The use of the free vascularised bone graft for nonunion of the scaphoid: a systematic review

Abstract

BackgroundFractures of the scaphoid are well known to be problematic especially when complicated by avascular necrosis, nonunion and carpal collapse. Fixation techniques have involved nonvascularised bone grafting; however, in the presence of avascular necrosis, generally poor union rates (47%) occur as identified by a meta-analysis performed by Merrell et al. The introduction of pedicled vascularised bone grafts showed further improvement; however, in the presence of carpal collapse, union rates as low as 50% have been reported by Chang et al. amongst others using the 1,2-intercompartmental supraretinacular artery pedicled graft. The difficulty lies in having a short pedicle with limited manoeuvrability to correct a humpback deformity and insert into the scaphoid cavity. Prior trauma to the soft tissues or distal radius may prohibit the use of pedicled grafts. The aim of this systematic review is to examine the published evidence for the use of free vascularised bone grafts in cases of scaphoid nonunion.MethodsA systematic review was performed with the following defined search strategy on MEDLINE and Google Scholar: ((scaphoid nonunion) OR scaphoid pseudarthrosis) AND bone graft. Articles were reviewed and data compiled into tables for analysis. Statistical analysis was performed with determination of descriptive statistics, and differences between the groups were calculated using categorical variables and chi-square test. A p value of 0.05 or less was considered to be statistically significant.ResultsTwo hundred and sixty-three articles were identified with a total of 12 articles meeting the inclusion criteria. Two hundred and forty-five cases of scaphoid nonunion were identified through the articles included in this systematic review. Fifty-six patients underwent free vascularised bone grafts from the medial femoral condyle with a 100% union rate and correction of humpback deformity, and 188 patients underwent free vascularised bone grafting from the iliac crest with an 87.7% union rate. The difference between the two similar groups was statistically significant (p = 0.006).ConclusionsThe promising data suggests that the medial femoral condylar free graft based on the descending genicular vessels can be considered in cases of proximal pole avascular necrosis and humpback deformity or in situations where other flaps are precluded or deemed unlikely to cause union.

Kahnbeinpseudarthrose: Erfahrungen aus mehr als 280 Rekonstruktionen mit einem vaskularisierten Knochenblock aus der medialen Femurkondyle

“…Nachdem neben den theoretischen Vorteilen die ersten Publikationen vaskularisierter Skaphoidrekonstruktionen mit einem Femurspan durchweg hervorragende Resultate bei allerdings naturgemäß kleiner Fallzahl und kurzer Nachbeobachtungszeit [4][5][6][7]19] zeigten und eine Metaanalyse gar eine Erfolgsrate von 100 % postulierte [8] und dabei -sicherlich unbeabsichtigt -identische Patienten zum Teil doppelt zählte, resultierte verständlicherweise ein enormes Interesse an dieser rekonstruktiven Technik. In erster Linie liegt das daran, dass es sich bei den in Frage kommenden Patienten zum weit überwiegenden Teil um junge aktive Männer handelt, die eine relevante Invalidität am Handgelenk unbedingt vermeiden möchten.…”

“…Eine entscheidende Erweiterung der Sanierungsmöglichkeiten war die Etablierung vaskularisierter Knochentransplantate von der medialen Femurkondyle, die formal die Vorteile nicht-vaskularisierter und vaskularisierter Transplantate kombinieren, nämlich mechanische Stabilität und zuverlässige Perfusion bei vergleichsweise risikoarmer Hebetechnik, und darüber hinaus als osteochondrale Transplantate die Rekonstruktion eines destruierten proximalen Skaphoidpoles ermöglichen. Unter dem Eindruck sensationeller Frühergebnisse in der Literatur [4][5][6][7][8] einerseits und einer großen Zahl komplexer Skaphoidpseudarthrosen mit bis dahin unbefriedigenden Sanierungsoptionen im eigenen Krankengut begannen wir 2008 kortikospongiöse und ab 2011 osteochondrale Femurkondylentransplantate einzusetzen. Da damals nur sehr wenige Zentren diese Verfahren anboten, hatten wir rasch eine beachtliche Zahl an mikrovaskulären Skaphoidrekonstruktionen unter Verwendung einer medialen Femurkondyle zu verzeichnen und dies, obwohl diese Technik nicht (!!)…”

The use of vascularised bone capping to prevent and treat amputation stump spiking in the paediatric population

“…Stump capping with osteocartilaginous grafts appears to be the most effective treatment for stump spiking. Vascularized bone flaps have been shown to be superior to non‐vascularized grafts in the setting of scaphoid (Al‐Jabri, Mannan, & Giannoudis, ), mandible (Foster, Anthony, Sharma, & Pogrel, ) and hip reconstruction (Tetik et al, ). For this reason we elected to use vascularized bone flaps in our series.…”

Upper and lower extremity reconstructive applications utilizing free flaps from the medial genicular arterial system: A systematic review

“…The MGA flap is versatile and well‐suited for reconstruction of a wide array of orthopaedic pathology including fracture nonunion (Al‐Jabri, Mannan, Giannoudis, ; Cavadas and Landin, ; Choudry, Bakri, Moran, Karacor, Shin, ; De Smet, ; Del Pinal, Garcia‐Bernal, Regalado, Ayala, Cagigal, Studer, 2007; Doi, Oda, Soo‐Heong, Nanda, ; Doi and Sakai, ; Fei, Danmou, Dong, Wei, Eberlin, Yan, 2015; Fuchs, Steinmann, Bishop, ; Hamada, Hibino, Kobayashi, 2014; Jones, Rhee, Bishop, Shin, ; Jones and Shin, ; Kakar, Duymaz, Steinmann, Shin, Moran, ; Rodriguez‐Vegas and Delgado‐Serrano, ; Pelzer, Reichenberger, Germann, ; Rahmanian‐Schwarz, Spetzler, Amr, Pfau, Schaller, Hirt, ; Sakai, Doi, Kawai, ; Sananpanich and Kraisarin, ), avascular necrosis (AVN) (Burger, Windhofer, Gaggl, Higgins, ; Doi and Sakai, ; Holm, Vangelisti, Remmers, ; Jones, Burger, Bishop, Shin, ; Larson, Bishop, Shin, ), failed arthrodesis (Grant, Berger, Ireland, ; Henry, ), infection (Caterson, Singh, Turko, Weaver, Talbot, ), loss of the Achilles tendon and calcaneal insertion (Haddock, Alosh, Easley, Levin, Wapner, ; Haddock, Wapner, Levin, 2013; Huang, Wang, Xu, Wang, Wu, Zhang, 2011; Mattiassich, Marcovici, Dorninger, Kerschhagl, Buerger, Kroepfl, 2014; Paier, Burger, Rab, ; Sananpanich and Kraisarin, ), and osseous defects (Bakri, Shin, Moran, ; Giessler and Schmidt, ; Rodriguez‐Vegas and Delgado‐Serrano, ; Ruston, Amin, Darhouse, Sivakumar, Floyd, ; Sakai, Doi, Kawai, ; Sammer, Bishop, Shin, ; Sananpanich and Kraisarin, ; Wong, Higgins, Katz, ) with or without overlying soft tissue loss. Many studies in the literature are limited by small numbers of patients, or are heterogeneous and report multiple flap recipient sites.…”