our case series of 21 patients treated between March 2013 and January 2019 will been presented (median follow-up 29 months). The surgical technique will be described and crucial technical steps explained. The mean age at surgery was 26 years (SD 5.8) and the median time between injury and rib graft surgery was 2 years (IQR 1.7–3.6). The median postoperative follow-up was 29 months (IQR 19.5–42.4). Results All patients returned to their pre-surgical occupation. Significant differences were found in active wrist movements, grip strength, QuickDASH and PRWE pain scores. Union was seen in all 21 patients. The postoperative capitolunate angles were within normal limits. 17/21 patients showed no progessive postoperative osteoarthritic changes, while 4/21 showed slight progression. Progressive ossification of the graft was noted in 14 /21 patients. No donor site complication occurred. One patient failed and underwent excision of the scaphoid and fourcorner fusion 9 months after the rib graft. At the time of revision, the graft was clinically united. We found statistically significant improvements in QuickDASH and PRWE. Conclusions Our results suggest that reconstruction of the irreparable proximal pole scaphoid nonunion with costo-osteochondral graft reconstruction (rib graft) is a reliable and straightforward procedure in this challenging problem.